ECLECTIC PRACTICE OF MEDICINE, 
B Y 
WM. BYRD POWELL, M.D., 
Formerly Professor of Chemistry in the Medical College of Louisiana; late Professor of Cerebral Physiology and Medical Geology in the Memphis Institute; Member "Societas Medica Chirurgica Marylandia;" Corresponding Member of Western Academy of Sciences; Honorary Member of Antiquarian and Natural History Society of the State of Arkansas; Honorary member of the " Societe Francaise Statistique Universelle," at Paris, France, etc., etc., etc.; 
and 
K. S. NEWTON, M.D., 
Professor of Practice of Medicine and Pathology in the Eclectic Medical Institute of Cincinnati; formerly Professor of Surgery in the same ; late Professor of Surgery in Memphis Institute, etc. 
_ (toft v ¦. ¦ i r '¦+% «. 
CINCINNATI 
PUBLISHED BY H. W. DERBY. 
1 854. 


Entered according to Act of Congress, in the year 1854, by 
H. W. DERBY, 
In the clerk's office of the District Court of the United States for the District of Ohio. 
Printed by ¦ 
E. MORGAN & CO. 


III 
PREFACE. 
The existence of the Eclectic branch of the Medical profession is too brief, although its development has been unprecedented in the history of innovations and professional revolutions, to have produced a library for the instruction of its disciples and the conversion of the public. The leisure of its professors and qualified practitioners has been devoted to doing battle to maintain existence against the increasing assaults of their more conservative brethren. But now, as their independence—their ability to maintain an independent existence, is tacitly acknowledged, they are bestirring themselves to advance and disseminate their doctrines — doctrines 
which have guided them to a practice that has, for success, been unrivaled at any period since the days of the Father of Medicine. 
The universally-acknowledged want of text-books to promote the advancement of Eclectic students, has alone impelled the authors of the following pages to bring them forth, as an embodiment of the practice in those forms of disease to which they are devoted; and, considering the multifarious duties through which they were prosecuted, it is not reasonably to be supposed that they are without errors .and imperfections; but the authors ardently hope, 


IV 
PREFACE. 
indeed, they are much disposed to believe that none will be discovered which will prove mischievous in practice. 
It is deemed proper that the public should be informed of the agency which the authors, respectively, have had in the work. Dr. Powell has devoted a large proportion of his life to physiological and pathological investigations, and Dr. Newton has been actively and extensively engaged for several years in the Eclectic practice of medicine, and both were educated in distinguished schools of the timehonored Allopathic principles and practice. With their respective acquirements and these advantages, they united their exertions, each acting in his own peculiar sphere, for the common cause of Eclectic medicine. 
For the Practice, as taught in this work, Professor Newton is alone responsible, and the balance of the work, Professor Powell—however with a full concurrence of Prof. N. in all the pathological views laid down, and so much of the peculiar views of Prof. P., as has been investigated and understood by Prof. N". 
It should be known, by the public, that both authors were regularly educated in strictly orthodox Allopathy — that they believe themselves to have abandoned no fact and no truly-founded principle which they acquired, and that, inasmuch as they were not bound, by an oath of allegiance, to the false doctrines and the mischievous practice that were taught to them (for, certainly, no one will contend that a professor ever lived who taught no error), they felt, and still feel, that they have not forfeited their right of private judgment, nor their privilege to abandon 


PREFACE. 
V 
errors, when discovered, no matter whence obtained, and to embrace truth, no matter by whom discovered. 
Whatever may be the feelings and the opinions of those who differ with us, on professional subjects, we can, with unfeigned sincerity, declare that we feel grateful to those professors, and to those writers, who have, in the least, contributed to the making us what we are. If we shall, even to a small extent, liquidate the obligation we owe to those who have preceded us, by our labors in the following pages, a large portion of our ambition will be achieved. 
When we commenced this work, we remembered how much we had been bored by those professors who seemed to regard it as all-important that they should advance authority for every opinion they uttered. Students visit medical schools, not to obtain and to remember the names of those who have placed upon record a medical opinion, but to be informed, by the professors, as to what are the standard or generally-received opinions or doctrines of the profession, and for the same purpose they read text-books. Special doctrines and opinions are subjects of future investigation. 
In. view, then, of the impatience with which students read quotations, and their indifference to authorities in textbooks, we have, as little as possible, given reference to authorities. We have simply labored to represent the profession, except where it has been our fortune to differ from it, and in such cases we have given our reasons for so doing. 


PREFACE BY PROFESSOR POWELL. 
Those who shall be benefited by that portion of the following work which devolved upon the writer, must feel themselves, to a no small extent, indebted to" Professors King, Newton, and Freeman—who, being upon a former occasion, his colleagues, had frequent opportunities of hearing his opinions upon various physiological and pathological subjects, and being pleased with his views in general, and in particular with his modes of thinking and investigating, have been principally instrumental in causing him, in this respect, to become an author. 
It will be found, furthermore, that in his portion of the work, there is not that rigid adherence to the subject before him, which is almost universal in the profession, and for this peculiarity the above-named professors must be held responsible, because they advised him to pursue that course which was characteristic of his professional lectures, which, being extemporaneous, gave him the latitude of suggestion, upon relative subjects, for the purpose of elucidation,. illustration, or instruction. To this circumstance, perhaps, more than to any other, they attributed that profound attention which his lectures always commanded. 
With reference to the professional library of the age, he acknowledges himself to be greatly indebted—-to extent of his means. It hrs served him for the purposes of suggestion, the support of truth, and the illustration of error; but, knowing how much students are bored by learned 


PREFACE BY PROFESSOR POWELL. 
VII 
references, he has avoided them as much as possible. This omission, with him, has, perhaps, a deeper foundation, and one that he would plant in the mind of every student' He has never permitted any author to produce in his mind a feeling of conviction, and for the reason that we have but one certain source of truth—and that is nature. All authority, for and against all subjects, he respects, until by an appeal to nature, it is found to be false; and it is by this rule that he would be tried with reference to any new or novel opinion he has advanced. 
He is aware that, in this sectarian age, his character in this respect, is as novel as any opinion he may have advanced ; and, consequently, he has not still to be informed that his abandonment of the lancet and of all indigestible substances, as remedial agents, has so affected those who still use them, that they cannot sufficiently suspect it to te possible that any truth could drop from his pen, as to read after him. Of course, in this respect, he believes that there are a few — very few exceptions. That such a state of the public mind should exist with reference to religion and politics, is to be expected; but it is disgraceful to discover it within the area of scientific research. Suppose no one to have innovated — to have outraged public opinion as much as he has, where would we, as a people, now be ? Look at our savages, and be reproved. 
He is very much of the opinion that the investigations of his life have resulted in a very considerable addition to our present stock of physiological knowledge — (not learning, God forbid). If the doctrines he has taught in the following pages, particularly upon the subjects of the human temperaments and organic constitution of disease, shall be sustained by a rigid comparison of them with nature, then the result cannot be less than a complete revolution in the sciences of pathology, diagnosis, and prognosis. And, inasmuch as these subjects have been rendered demonstrable 


VIII 
PREFACE BY PROFESSOR NEWTON". 
even by his pupils, he cannot entertain a reasonable doubt about their final reception. 
He does not doubt but that he has taught some hitherto unknown truths, and he is willing to admit it as possible that he may have taught as many hitherto unknown errors; and, although the two classes may be equal, in both number and magnitude, yet there will still be a positive gain to the profession; because the cupel of time will absorb the latter, while the former will continue to requite, to some extent, the heavy obligation he is under, not to a pai't or sect, but to the whole of it — as he acknowledges but one Medical profession. Oovjngton, Kt., January, 1854. 
PREFACE BY PROFESSOR NEWTON. 
Having prepared his portion of this work while constantly engaged with his professional duties, he is conscious that it is not as minute in the details of treatment as might have been the case under other circumstances, and that many imperfections have been passed without correction; yet he is confident that they are of a character that will not detract from the real value which he hopes the friends of Eclecticism will place upon the book. It will be seen by the reader, that it embraces, principally, his own practice, and, so far as he has, been able to learn, that of the most successful Eclectic practitioners. 
Hoping that he may have added something more for the good of Eclecticism, he confidently resigns the work into the hands of the profession. 
89 West Seventh street, Cincinnati, O., January, 1854. 


CONTENTS. 
BOOK I. 
1. Sanguine bilious encephalo-lymphatic temperament. 
III. Quarternary combinations. 
4. The bilious encephalo-lymphatic temperament. 
3. The sanguine encephalo-lymphatic temperament. 
2. The sanguine encephalo-bilious temperament. 
1. The sanguine bilious-lymphatic temperament. 
II. Ternary combinations. 
6. The encephalo-lymphatic temperament. • 
5. The bilious encephalic temperament. 
4. The bilious lymphatic temperament. 
3. The sanguine encephalic temperament. 
2. The sanguine lymphatic temperament. 
1. The sanguine bilious temperament. 
I. Binary combinations. 
Chapter III.—The combinations of the elementary temperaments. 
IV. Encephalic temperament. 
III. Lymphatic temperament. 
II. Bilious temperament. 
I. Sanguine temperament. 
Chapter I.—A review of the prevailing opinions on this subject. " II.—Of the elementary temperaments. 
Part II.—The human temperaments. 
Chapter II.—Pathological relations of the cerebellum. 
IV. Physiological inferences in reference to the cerebellum. 
III. Animal sensibility. 
II. Muscular motion. 
I. Amativeness. 
Sect. II.—Special functions of the cerebellum. 
Section I.—A summary of the prevailing opinions on the functions of the cerebellum. 
Chapter I.—Functions and relations of the cerebellum. 
Part I.—Of the functions and pathological relations of the cerebellum. 
OF THE FUNCTIONS AND PATHOLOGICAL RELATIONS OF THE CEREBELLUM, AND OF THE HUMAN TEMPERAMENTS, FOR THE ELUCIDATION OF DISEASE. 


CONTENTS. 
X 
BOOK II 
Part I.—'Manifestations of disease in the animal or cerebro-spinal system Class I.—Manifestations of disease in the cerebral apparatus. Order I. —Inflammatory forms of cerebral disease. Genus I.—Encephalitis. " II.—Acute hydrocephalus. 
THE NATURAL HISTORY, PATHOLOGY, AND TREATMENT OF THE VARIOUS FORMS OF , DISEASE INCIDENTAL TO INFANCY AND CHILDHOOD. Pathological considerations. Symptomatology. 
BOOK III. 
Appendix to Book II. 
Appendix to Book I. 
" IX.—Of the necessity and utility of juvenile mortality. 
Section I.—Location and construction of the nursery. " II.—The temperature of the nursery. " III.—Physical training of the nursery. " IV.—Mental training of the nursery. Chap. VIII.—Causes of infantile mortality. 
Chapter VII.—The nursery. 
Section I. —Washing the child. II.—The dress of the child. " III. —Feeding the child by the mouth. 
Chapter VI.—Of personal attentions to the child. 
Section I.—The vital forces. " II.—The defensive faculties. " III.—The moral faculties. " IV.—The social faculties. V.—The intellect. 
Chapter V.—Of mental injuries to the child. 
Section I.—Necessity of a foster-mother. " II.—Of improper nourishment. " III.—Infectious poisons in the milk. " IV.—Infectious diseases. " V.—Inattention to child's necessities. 
Chapter III.—Of maternal duties in relation to her child. " IV.—Of physical injuries to the child. 
with reference to children by a second. 
Section I.—Psychological influence of the mother on the fetus. " II. —Influence of children on a mother by a first husband, 
Chapter II. —Influence of maternal conditions on the fetus. 
Section I.—Marriage eligibility. " II.—Parental constitution. " III. —Improper Marriages. " TV.—Present health and qualifications. 
Chapter I.—Parental conditions considered with reference to children. 
PHYSIOLOGICAL CONSIDERATIONS IN RELATION TO PARENTS AND THE TREAT MENT OF CHILD LI EN. 


CONTENTS. 
XI 
Oeder II.—Non-inflammatory forms of cerebral disease. • Genus I.—Cerebral congestion. Species I.—Acute cerebral congestion. " II.—Passive cerebral congestion. Genus II.< —Chronic hydrocephalus. 
" III.—Cerebral hypertrophy. " IV.—Hydrocephaloid disease. Order III.—Nervous forms of cerebral disease. 
Genus I.—Epilepsy. " II.—Chorea. " III.—Paralysis. " IV.—Night Terrors. " V.—Trismus Nascentium. " VI.—Convulsions. 
Class II.—Manifestations of disease in the spinal apparatus. Order I.—Inflammatory forms of spinal disease. Genus I.—Spinal meningitis. " II.—Myelitis. 
Class III.—Manifestations of disease in the respiratory apparatus. Order I.—Inflammatory forms of disease in the respiratory apparatu s Genus I.—Catarrh. Species I.—Coryza. Genus II.—Laryngitis. Variety I.—Mucous laryngitis. " II.—Sub-mucous laryngitis. " III.—Pseudo-membranous laryngitis. " IV.—Spasmodic laryngitis. Genus III.—Bronchitis. 
Species I.—Acute bronchitis. " II. —Chronic bronchitis. Genus IV.—Pneumonia. 
" V.—Pleuritis—Pleurisy. " VI.—Phthisis pulmonalis. Order II.— Non-inflammatory forms of disease in the respiratory 
apparatus. Genus I. —Absent or imperfect respiration. 
" II.—Congestion of the lungs. " III.—Apoplexy of the lungs. Order III.—Nervous forms of disease in the respiratory apparatus. 
Genus I.—Infantile spasm of the glottis. " IT.—Nervous cough. " III.—Hooping-cough. Class IV.—Manifestations of disease in the circulatory apparatus. 
Order I.—Non-inflammatory forms of disease in the circulatory apparatus. Genus I.—Establishment of independent circulation. 
1. Period of the obliteration of the fetal openings. 
2. Mode of obliteration of the fetal openings. ** II.—Cyanopathy—Cyanosis—Blue disease of infancy. 


XII 
CONTENTS. 
Order II.—Inflammatory forms of disease in the circulatory apparatus. Genus I.—Imperfect cicatrization of the umbilicus. " II.—Pericarditis—Inflammation of the heart's envelope. 
Class V.'—Manifestations of disease in the derma. Order I.—Malformation and disease of the derma produced before or at birth. Genus I.'—Malformation of the derma produced before birth. 
Species I.—Alterations of color. " II.' —Excrescences. " III.—Naevi materni. Genus II.—Disease of the derma produced before or at birth. 
Species I.—Absence of the skin. " II.—Tumor of the scalp. " III.—Petecchise. " IV.—Ecchymosis. Order II.—Moist form of disease in the derma. 
Genus I.—Vesiculee. Species I.—Herpes. Variety I.—Herpes zoster. " II.—Herpes circinatus. " III.—Herpes prseputialis. Species II.—Scabies—psora. 
Genus II.—Bulla?. Species I. —Pemphigus. " II.—Erysipelas. " III.—Rupia. Genus III.—Pustulae. 
Specils I.—Variola. Variety I.—Complications of variola. " II.—Vesicula varicella. 
1. V. Lenticular. 2. V. Conoidal. 3. V. Globate. " III.—Variola vaccina. 
" IV.—Inoculated variola vaccina. Speciis II.—Ecthyma. 
" III.—Impetigo. Variety I.—Impetigo larvalis—crusta lactea. 
" II.—Impetigo capitas. Species IV.—Porrigo or favus. 
Variety I.—Porrigo lupinosa. " II.—Porrigo scutulata—Tinea annularis. 
Order II.—Dry forms of disease in the derma. Genus I.—Exanthemata. Species I.—Roseola. " II.—Urticaria. " III.—Erythema. " IV.—Rubeola. " V.—Scarlatina. 


CONTENTS. 
XIII 
Variety I.—S. Simplex. " II.—S. Anginosa. " III.—S. Maligna. Genus II.—Papulae. 
Species I. —Strophulus. Variety I.—Strophulus intertinctus. " II.—Strophulus confertus. " III.—Strophulus volaticus. " IV.—Strophulus albidus. " V.—Strophulus candidus. Species II. —Lichen. 
Variety I.—Lichen simplex. " II.—Lichen agrius. " III.—Lichen urticatus. Species III. —Prurigo—Pruritis. 
Genus III.—Squamae. Species I.—Pityriasis. " II. —Psoriasis. " III.—Ichthyosis. 
Class VI.—Manifestations of disease in the cellular system. Order I.—Non-inflammatory forms of disease in the cellular tissue. Genus I.—Edema. " II.—Gangrene of infants. 
Class VII.—Manifestations of disease in the organs of the external senses. Order I.—Inflammatory forms of disease in the organs of the external senses. Genus I.—Ophthalmia purulenta. 
" II.—Scrofulous ophthalmia. 
III. —Otitis. 
Class VIII.—Manifestations of disease in the genital apparatus. Order I. Genus I.—Adhesion of the labia pudendi. " II.—Discharges from the infantile vagina. " III.—Hydrocele, or dropsy of the scrotum. 
Part II.—Manifestations of disease in the vegetative system. 
Class I. —Manifestations of disease in the parts above the diaphragm. 
Order I.—Inflammatory forms of disease in parts located above the diaphragm. Genus I.—Stomatitis. 
Species I.—S. Erythemata. " II.—S., with altered secretion. " III.—S. Follicular. 
IV. —S. Vesicular. V.—S. Pustular. " VI.—S. Mercurial. 
Genus II.—Angina. Species I.—A. Simplex. " II.—A. Membranacea. " III.—A. Tonsillaris. 
Order II.—Non-inflammatory forms in parts above the diaphragm. 


XIV 
CONTENTS. 
Genus I.—Stomatitis gangrenous. " II.—Irritations of dentition. 
Class II.—Manifestations of disease in apparatus below the diaphragm. Order I.—Inflammatory forms of disease in the digestive apparatus. Genus I.—Peritonitis. " II.—Cholera infantum. 
Order II.—Non-inflammatory forms of disease in the digestive apparatus. Genus I.—Gastric indigestion. 
" II.—Intestinal indigestion. III.—Colic. " iy.—Diarrhea. 
Species I. —D. Feculent. II.—D. Bilious. " III.—D. Mucous. 
" IV.—D. Chylous. " V.—D Lienteric. « VI.—D. Chronic. Genus V.—Invermination. 
" VI.—Costiveness. " VII.—Prolapsus of the rectum. 
BOOK IV. 
treatment of those forms of disease to which adults, more than children, are liable. 
Class I.—Pyrexia or febrile forms of disease in general. Pathological and etiological considerations. Order I.—Special forms of fever. 
Genus I.—Continued fever. Species I.—Pyrexia sthenica. " II.—Synochus fever. " III —Tj phous fever. Genus II.—Periodic fever. 
Species I.—Intermittent fever. Variety I.—Inflammatory intermittent. " II.—Congestive do " III.—Gastric do " IV.—Malignant do " V.—Masked do Species II.—Remittent fever. 
" III.—Congestive fever. " IV.—Yellow fever. " V.—Infantile remittent fever. Variety I.—Acute infantile remittent. 
II.—Slow do do " III.—Low do do 
Typhoid and typhous fevers. 
Order II.—Inflammatory forms of disease, or those which are cured by inflammation. 


CONTENTS. 
XV 
Genus I.—Cerebritis. " IT.—Pleuritis. Species I.—Acute pleuritis. 
" II.—Chronic do Genus III. —Pulmonitis. 
IV.—Phthisis. 
Variety I.—Acute phthisis. " II.—Chronic do III.—Febrile do " IV.—Latent do 
Genus V.—Parotitis. " IX.—Gastritis. Species I.—Acute gastritis. 
" II.—Chronic do Gen. VII.—Duodinitis. 
" VIII.—I nteritis. Species I.—Acute enteritis. 
" II.—Chronic do Genus IX.—Colorectitis. 
" X.—Peritonitis. Species I.—Acute peritonitis. 
" II.—Chronic do Genus XI.—Hepatitis. 
Species I. —Acute hepatitis. " II.—Chronic do Genus XI I.—Splenitis. 
Species I.—Acute splenitis. " II.—Chronic do Gen. XIII.—Nephritis. 
" XIV.—Cystitis. Species. I.—Acute cystitis. 
" II.—Chronic do Genus XV.—Hysteritis. 
Species I.—Acute hysteritis. " II. —Chronic do Gen. XVI. —Rheumatism. 
Acute rheumatism. Chronic do 
" XVII.—Arthritis. Acute arthritis. Chronic do « XVIII.—Pericarditis. 
Acute pericarditis. Chronic do «' XIX.—Ophthalmia. 
Catarrhal ophthalmia. Purulent do 
« XX.—Iritis. « XXI.—Eczema. 


XVI 
CONTENTS. 
Gen. XXII.—Miliaria. « XXIII.—Phlebitis. 
Class.—Non-febrile forms of disease. Order I.—Morbid actions from vascular irritation. Genus I.—Epistaxis. " II.—Hematemesis. " III.—Hematuria. " IV.—Hemoptysis. " V.—Menorrhagia. Order II.—Nervous or functional forms of disease. 
Genus I.—Morbid actions in the organs of internal relation. 
Species I.—Asthma. " II.—Asphyxia. " III.—Aneurism of the aorta. " IV.—Angina pectoris. " V.—Hemorrhoids. " VI.—Diabetes millitus. " VII.—Diabetes insipidus. " VIII.—Ischuria renalis. " IX.—Enuresis. " X.—Scorbutus. ** XI.—Chlorosis. " XII.—Hydrops. Variety I.—Ascites. 
" II.—Hydrothorax. " III.—Anasarca. 
Spe. XIII.—Colica pectonum. " XIV.—Delirium tremens. »« XV.—Lithiasis. " XVI.—Scrofula. '• XVII.—Epidemic cholera. XVIII.—Tetanus. " XIX.—Puerperal convulsions. XX.—Hydrophobia. Genus II.—Morbid actions in the organs of external relation. 
Species I.—Catalepsy. " II.—Hysteria. " III.—Neuralgia. *« IV.—Mania. " V.—Monomania. Genus III.—Morbid action of the organs of mixed relation. 
Species I.—Exoneirosis. " II.—Masturpatio. " III.—Leucorrhea. IV.—Dysmenorrhea. " V.—Amenorrhea. 


BOOK I. 
OF THE FUNCTIONS AND PATHOLOGICAL RELATIONS OF 
THE CEREBELLUM, AND OF THE HUMAN TEMPER- 
AMENTS, FOR THE ELUCIDATION OF DISEASE. 


P A E T I. 
ON THE FUNCTIONS AND PATHOLOGICAL EELATIONS OF THE CEREBELLUM, 
CHAPTER I. 
FUNCTIONS AND RELATIONS OF THE CEREBELLUM. 
SECTION I. 
A SUMMARY OF THE PREVAILING OPINIONS ON THE FUNCTIONS OP THE CEREBELLUM. 
We have been convinced for many years, that the animal functions of the entire system are, in a great measure, if not entirely, founded in, or controlled by, the cerebellum; and hence, for the convenience of a name, we have designated its functions by the title of the " vital forces." 
This investigation will expose physiological and pathological relations which hitherto have not been thought of; and, although we do not profess to have advanced beyond the portals of the subject, yet from this position we are enabled to obtain a shadowed glimpse of the immense advantages which it is destined to confer upon pathology and therapeutics. By the time we shall have done with this chapter, it will be seen, that many of the most obstinate and fatal diseases, to which humanity is heir, are associated with, or founded in particular portions of, this viscus. 
2 (17) 


18 
PREVAILING OPINIONS OF THE FUNCTIONS 
Dr. Carpenter has, in the fifth American edition of his work, set forth, in a very impartial manner, all the evidence that has been had concerning the cerebellar functions, and then drops the subject, simply because the contradictory and entangled character of the evidence, thus far obtained, will not justify a conclusion. In order that our readers may have a just idea of the darkness which envelopes it, and the value of our contributions, we refer them to that work, after they shall have perused the following brief statement of the evidence to which we have alluded. 
Flourens discovered that incisions into the cerebellum produced, in the animals experimented upon, no indications of sensation, but that when it was being removed by slices, they became restless, and that when the organ was entirely removed, they " had entirely lost the power of springing, flying, walking, standing, and preserving their equilibrium." According to Magendie, a deep wound inflicted upon the cerebellum on both sides, irresistibly forces the animal to move backward. The section of one of the crura cerebelli causes the animal to fall upon one side and to " roll upon its longitudinal axis." 
" Foville, Pinel-Grandchamp, and Duges have regarded the cerebellum as the center of common sensation." Dr. Carpenter seems to regard it as possible that the cerebellum is the seat of the " muscular sense." It is probably well known to the public that Dr. Gall and his disciples have maintained that the cerebellum was the organ of the sexual desire or instinct. Thus we find that one party contend that the cerebellum is the organ of certain influences over the muscular system ; that another regard it as the organ of common sensation ; and a third believe it to be demonstrably certain that it is the organ of sexual love. This, in brief, is the sum of what is known upon the subject, and which, so far as regards general utility, amounts to about nothing. 
We are of the opinion that there is not a question in natural history better established than that the sexual desire inheres in the cerebellum; but this conclusion is not incompatible with the idea, that the same viscus may contain the organs of many other functions. The experiments of physiologists and the varying development of this viscus, induced Mr. George Combe to suspect that it might perform a plurality of func- 


OF THE CEREBELLUM. 
19 
tions. Amativeness, or the sexual desire, however, he conceives to appropriate much the larger portion of it, and the balance, he supposes, to be concerned with muscular motion.* 
But four years before he announced his suspicion, we had discovered as much ; and two years before this event, we had demonstrated the independence of two powers, beside that of amativeness, and determined their organs. That volume of the Journal which announces his suspicion, contains a paper from us, which details a definite account of the organ and function of Muscular Motion. 
But upon what principle he supposed the larger portion- of the cerebellum to be employed in the sexual function, we cannot imagine; because, if this viscus perform a plurality of functions, it must be admitted, as with other divisions of the encephalon, that while in one person the sexual function might appropriate the larger portion of it, yet, in another person, another function might appropriate the larger portion of it; and this we have found to be absolutely the case. 
We believe that no one of the experimental physiologists have detected any indication of the existence of the sexual function in the cerebellum ; and, for this obvious reason, vivisection is not the means of exciting such a manifestation of it. Their failure to produce such a manifestation of this viscus, viewed in connection with the results of the comparisons they have made between the cerebelli of stallions, geldings, and mares, leaves us no room to wonder that they should conclude that the cerebellum had no agency in the sexual function. But when it shall be shown that it performs two other functions, which are just as indispensable to procreation as amativeness, then the whole aspect of the question becomes changed. The reason why a mare or gelding shall have a cerebellum as large as that of a stallion will become obvious. 
No important pathological purpose has been achieved by the investigations that have been made into the functions of the cerebellum; so true is this, that if we had nothing to add, to what is now known upon this subject, we could have no 
* American Phrenological Journal and Miscellany. 


20 
THE SPECIAL FUNCTION'S 
reasonable apology for introducing it in a work which treats professedly upon the diseases of children; and yet, we feel that we could not dispense with it. We think it much more than probable that the time is not very far distant when all human diseases will be founded upon the functions of the cerebellum and base of the cerebrum. 
SECTION II. 
THE SPECIAL FUNCTIONS OF THE CEREBELLUM. INTRODUCTORY REMARKS. 
We regret that our convictions of propriety will not permit us to present, in this place, the evidence upon which we contend for the independence of some of the functions of the cerebellum; but, fortunately, if this independence be admitted, so far as our present purpose is concerned, the proof is not requisite. For this reason, and the fact that in a forthcoming work on cerebral physiology, the proof of the functions, to which we allude, will be found, our regret, at our present necessity, is considerably mitigated. For the sake of the relations which we shall unfold, and the arguments which we shall found upon them, we ask our readers, for the time being, to consider the functions that we shall name as being established, and their organs as demonstrated. With this understanding, we proceed with our subject. 
1. Amativeness, or Sexual Desire. 
The proof that this is an independent desire, and that it inheres in the cerebellum, is now before the world, and when we shall, before concluding our treatise on the cerebellum, remove the objections which physiologists have suggested, it will stand as an undisputed and an undebatable proposition. 
The function of this faculty is a desire for congress with the opposite sex, and its object the perpetuity of the race. In these two relations it acts as a sine qua non. Hitherto the magnitude of the cerebellum was regarded as the measure of its power; and this is most emphatically true; but this language contains, with reference to the function in question, a 


OF THE CEREBELLUM. 
21 
very great error, unless we restrict the meaning of the word power, to the abstract strength of the desire, without any reference to a manifestation of the function. Some individuals have an insatiable and an uncontrollable desire, and yet very little procreative ability. Dr. Gall maintained that the procreative ability of a male animal was indicated by the magnitude of the cerebellum, and in this he was correct: but he did not know that there were other powers as indispensable to successful coition as desire, which is the whole function of amativeness. Let it be remembered, then, that desire is the whole of the function of this faculty. 
The organs of this propensity are situated immediately on both sides of the median line, and are, therefore, in contact. So far as we now know, if an equally balanced cerebellum, between the mastoid processes, be divided into five spaces, the middle one will represent the location of the organs in question. In proportion to the development of the neck backward, at its junction with the occiput, is the development of these organs. When, they are largely developed, and those, which are to be treated of, are small, the neck, posterior to the mastoid processes, will be narrow or thin. 
II. MUSCULAR MOTION. 
The function of this faculty is simply a desire of muscular resistance and counter-resistance, or a love of muscular motion. Those who have the organ large cannot brook sedentary habits without an impairment of health. The faculty does not imply a power to use or to command the muscles with facility or ability; but a high endowment of its organ has, incidentally, a powerful influence upon the whole system. The motion that is requisite to secure its gratification, results in a full development of the osseous, muscular, respiratory, and arterial systems. Many persons who have it rather feebly developed, live very active lives, but this results from other motives than a love of motion. Many of this class, furthermore, are very active, and use their muscles with great precision. The power of controlling or guiding the muscles, we refer to the organ of weight or momentum —an intellectual faculty. 
All men will be lazy or indolent who have not the requisite motives to industry; hence many men, with large muscular 


22 
THE SPECIAL FUNCTIONS 
motion, are very idle, but at the same time they will not be stationary. When these organs are small, the chest is flat and contracted, the muscles are flaccid, the spine and shoulders are drooping and the movements of the body are dragging. 
It is a matter of some surprise that physiologists, particularly of the phrenological school, should not have had this faculty suggested to them, long before it was, in consequence of its indispensable relation and importance to the execution of the function of amativeness. There is not in the life of a 
male animal another function that requires as much muscular energy as the copulative. We have invariably observed, 
among men, in connection with a high endowment of this power, a disposition to resist whatever was not agreeable to them. We are, furthermore, disposed to regard it as the source of the faculty of touch, which we conceive to consist in a sense of resistance; but the perception that is founded upon its function, is made by eventuality ; because the weight or resistance, and the hardness or softness of a body, are but conditions that attend its existence. 
The organs of this faculty are located in both sides of the cerebellum, midway between the median line and the mastoid processes, respectively ; and when large, produce a fullness of the corresponding portions of the neck. These organs, like those of amativeness, are usually more developed in males than females. 
III. ANIMAL SENSIBILITY. 
Inasmuch as a delicate sensibility of the cuticular surface is just as indispensable to the success and the enjoyment of the sexual congress, as either or both of the preceding powers, we are again led to marvel that its existence was not long since suspected and even discovered. Indeed, without this faculty, there could be neither success nor enjoyment—it is absolutely indispensable to the perpetuity of the race. 
The function of this faculty appears to consist in a desire for such impressions as can agreeably excite the sense of feeling, and, consequently, in proportion to the development of its organs, is the impressibility or sensibility of the cutaneous surface. Those who have them large are sensitive to all external causes of impression, as atmospheric conditions —they 


OF THE CEREBELLUM. 
23 
dread surgical operations, and suffer much under their infliction. 
It has, perhaps, ever been remarked, that females are usually less gross than males, more indifferent to atmospheric conditions, and complain less under surgical operations. In the fact that they have generally the organs of this faculty much less developed than men, we find an explanation of these differences between the sexes. 
The organs of this faculty are located immediately behind the mastoid processes, and upon the lateral sinuses, and when large, they give a fullness to the corresponding portions of the neck. When all three of the powers of the cerebellum are well or largely developed, the neck, at its junction with the head, is broad and full. 
IV. PHYSIOLOGICAL INFERENCES. 
When we reflect upon the care which has, in all parts of organic nature, been manifested for the preservation of species, we cannot rationally conclude that three powers, so essentially constituting a sine qua non, as they do, in the procreative function, would have been located otherwise than as we find them—in close and co-operative relation to each other. That they are independent powers, no one can entertain a doubt; between either two of them there is no affinity. 
A moment's reflection upon the preceding cerebral faculties, will discover a satisfactory solution of the difficulties that have existed for some time among physiologists. We can now understand how it may be that individual mares and geldings, by having large organs of motion and sensation, may possess a larger cerebellum than a stallion. And we can anticipate how the proprietors of stallions may, by stable confinement, render them incompetent to discharge, with general success, the function for which they are maintained. 
We are, furthermore, by a knowledge of the functions of the cerebellum, enabled to analyze some of the most difficult questions that can arise in mental science. For the purpose of illustration we will present one or two. 
A Mr. Kennedy (the measurement of whose cerebellum will be found in table on page 30), who was hung in Maryland for the violation of a young girl, remarked, while standing on the 


24 
THE SPECIAL FUNCTIONS 
drop, that such an intercourse with female children, had been the leading passion of his life, and that he had been several times guilty of it. Now, we feel sure that the psychologist does not live who can, without the developments we have made, give a satisfactory explanation of this fact. Suppose his Amativeness very strong, and Muscular Motion and Animal Sensibility both very feeble, which were the facts, as we have his skull, and it becomes obvious that he would not desire an adult woman, because he would not associate with her the idea of so close a copulative intercourse—a condition so indispensable to both his success and his enjoyment. He would avoid an adult for another reason : he would expect resistance, which would be incompatible with his feeble sense of resistance. 
A very feeble condition of the organs of Animal Sensibility explains, also, the fact that onanists will leave the bed of a wife and resort to self-pollution. All the persons whom we have known to suffer from excessive or intemperate indulgence with the opposite sex, had, relatively, large Amativeness, and feeble Muscular Motion and Animal Sensibility ; and the philosophy of it appears to be about this : the former power does not so sustain the function and the latter does not so abridge it, as to prevent exhaustion. 
Furthermore, when all three of the cerebellar organs are well developed, the excitement of the whole viscus may be expended in motion, or in the ordinary pursuits of life, or even by social intercourse with refined society, provided the social sentiments are well developed. But when Amativeness alone is fully developed, the whole tendency is salacious, and frequently so importunate as to impel to excessive venery or to self-pollution. 
We do not believe that all of the functions of the cerebellum are yet discovered—we are much inclined to think, that, connected with Muscular Motion, or situated in the midst of the convolutions appropriated to the functions of this faculty, and that of Amativeness, are two others, in which inhere the desires of urination and defecation. We do not attribute that motive power to the cerebellum which is essential to the execution of these functions, or that of Muscular Motion; but merely the desires—the source of their respective volitions. 


OF THE CEREBELLUM. 
25 
The respiratory desire Dr. Grimes locates in the middle xohes of the cerebrum; and, although we think that we have seen some strong confirmations of his opinions, yet, all a priori reasoning would locate it with Muscular Motion in the cerebellum. If we could conceive the medulla oblongata as being the seat of any one desire, we should be inclined to locate the respiratory one in it; because we have uniformly found it large in those persons who manifested the most anxiety about this function—namely, consumptives. And as a very it will be found that those who have the most feeble endowment of the organs of Muscular Motion and Animal Sensibility, and the most feeble muscles, have the medulla oblongata as large as that of the most muscular men. 
This relation of the medulla oblongata and the organs of Muscular Motion and Animal Sensibility, very clearly shows that the cerebellum has no direct agency in the respiratory function, and yet, without its incidental influence, a high endowment of the muscular system and of the respiratory function cannot exist. The mutual dependence of these relations is rendered apparent by the table previously referred to. 
In the course of many years of diligent observation, we have not found a well developed thorax associated with a small endowment of the organs of Muscular Motion ; nor have we, in the same time, discovered a dry, contracted, and parchmentlike skin, and condensed subcutaneous cellular tissue, associated with a full development of the organs of animal sensibility. 
CHAPTER II. 
PATHOLOGICAL RELATIONS OF THE CEREBELLUM. 
For many years, when we have found a large endowment of the organs of Muscular Motion and Animal Sensibility, but more especially of the former, we do not remember to have been disappointed, in a single instance, in predicting the existence of a rheumatic predisposition. We have seen syphilitic and other symptomatic varieties of rheumatism under contrary circumstances, but never the idiopathic; and from 


26 
PATHOLOGICAL RELATIONS 
what we have learned, we conclude that gout is a disease of the same family. 
Dr. Wood, speaking of rheumatism, says, that " there must be a peculiar state of system predisposing to this form of disease. There must be a rheumatic diathesis. In what this diathesis consists, has not been discovered. There are no signs by which its existence can be detected, with an approach to certainty." We contend that it exists in a high endowment of the animal muscles, with considerable sensibility of the skin. And, in confirmation, to some extent, of this opinion, are the following remarks of Dr. Wood: " Children under ten years, and adults over sixty, are seldom attacked ; and men are more subject to the disease than women." Women, as we have before remarked, have all parts of the cerebellum less developed than men, and so have boys, and in men of sixty they are on the decline. 
We have not been able to learn of a single instance of active congestion of the brain, terminating either in apoplexy, palsy, or epilepsy, which, when of an idiopathic character, was not associated with a high endowment of these organs. 
We have not known erysipelatous inflammations, of an original character, to be unattended by a similar endowment. 
Attending this condition of the cerebellum, is a corresponding liability to cutaneous diseases ; while those of a contrary organization contract such diseases with difficulty, and with an equal difficulty are they cured. 
In proportion to the development of the two organs above named, will be the liability to, and the progress of, cancerous diseases. 
And, on the contrary, onanism is associated with a feebleness of these organs, and particularly of that of Animal Sensibility. Those boys who are seduced into this practice, will spontaneously abandon it, unless they should be organically predisposed to it. 
We have never known passive congestions of the brain, convulsions, chronic hydrocephalus, chorea sancti viti, tubercular diseases of the lungs, etc., to be unattended by a feeble endowment of the organs above named. But it is proper to remark, that there is one exception to this doctrine as it now stands. When the hemispheres, or that portion of the cere- 


OF THE CEREBELLUM. 
27 
brum which includes the peculiarly human faculties, preponderates over the balance of it, then it follows that the vital forces may be very feeble, and yet indicate no tubercular disposition, because, under such circumstances, the venous system preponderates over the arterial—a condition which has been discovered to be incompatible with tuberculosis. This condition of the cerebral system will be in a future page, under the name of " Encephalic Temperament." 
It appears then, that the cerebellum is indirectly connected with all the morbid affections which we have named, and, perhaps with many others. Animal sensibility presides over the cutaneous surface, and derangement in it may be followed by abnormal actions in the functions of the urinary apparatus, and to these may succeed, as sequents, rheumatism, gout, epilepsy, palsy, and other diseases among those before named. 
When the organ of Muscular Motion is but feebly developed, then we have passive congestions of the brain, convulsions, hydrocephalus, and consumption. When largely developed, with deficient exercise, we have pulmonary congestion and hemorrhage, or cerebral apoplexy, or gout. And when over exercised, the kidneys may fail to eliminate the urea that is elaborated in the metamorphosis of the muscular tissue, and then rheumatism, epilepsy, or some other disease may result. 
And attending a high endowment of Amativeness, under a deficiency of the other two organs of the cerebellum, amaurosis, paralysis and imbecility; and with a high endowment of the other two, and a deficiency of the posterior lobes of the cerebrum, to furnish motives for such exertions as would expend cerebellar irritation, we have cerebellar apoplexy and mania. 
There is yet another physical condition connected with a relation that is sometimes found to exist between the cerebellum and medulla oblongata. When the latter organ preponderates over the former, there exists a liability to tuberculosis; and when this condition is reversed, there exists an idiopathic disposition to fat, or obesity and dropsy. In these cases the thorax is large enough, but the lungs have but little expansive power — persons thus constituted are said to be shortwinded. They never manifest in the facial muscles any respiratory action. 


PATHOLOGICAL RELATIONS 
28 
If our premises be. correct, it will be perceived that all the diseases we have named originate in parts which are exclusively appropriated to the functions of animal vitality; and when we shall conclude the consideration of the temperaments, it will be understood how they may so modify the influence of predisposing and exciting causes, as to produce many, and apparently very different, diseases. 
If we shall be asked for the source of the diseases of the vegetative system, we can only answer that we do not know; but very strongly suspect that it is in the ganglionic system, and connected, by a telegraphic arrangement, with the anterior extremities of the middle lobes of the cerebrum. 
Thus far, we have introduced no evidence in support of our conclusions, but it is not yet too late. 
As to the independence of the cerebellar functions, as we have stated, we shall offer no proof in this place, but will simply ask to have it admitted that the cerebellum does perform a function; and then, after assuming it to have been clearly shown by physiologists that the medulla oblongata expends its force directly upon the respiratory function, we beg leave to refer our readers to the following table while attending to the explanations we are about to make—assuming as true that the size of the occipital foramen indicates the size of the medulla oblongata. 
In the first class will be found those Avho have large chests and thoroughly developed animal muscles—those in whom respiration and circulation are greatly promoted by muscular action—those in whom the cervical, thoracic, and abdominal muscles aid the diaphragm in securing the full accomplishment of the respiratory function—those in whom, accordingly, we find a high development of both the medulla oblongata and cerebellum. Such a coincidence, as is here presented, and, as we believe, uniformly obtains, cannot be regarded as one of accident, nor as one of no import. 
Nixon Curry, the first on the list, is the only one in his class who could be, even remotely, suspected to possess a liability to phthisis—his vital forces are not large enough, considering the magnitude of his medulla oblongata—he was a largo and muscular man, without lymph or obesity. 
Now, compare the first class with the third: In this the 


OF THE CEREBELLUM. 
29 
medulla oblongata is equal to that of the first; but mark how inferior is the cerebellum; and mark too, the relation of this inferiority to the existence of consumption ! We infer from the feebleness of the animal muscles of this class, that respiration is mainly sustained by the diaphragm, and, consequently, the superior portions of the lungs are but rarely inflated, and becoming feeble from inactivity, they become the seats of tubercles—for we believe that it is now admitted that tubercles first invade the superior portions of the lungs. 
It is a very general opinion that tubercular consumption is of hereditary origin, perhaps in all cases, but this is not our conviction; while we admit that it is hereditary to a great extent, we contend that certain violations of the procreative laws result in that state or condition of cerebellar development, that disposes to pulmonary tubercle, and the most frequent variety of this violation consists in the marriage of individuals who are too nearly of the same temperament. And we as much believe that a perseverance in dancing, fencing, and public speaking, with a constant change of air, diet, climate, and society will remove the predisposition from those who have inherited it. 
In the second class of subjects, exhibited by our table, it will be seen that the cerebellum is sufficiently developed, but that the medulla oblongata is deficient; and the consequence, is a disposition to adipose deposition—a mode of decarbonizing the blood that predisposes to dropsical affections of the vegetative system, and possibly of both systems; because, in this constitution, we have seen oedema of the inferior extremities, hydrothorax, and ascites. 
We may not be able to give the rationale of the conditions above unfolded to the production of the diseases to which they give origin, but we flatter ourselves that we have produced a permanent foundation for the future observation of others. 
In the fourth division, there are but two cases, and they were introduced for the purpose of a few remarks. Kennedy had altogether a consumptive organization, and when hung may have had tubercles in his lungs. His organ of Amativeness is not larger than that of the Osage and Kaskian Indians, but the difference between the development of the organs of motion and sensation, respectively, explains, or rather confirms 


30 
PATHOLOGICAL RELATIONS 
the rationale previously given with reference to the propensity of the former. 
Davis was more than eighty years of age, and when in the prime of life, was six feet seven inches high and very muscular. For some time before his death, which happened by a mechanical accident, he was much troubled with a cough, and would probably have died of phthisis. As he advanced in age, it would seem that his cerebellum decreased in size, which enables us to understand why it is, as Dr. "Wood remarks, that men over sixty years of age are not the proper subjects for rheumatism. 
In the case of the eunuch, we have put the organ of Amativeness down as absent, and so it appears by external measurement, but internally it existed, but was not more than an eighth of an inch thick. His skull presents an unusually extensive hypertrophy of the social and reflecting regions, produced, no doubt, indirectly, by the feebleness of his vital forces. 
1 2 3 4 5 6 FIRST CLASS. 1. Nixon Curry, alias John Hill 3113 11 7 8 5 2. Piper 32 12 11 6 7 8 3. Loper 33 12 11.1 6 7 7 4. Osage Indian 35 12 10 8 9 8 5. Kaskian Indian 36 12 10 8 ! 8 7 6. Negro man 34 13 11 5 8 7 SECOND CLASS. 7. A patricide, who died of dropsy 32 9.1 9 6 4 5 8. Choctaw Indian do 30 10 7.1 5 6 7 9. Creek Indian chief 33 10 8 5 4.1 5 10. Polish officer 32 9.1 9 8 7 5 11. Spanish pirate 29 10.1 9 7 6 4 12. Natural eunuch 28 9 8 03 3 THIRD CLASS. 13. Fegan, died of consumption 28 11.1 10 4 3 3 14. Negro, do 33 11.1 9 4 5 4 15. Dubois, do 29 11.1 11 43 3 16. A Preacher, do 30 11.1 11.1 5 5 4 17. A German, do 32 12 10 4 6 3 18. Dr. L , do 31 12 10 6 4 3 FOURTH CLASS. 19. Kennedy, hung for rape 30 11.1 9 84 3 20. Davis 27 13 11 2 3 2 
The above measurements or numbers represent eighths of an inch, and the fractions a sixteenth. In the first column is placed the space between the mastoid processes; the second, 


OF THE CEREBELLUM. 
31 
the longitudinal diameter of the occipital foramen ; -the third, the transverse diameter; the fourth, fifth, and sixth, the vertical depth of the cerebellum at the center of the external surface of Amativeness, Muscular Motion and Animal Sensibility. The measurements being made upon the external surface of the cranium, cannot be absolutely correct; but, as all of them are upon an equality, in this respect, the accuracy is sufficient to develop the inferences we have drawn from them. The crania belong to our cabinet, and in each instance we either knew the subject or had correct information of him. 
It will be perceived, by a proper attention to the preceding facts, that a special liability to many diseases, if not to all, is founded in a want of a proper balance, or equilibrium, in the organization of the brain ; and this is indicated, and indeed demonstrated, by an inequilibrium of its various portions ; and, therefore, it is impossible that life can be prolonged, to any considerable extent, by medication; more particularly in those diseases that involve the respiratory and circulatory functions. 
We have incidentally expressed the opinion that the cerebellum performs other functions than those which we have, with a certainty ascribed to it, and these are mere desires—appetites—and the reason why we have supposed it to perform other functions, is its varying modes of development. In some, its greatest development is immediately around the foramen magnum—in others, it extends scarcely more than half the distance backwardly of the occipital foramen, that obtains in other instances. These differences have caused us to suspect that the organs of some executive functions may inhere in it. But without a discovery of these supposed organs and functions, the measurements we have made, with the conditions that were associated with them, authorize some interesting conclusions, beside those we have presented. 
It is well known, that persons like those of the first class, are the most liable to inflammatory affections, and that it is far more easy to augment their vital manifestations than to reduce them; while those who are constituted like those of tho third class, are but little liable to highly inflammatory diseases, and that the vital manifestations are easily reduced, but are again elevated with great difficulty; and hence the danger 


32 
PATHOLOGICAL RELATIONS 
of antiphlogistic treatment in febrile and inflammatory affections of this class. So true is this, that we have discovered, and others have reported to us the same, that a phlogistic course is the best from the very start. 
There are yet to be developed other interesting relations of the cerebellum. In youth, when the cares and responsibilities of life exert but a trifling influence, the tax levied by the cerebrum upon the vital resources is remarkably slight; and hence the cerebellum is adequate to the demands of physical repair and development. As age advances and responsibilities increase, the cerebellum increases, so that at life's meridian, which, from the feebleness of the cerebellum in some individuals, happens at an early period of their history, we have as much of an equilibrium between the size of this viscus and the demands that are made upon it, as will ever obtain—in other words, we have an equilibrium between the vital and the chemical forces, and with the succeeding decrease of the cerebellum, there is a corresponding increase of the chemical forces and decrease of the vital. The facts we have got and have presented, render these relations as demonstrable as any proposition in Euclid. 
In those who correspond with the third class, the vital and chemical forces are too nearly balanced to admit, even in fevers and inflammations, of any reduction of the former. We deny that either class have too much vital force, even when inflammation or fever is present, and those who think that inflammatory manifestations indicate an antiphlogistic treatment, have frequently found their patients of the third class unable to rally, even after a moderate depletion, the pulse in the outset indicating a very contrary condition. 
The preceding facts and illustrations seem to authorize the conclusion that other faculties than mere desires inhere in the cerebellum—that a high endowment of it imparts a corresponding vital capacity to all the parts below —-directly to the animal and indirectly to the vegetative—that it antagonizes the chemical agencies—those which are exerting a constant war upon the fundamental principles of life. 
Every practitioner who has been, only to a small extent, a pathological observer, must realize the truth of the preceding discriminations; and if he will reflect, he will perceive that 


OF THE CEREBELLUM. 
33 
the conditions cannot be otherwise than we have reported them. He knows that a destruction or a paralysis of the sensitive and motor nerves of the whole body, below the head, would deprive him of all chance to restore the patient; consequently, in proportion to their feebleness must be the slightness of the impressions that can be therapeutically made. In keeping with these views, is the uniformly tardy convalescence of all patients who are constituted like those of the third class. Let it be further observed, that the truth of these conclusions does not depend upon the soundness of our views as to the functions of the cerebellum, but upon the figures we have presented. "Whatever may be the views entertained by any one upon the special functions of this portion of the encephalon, it is now demonstrable that the extent and modes of its development, hold certain relations to health, vigor, and longevity. 
Our hopes, then, should be, for the future, founded upon a physiological prophylaxis. We must commence in infancy, and, by a proper physical education, restore the organization to such an equilibrium as shall be compatible with life, health and longevity. In every age of the world, human observation forced upon the thinking portion of society the indispensable necessity of physical education; but it was appreciated more by the ancients than it now is by existing society, and hence they gave more attention to it; and so it is with our existing savage tribes; and we do not believe 4hat the two hundred savage crania, in our cabinet, furnish a single specimen marked like those of the preceding third class. 
As much as we have been among many of our savage tribes, we never saw a case of phthisis pulmonalis; and, in harmony with this fact, we find their cerebelli largely developed, and their cerebral hemispheres peculiarly feeble or undeveloped. Sedentary habits, or extreme old age (which are adequate in their condition to the reduction of the cerebellum) could alone produce in them this disease. 
The moral, social, sustaining, diplomatic, and reflecting faculties, and their corresponding organs in the cerebral hemispheres, are peculiarly human ; and while their support and development depend upon the vital and vegetative forces, their activity and power are antagonistic to the former—evet tending to reduce and to break them down. 
3 


34 
OF THE CEREBELLUM. 
If, now, we will contemplate the neglect of gymnastic exercises, by those children whose parents intend them for scholastic honors, and the ever excited and restless condition of American society, particularly that of our cities—equaled in this respect by the people of no other portion of the earth, we can certainly have no difficulty in comprehending how that condition of the cerebellum is produced, which is ever associated with phthisis pulmonalis,.and why it is that this disease is so frequent in our country. 
The differences that exist between the first and third classes, in the preceding table, and their associated consequences, should dictate a complete revolution in the education of those whose cerebellum is comparatively feeble, or whose cerebral hemispheres are particularly large. The public mind must become penetrated with the conviction that a continuance of life depends upon an adequate endowment of the vital and vegetative systems —that a large and finely endowed cerebrum is of no consequence, without a cerebellum that can impart to it, and maintain in it, a vigorous, and, therefore, a useful action. 
Hitherto, exercise, in the abstract, has been contended for, and particular kinds have been empirically recommended, for given purposes ; but the developments we have made, will enable every physician to decide upon the precise variety that may be required. I In the second Book, this subject will claim our particular attention. 


PART II. 
THE HUMAN TEMPERAMENTS. 
CHAPTER I. 
A REVIEW OP THE PREVAILING OPINIONS ON THIS SUBJECT. 
The constitutional diversities that exist, even in a single race of the species, have, no doubt, engaged the attention of the observing and reflecting from a period far more remote than the earliest recorded history. Sure we are, that attempts were made to classify them, as early as the time of Hippocrates ; and, strange to tell, so far as regards description, little advancement has since been made. 
In every age of medical history, and by every school of medicine, the subject has been regarded so important as to command the attention of the most talented and distinguished physicians and physiologists ; and yet, in this great length of time, and by this immense amount of labor, almost the whole of the advancement consists in the single discovery, that the ancients committed an error in attributing the melancholic to the supposed secretions of the atrabiliary capsules and spleen. 
But the detection of this error was followed by the perpetration of another of equal magnitude—that of attributing this constitution—a supposed physiological state —to a deranged or pathological condition of the bilious. 
The moderns have committed another error, of no less magnitude, in founding what they have been pleased to denominate the nervous temperament on a pathological stato of the 
35 


36 
REVIEW OF PREVAILING OPINIONS] 
nervous system. This temperament, says Professor Dunglison, like the melancholic, is " seldom natural or primitive." It is morbid, or secondary, being induced by sedentary life, sexual indulgence, or morbid excitement of the imagination from any cause. To found a physiological condition of the system upon a pathological one, appears to be a gross violation of all sound philosophy. 
We define Temperament to be a mode of animal being, sui generis, compatible with life, health, and longevity. This definition agrees with Professor Dunglison's in every essential point; and with it the ancients were consistent; they founded the melancholic constitution upon two supposed physiological facts; but the moderns have been anti-philosophical enough to found two physiological states upon two pathological ones— and that, too, in violation of their own definition ; for it cannot be concluded that life, health, and longevity are compatible with pathological conditions of the system. 
The classification and doctrines usually adopted are those of Bicherand; consequently, before attempting to advance anything new, it will be proper briefly to review them, and even some others which are not without advocates. But, before proceeding to the discharge of this duty, it may be well to observe, that no one will doubt that it is conformable to natural law, to infer that where there is an equal number of similar organic parts, there may be induced an equal number of similar organic changes. Negroes, Indians, Malays, and Mongolians, have as many, and similar, organic parts as the white race; and, consequently, are liable to the same peculiar organic changes. It may, therefore, be physiologically supposed that the same constitutional peculiarities that distinguish the white, may also distinguish the other races. In making the proposed reviews, it will be necessary to bear these remarks in remembrance. In the examination of this subject, we shall quote from Professor Dunglison's Physiology, which presents as correct an account of what is known upon it, as any work with which the profession is acquainted. 
The Sanguine Temperament is characterized by a " ruddy complexion, animated countenance, firm flesh, light hair, fair skin, blue eyes, quick conception, ready memory, lively imagination," etc. The further account given of it by various 


ON HUMAN TEMPERAMENTS. 
37 
writers, amounts to about this: The sanguine man is only fit to love; to feed ; to indulge in every species of sensuality ;, to be a friend in prosperity, and a coward in adversity. Such unqualified generalizations are unworthy of philosophers. When it shall be known that two of the most distinguished of the human race were sanguine men, this class of the species, at least, will know how much physiological opinions are generally worth. 
Have not some Negroes, Indians, Malays, and Mongolians firm flesh, quick conception, ready memory, and a lively imagination ? And yet, none of them have a ruddy complexion, light hair, and fair skin. How, then, shall we know a sanguine man of the universally dark-skinned races ? If there is any truth in the doctrine of the temperaments, it should have as discriminating an application to the colored races of the species as to the white. 
In the description of the Bilious Temperament, there is not a single circumstance named which does not occur in other temperaments, except the brown color of the skin and the dark hair; and these peculiarities are common to all Indians, Malays, and Mongolians. And yet, all the individuals of these races are not of the bilious constitution. 
It is a remarkable circumstance, that physiologists, almost without exception, have classed all the great men of the world under this head; and, as strange as it may appear, in doing so, they have violated their own definitions. Under this head they have classed Peter the Great, Cromwell, Julius Caesar, and Napoleon; and General Washington, too, and probably by this time General Jackson and General Scott are placed in the same category. 
How can physiologists venture upon such violations of all scientific discrimination, for the shallow and unworthy purpose of supporting a mere hypothesis ? Bonaparte, Cromwell, and Julius Csesar had bluish gray eyes; Bonaparte and Peter the Great did not possess the firm muscle and sharp outline of the bilious man ; and Washington had light hair and blue eyes. Hence, it appears, that there have been some great men who were not of the bilious temperament. 
In the Melancholic Temperament, we are informed that " the skin assumes a deeper hue than in the bilious; the 


38 
REVIEW OF PREVAILING OPINIONS 
countenance is sallow and sad; the bowels are torpid, and all the excretions are tardy; the pulse is hard and habitually contracted ; the imagination is gloomy, and the temper suspicious." As we are not informed of the precise depth of " hue" in the color of the bilious man, we cannot judge, with any accuracy, as to the complexion of this temperament; it may be presumed, however, to be about that of our Indian tribes. The balance of the description applies with much accuracy to a bilious man laboring under a chronic disease of the liver. 
This temperament, furthermore, is founded upon no anatomical or physiological condition of the system. From all that has been said about it, by modern physiologists, it must be regarded as a pathological condition of the portal system ; and yet they have treated it as a physiological or normal one. 
In the Lymphatic Temperament, "we find soft flesh; pale skin; fair hair; weak, slow, and soft pulse," etc. It is probable that any observer might distinguish a lymphatic negro from any other, by his soft flesh and shapeless body; nevertheless it is not true that a lymphatic negro, Indian, or Malay has a "pale skin and fair hair." 
Great importance has ever been attached to a knowledge of the temperaments in the practice of Medicine ; and yet the knowledge of them that has been acquired, has proved to be scarcely of any avail. The primitive temperaments are but rarely met with, and what is generally known of them, even by the ablest physiologists, is so inconsiderable as to render the combinations unintelligible, and, of course, the whole subject unimportant in practice. 
Phrenologists are as much in the dark on this subject as are the physicians ; they are compelled to be informed of the temperament of an individual before they can venture an opinion upon his character, from his skull or bust. 
Inasmuch as the Edinburgh "Phrenological Journal and Miscellany," and the American "Annals of Phrenology," have highly complimented the views, on this subject, of F. Thomas, D. M. P., of Paris, it may not be uninteresting, nor without utility to review them briefly. 
In his classification there are three primitive or elementary temperaments —the encephalic, thoracic, and abdominal—and, 


ON HUMAN TEMPERAMENTS. 
39 
by the combination of these, he produces four others — the mixed, encephalo-thoracic, encephalo-abdominal, and the thoracico-abdominal: making in all, seven. 
It cannot be discovered that this system is more practically useful than the other. It has, however, the merit of being equally applicable to all races, and in being founded upon real anatomical conditions. But his treatment of the subject shows that with him, it is a mere theory—more plausible than useful — that it is not the result of extensive observation and generalization. 
A single illustration will show that his system can be of no use in the practice of medicine. A walk of twenty minutes in any one of our cities will discover men who possess his abdominal temperament; but in one will be found an active and extensive portal system, while in another it is too unimportant, comparatively, to deserve notice. The pathological conditions of these two are so widely different in any one type of disease, as to require very different, almost opposite — therapeutic agents. This single illustration is enough to destroy his system in the estimation of a discriminating physician. 
He says, that when the brain and lungs are small, and the abdominal viscera are largely developed, we have the lymphatic constitution. He seems not to have known that lymph, in a normal condition of the body, never pervades one part of the system to the exclusion of any other. A lymphatic man, with, relatively, a small head, has never been seen. A man may be fat and have a small head, because the brain secretes no fat. The magnitude of this error is sufficient to place under the ban of suspicion every opinion he has advanced upon the subject. If his statement were true, all lymphatic men would be idiots; but, fortunately, the truth is that some of them are distinguished for their mental abilities. 
He further states, that when the brain and abdomen are small, and the lungs and heart are large, the individual is sanguine. We are confident that this is a condition which he never saw. Can vigorous respiration and circulation be maintained without a vigorous abdominal apparatus ? The brain may be relatively small because of its superior density, which makes ample compensation. 
His encephalic and his encephalo-thoracic temperaments 


40 
REVIEW ON HUMAN TEMPERAMENTS. 
are most certainly and demonstrably one and the same; in the first, he includes the entire encephalon—the cerebrum and cerebellum. Now, it so happens that the cerebrum may be exceedingly large, while the cerebellum may be as remarkably small; and with a small cerebellum, there is a small chest; with a large cerebellum, a large chest—and an exception to this relation between the cerebellum and chest cannot be found in any department of creation. The existence then, of a large cerebellum, implies that of a large chest. "We trust that we have made this matter unanswerably clear in our expositions of the functions of the cerebellum. 
Again, he teaches that when the thoracic and abdominal viscera are small and the brain large, the individual possesses great mental energy. It may be concluded then, that if the little he has of abdominal and thoracic viscera were converted into brain, he would possess still more mental energy.(?) The truth is, that it would be just as philosophical to speak of a large steam engine having or manifesting great power without steam. How is it possible for the brain to manifest great power without vigorous nutrition, respiration, and circulation? Can a Bonaparte, a Cromwell, a Scott, or a Washington be found with small thoracic and abdominal viscera \ 
It is useless to pursue the views of Mr. Thomas any further, except to remark that they are not more inservient to the wants of phrenology than they are to those of medical practice. The phrenologist, when examining a skull, or when comparing certain parts of one with those of another, cannot have before him the chest and abdomen which were, at one time, associated, respectively, with the heads. The ethnologist, in the investigation of national character, from crania, cannot have before him the national chests and abdomens. 
We are not surprised that Mr. Thomas conceived this theory of the temperaments, nor that he placed it before the public; but we are truly surprised that the Scotch and Boston phrenologists should have so highly eulogized it as they have. His, like many others, is a useless theory —plausible until put to the test of extensive observation and rigid comparison. 


ELEMENTARY TEMPERAMENTS. 
41 
CHAPTER III. 
OF THE ELEMENTARY TEMPERAMENTS. 
INTRODUCTORY REMARKS. 
It is generally agreed that very important changes take place in the temperament of individuals; but to this opinion we can only give a very partial assent. We have never known a sanguine man to become bilious; nor a bilious one to become sanguine or lymphatic. We have seen no very important change to take place in any one of the temperaments. The black or red-headed child will show a black or red-headed man. Those persons who possess only moderate powers of assimilation, if mentally constituted to be indifferent to care and responsibility, will become obese; and it is for this reason that children and all of the inferior animals may become fet. Lymph is a very different matter; so different that it is not true, as it has usually been represented, that children are generally lymphatic. Lymph prevails in the brain, in common with all other parts of the body; but this is not the case with fat—it never obtains normally, in the brain. Obesity may occur in several of the temperaments, possibly in all of them, if the mental constitution be favorable to ease and repose. Many, and probably all, normally lymphatic persons, were lean either in youth and early manhood, or during the period of muscular activity, growth, and development; but their heads always indicate their lymphatic constitution; and if they had not become lymphatic they would have become unhealthy and nervous. It sometimes happens, from close application to study, and perhaps other causes, that they do not acquire lymph, and thus the supposed nervous temperament of some authors, originated, we have no doubt, in many instances. 
All the temperaments can be modified by the influence of circumstances; but not to such an extent as to change one into another. The sanguine and the bilious, by early habits of confinement and study, may become more encephalic, or by active and highly responsible positions, they may become, to a 


42 
ELEMENTARY TEMPERAMENTS. 
small extent, a quadruple, as in the case of Gen. Washington. But a sanguine man never becomes sanguine-bilious, nor do any of them ever pass into the equally mixed binary combination ; either element, however, can be strengthened or weakened. 
Wealth may produce, as it frequently does, ease and luxury, and when it happens with those who are not ambitious—who are well endowed with hope and the vital forces—they pass into what some call the abdominal temperament. This condition obtains very frequently in old and wealthy communities; but in new and poor ones, it is but rarely met with. 
Physiologists have attributed every degree of talent, and every peculiarity of character to the temperaments; while the phrenologists have gone to the other extreme. The former were ignorant of the true cause of mental peculiarities, and the latter have yet to learn the range of constitutional influence. It is a little surprising that phrenologists have not discovered that although no single affective or intellectual peculiarity can be assigned, as a distinguishing feature of any one temperament, yet each of them is distinguished from the others by a sui generis outline of cerebral development, such as gives to each a marked outline of character. 
Phrenologists have supposed that the temperaments indicated only to some extent the quality of the brain, but not in anywise its configuration or general functions. If they had taken the trouble to compare the heads of the bilious with those of the lymphatic, they would have discovered their mistake. Professor Caldwell, who has been laboring in the science some thirty years, and in physiology nearly all his life, was sufficiently unacquainted with the subject, as to suppose that we were guided in our discriminations, by the texture of the bone, or some other condition of it, not less insignificant.* 
Various physiologists have adopted different names for the temperaments ; but this is a matter of but little moment, provided we understand and properly define them. The classification with which we have been content, is that of the v.a-cients, with but one exception. We divide them into the sanguine, the bilious, the lymphatic, and the encephalic (which 
? American Phrenological Journal. 


INTRODUCTORY REMARKS. 
43 
we believe to be identical with the melancholic of the ancients ; at all events it agrees with the one of this name in Lavater's works); and their combinations, making in all fifteen. 
The outlines and peculiarities of the several combinations are more easily perceived, by one of our practice, than described. Nevertheless, they soon become obvious to an industrious observer. By the use of crania and crayon portraits, we have found many students who succeeded, by one course of lectures, in distinguishing the temperaments and their combinations in both living subjects and crania. A few soon learn to do it even by chirographic marks. It must be confessed, however, that much difficulty attends some portions of the subject, without the aid of a practical teacher. As complexion of akin, eyes, and hair, in the white race, will greatly aid in distinguishing the temperaments, students, who have not the advantage of a practical teacher, should study the subject thoroughly in this race, before attempting any application of the science to crania and the colored races. 
With these general remarks, we proceed to the consideration of the subject in detail. Our descriptions of complexion, etc., will have reference alone to the white race, and those of crania will apply to all races. 
It should be further remarked of this, as of other departments of natural history, that no description that can be given of a species, will appear applicable to all the varieties, in the judgment of an unpracticed observer. Apparently strong exceptions to the descriptions we shall give, will be found in each division ; but a close investigation will discover that the apparent exceptions consist in a departure from the rule, of only some of the features—enough of them preserving their integrity to determine the species to which it belongs. An unpracticed observer, in looking at the shells that may cover a table, will discover a striking resemblance between individuals of different species, and striking differences between others of the same species — he knows not how to make the first move toward a classification of them; but a conchologist will, in a few minutes, dispose of a majority of them—a few of them may give him some trouble. It is precisely so with the human temperaments. Hence, Professor Caldwell is not the only well informed medical scholar who has manifested an obstinate 


44 
ELEMENTARY TEMPERAMENTS. 
incredulity when first told that we could determine the temperament and complexion by an examination of the naked skull; and this incredulity and obstinacy increased, when informed that we could do the same with equal facility, by chirographic marks. But no naturalist should be astonished or incredulous upon receiving such information; and no philosopher should venture to oppose and denounce such a pretension, before he finds it to be in contravention to some known and established law. 
(GENERAL WASHINGTON.) 
I. SANGUINE TEMPERAMENT. 
Our conception of this constitution is precisely analogous to the mixed temperament of Dr. F. Thomas, and to the tonic one of Dr. Darwin, and our observations have induced us to believe that it is the primitive constitution — that it is the only one that can be regarded as perfectly normal. The strongest reason we have for this opinion, consists in this fact—-we have, in no instance, discovered any indications of degeneracy to result from parents, wherein both of them were of this 


SANGUINE TEMPERAMENT. 
45 
constitution. In another place we shall have more to say upon this subject. 
The picture of the Apollo Belvidere, as drawn by Dr. Thomas, is so applicable to the best or most finished specimens of this constitution, that we cannot refrain from placing it before our readers. 
He says, " not only do none of the three cavities preponderate, but there is a just proportion in the limbs as compared with the rest of the body and with each other; and the bones, muscles, bloodvessels, nerves, cellular tissue, and all the secondary parts, are also in beautiful proportion. This chefd'oeuvre of art represents man in his most perfect type; there is nothing too strong and nothing too weak ; nothing in excess and nothing deficient. Phidias, inspired, has created something celestial!—that brain cannot be the seat of too violent or too impetuous passions, although it can experience them all. The intellectual faculties, sufficiently developed, do not hurry him on to the vagueness of hypothesis and conjecture: his blood is neither too fibrinous nor too much animalized; his abdominal functions are performed with facility ; the chyle is separated and absorbed in sufficient quantity for the nutrition of his beautiful body ; the limbs have all that is required for exercising with the greatest facility all the movements necessary to the whole ; and the physiognomy represents, in all its features, a perfect equality of the whole body." 
This description is not, probably; more applicable to the production of the artist, than it would have been to General Washington and General Scott, in the prime of their lives, or to Tuskena, a sub-chief in the Creek Indian nation, who was the most beautifully proportioned man we ever saw. 
The language which the Marquis of Chastellux has used with reference to the Antique Apollo and General Washington, may be applied to this division of the human race, as a whole. He says that if you are " presented with medals of Caesar, of Trajan, or Alexander, on examining their features, you will still be led to ask what was their stature, and the form of their persons; but if you discover, in a heap of ruins, the head or the limb of an Antique Apollo, be not curious about the parts, but rest assured that they were all conformable to *3iose of a god. Let not this comparison be attributed to en- 


46 
ELEMENTAYY TEMPERAMENTS. 
thusiasm ! It is not my intention to exaggerate, I wish only to express the impression that General Washington has left on my mind ; the idea of a perfect whole,* brave without temerity, laborious without ambition, generous without prodigality, noble without pride, virtuous without severity." 
In fine, the sanguine constitution is just the one for the primeval or Adamic age of the world, in which the only book was nature, and the only duties were those which we owe to our God, our families, and our neighbors—an age in which there were no crowns to covet, nor empires to conquer. It is a constitution in the highest degree compatible with life, health, and happiness; and a source of pure vitality for the population and replenishment of the world. 
Fickleness and inconstancy have long been charged as characteristics of this constitution. Lavater almost hated every ono who possessed a blue eye, and Mr. Cook says, that persons of this temperament are light and inconstant, fitted rather for the companionship of the hour than for the vicissitudes and trials of mortal destiny. " In the gay days of hilarity and prosperity, the sanguine man or woman basks beneath the sunny beam, lively, joyful, and extravagant; but you must not be surprised if you look in vain for this character in the hour of darkness and adversity ; or if it should grow pale at the prospect, when summoned by duty or affection, to walk by your side through the valley of the shadow of death. This is not the temperament of the martyr or hero." Similar opinions, though not expressed in so many words, are advanced by Broussais, Richerand, Good, and others. 
These traits of character are frequently to be found in all of the temperaments, but the exceedingly elastic character of this one, may render it more vulnerable to the charge. The perfect adaptation and equality of strength which marks it, and the purity of the blood that stimulates all its organs into 
* Abating a little of his obesity, incidental to his age, we were similarly impressed with the person of General Scott. He is six feet four inches high, and yet, when seen alone, he does not appear to be above a good average size ; and this is because of the fine proportion of all his parts. We once saw a young lady of this temperament, who was six feet two inches high, and who, when seen alone, attracted no attention, on account of her size, but when seen with other ladies, she appeared as a giantess. There was no want of symmetry in any part of her person. 


SANGUINE TEMPERAMENT. 
47 
action, show that its equilibrium must be easily disturbed by any cause, however inconsiderable; and for this reason, it is evident, that as soon as the disturbing cause is removed, the equilibrium would be restored. This is positively the condition of the sanguine constitution ; hence it follows that it continues to act during the existence of the motive which produced the action. This is the reason why the sanguine man is never absent-minded or abstracted, but is at all times present to all that surrounds him. It matters nothing whether this peculiarity be attributed to the shortness of the posterior lobes of the brain, or to the influence of temperament, because the one always attends the other in this constitution. 
That peculiarity of this constitution which has so disgusted some physiologists, has had the effect to save the whole class from lunacy and suicide. The internal motives with which it is endowed, are usually too feeble and evanescent, to impel them forward after crowns and conquests; but, when engaged in such enterprises, as instruments, there are very few, if any, who prove to be more safe or useful. 
Physiologists define this constitution to consist in a preponderating activity, influence or development of the sanguiferous system. Such a state of it would be pathological, or at least incompatible with health and longevity. It has been admitted that there pervades the whole of it, a perfect adjustment of all its organs and tissues, and therefore, to speak of a preponderating influence, is to admit imperfection and a tendency to disease. The great peculiarity of this constitution appears to consist in the purity of the blood, its thorough distribution and adaptation of all the tissues to its impression. 
This constitution may be usually known by its light hair, blue eyes (not a sky blue, but a mixture of blue and white, or a blue ground with white specks), fair skin, nose usually large and frequently convex on the bridge, lips well defined, having the superior one the more prominent; the limbs and all parts of the body being round, well turned, and more adapted to strong, dignified, and graceful movements, than such as are remarkable for activity or suppleness. 
In consequence of very large perceptive or small reflective powers, the forehead recedes ; the cerebellar portion of the occipital bone, between the mastoid processes, is full and large, 


48 
ELEMENTARY TEMPERAMENTS. 
particularly the lateral portions; the posterior lobes of the cerebrum are short, when compared with those of the bilious; the vertex is, relatively, more elevated; the corona is not fully expanded ; the superciliary ridge is well defined and the glabella is prominent and rough; the head rests more vertically upon the cervical column, than in the bilious, the only one with which it can be confounded. 
Sanguine people readily know or perceive the things and the relations that exist within the sphere of their pursuits and the results that may grow out of them, without the toil of ratiocination. They appear never to reason, and yet their judgment, for soundness, will favorably compare with the best that the race produces. They are not adapted to the inductive sciences, or to sedentary and studious pursuits, but to the active. They are admirably constituted for horticulture, agriculture, the mechanic arts, and the descriptive sciences. Affectively, they are better adapted to occasions that require fortitude and submission, than any other class—they make the best subjects and the best servants, and notwithstanding other physiologists to the contrary, there is none more brave, and certainly none less revengeful. They are furthermore, well constituted to enjoy all the amenities of life, and, as a consequence, they frequently become fat, but they very rarely indulge to intemperance, and still less frequently to brutal excesses. 
When we contemplate the strong and muscular character of this constitution, we should be entirely unable to assign a reason for the fact, that not a single specimen of it is to be found in the English Boxiana, but for that discovery of its internal motives which we have explained. 
The brain of the sanguine constitution is neither so dense nor active as that of the bilious or sanguine bilious. As illustrations of this constitution, General Washington,* General Scott, Lord Cornwallis, Petrarch, and Dr. Caspar Wistar may be cited. 
* In Trumbull's portrait of Washington, the superior part of the forehead is rendered too prominent, and the inferior is not prominent enough. In this wise, the character is weakened rather than strengthened. These faults, as we conceive them to be, we have observed in no other representation of this extraordinary man. 


BILIOUS TEMPERAMENT. 
49 
(abiosto.) 
II. BILIOUS TEMPERAMENT 
Under this head, we have, in the white race, two varieties, which are, externally, exceedingly unlike, and yet they are intrinsically the same. The one has black hair, dark eyes, and brown skin; the other has red hair, bluish gray eyes, and a florid complexion. We regard these two varieties as being essentially the same, and for these reasons: 1st. Black-headed parents have occasionally red-headed children; 2d. The red-headed variety combines with the other constitutions just as the black does ; 3d. The red and black do not combine with each other to the production of a cross; 4th. Their skulls resemble so closely as not to admit of a distinction ; 5th. We cannot distinguish the one from the other by their chirography—the most delicate of all tests ; 6th. Quinine and mercurials have the same effect upon both; and, 7th. Both possess the same special and general character. For these reasons we treat of both as being one and the same. As we have no facts to show conclusively why this difference should exist in the same species, we will not trouble our readers with any speculations on the subject; but we may add that we were engaged many years before the conclusion we have expressed was forced upon us. Physiologists have uniformly taught, that the more florid the complexion the more sanguine the constitution. At one time this was our own impression, 
4 


50 
ELEMENTARY TEMPERAMENTS. 
but close and continued observation, for twenty-five years, has relieved us of all doubt, as to the soundness of our conclusion. It may be possible that the red variety was originally produced in the north, and the dark in the south, or they may represent two distinct races. 
In this constitution, every feature and every articulation throughout the system is attended with angularity and abruptness ; the pulse betrays more activity and the subcutaneous veins more prominence than in the sanguine. The complexion is brown or florid, the hair is black or red, the muscles are more moderately developed than in the sanguine, but they are more dense or firm; the nose is rather large and frequently aquiline, but more frequently, in this country, perhaps, long, slender, and pointed, having the nares well developed and the alse very thin ; the lips are well defined, with the superior one, as in the sanguine, more prominent than the inferior; the forehead, as in the sanguine, recedes, and for the same reason; the posterior lobes of the brain are much developed backward and upward; the hemispheres are less elevated; the corona, as in the sanguine, are not expanded: the cerebellum is more contracted or less developed laterally and downwardly than in the sanguine, but developed more in a posteriorly direction, and the whole head is adjusted more obliquely upon the cervical column. The brain is not usually so large as in the sanguine, but is more dense and much more active. The perceptions, conclusions, and actions follow each other in such quick succession, as to be incomprehensible to other classes of men, and hence they are usually suspected of being rash and visionary. 
Physiologists attribute this temperament to a preponderating influence of the liver and portal circle. This doctrine, to us, is objectionable, because it certainly implies a constituted liability to disease or derangement. As persons of this constitution are as healthy and live as long as those of the sanguine, we certainly have no evidence that the same law of adjustment or adaptation does not obtain as much in it as in the former constitution. The sanguiferous system in this, is about equal to that of the sanguine, except that the organs of its manifestation are smaller, but then, they are more dense and active, which amply compensate for their inferiority in 


BILIOUS TEMPERAMENT. 
51 
size. It manifests as much force as does the sanguine and considerably more energy; it is as easily impressed, but the impression lasts much longer and leads to a greater persistance of action. 
Then what is the cause of the difference between them ? In this: the posterior and superior posterior portions of the brain are considerably more developed, and thereby produce stronger motives to action. But did this cerebral development produce the difference, or did the latter produce the former ? As a sanguine man is sometimes changed into a partially sanguine bilious one, by strong external agents, it may be concluded that the cerebral development and the constitutional difference between the two, were both produced simultaneously, and that when produced, they act reciprocally upon each other. 
As the capacity of this constitution to retain impressions cannot be attributed alone to the cerebral developments above named, we are still called upon to inquire, what it depends upon ? Our own impression is, that the portal system imparts to the blood qualities which have the power, by acting upon tissues constructed in harmony with them, to produce those phenomena, which, taken together, constitute the bilious temperament. 
The bilious constitution is not so elastic as the sanguine—it does not cease to feel, and consequently to act, when the cause is removed; and hence the reason why it is so liable, as it is, to become morbid, even to insanity. The capacity of this temperament to produce great men, has been much overrated. In this respect it differs from the sanguine thus: the great men of the latter are those who discharged with able and distinguished faithfulness the obligations imposed upon them by their country or others in authority; and the great men of the former are those who were impelled to great achievements by a will or purpose of their own. The latter will never usurp the power intrusted to them ; and the former will never surrender it without reluctance. 
As illustrations of this temperament, physiologists have given Mahomet, Charles XII, Dante, Cortez, Pizarro, Charlemagne, Francis I, king of France, and Lady Huntington. They have cited many others whom we know are not bilious, and hence we exclude them. 


52 
ELEMENTARY TEMPERAMENTS. 
This constitution is favorably adapted to the elementary sciences, particularly the descriptive, and to the active pursuits of life; but not to sedentary habits and philosophical investigations. 
In consideration of the very active and muscular character of this constitution, we would, a priori, expect to find in it a proper proportion of professional pugilists, and, accordingly, the "Boxiana" gives us three, Fosbrook, Stevenson, and Cooper. The former two, though pretty good boxers, never acquired much fame. Cooper was a sturdy fellow, and possessed much good sense ; but he was not a scientific boxer; he was, however, " a hard, slashing hitter and a long laster." His battle with O'Leary lasted sixty eight minutes, and ended in the death of the latter, though he was regarded as the best boxer. The decisive blow of Cooper is said to have been thrown out as the last paroxysm of a beaten man. 
VAN-TA-GIN —A CHINESE GENTLEMAN OF DISTINCTION. 
III. LYMPHATIC TEMPERAMENT. 
In this constitution, says Professor Dunglison, " the proportion of the fluids is conceived to be too great for that of the solids; the secretory system appearing to be active, while the 


LYMPHATIC TEMPERAMENT. 
53 
absorbent system does not act so energetically as to prevent the cellular tissue from being filled with the humors." 
For many years this view of the subject satisfied us, as it has no doubt everybody else; but now, we doubt whether the presence of the lymph is not a mere circumstance, which, though incidental, is not essential to the temperament —a mer§ effect and not the cause. Though the lymph is present, generally, perhaps, from childhood, yet it is frequently delayed to the twentieth or twenty-fifth year of age and sometimes to the end of a life extended to fourscore years. 
Now, of what constitution are such individuals ? They are neither the sanguine, the bilious, nor the encephalic. To a scientific observer they are just as distinguishable by the head and the features of the face as they are after the appearance of the lymph. In them, the sanguiferous and portal systems are much less developed than in the bilious ; the hair is light, the nose is pugged, the eyes appear, in some measure, heavy, and are of a dirty blue color, the lips are tolerably thick and their cleft is straight, the forehead is rather square and perpendicular, the head, in figure, is quadrangular and not larger than is common to the dense temperaments, and the disposition is irritable and fidgety. 
As an illustration of this unlymphatic peculiarity of what is denominated the lymphatic temperament, the Reverend Samuel Parr, L. L. D., may be adduced. 
"Independently of his great acquirements and profound erudition, Dr. Parr possessed much of what is called character ; that is to say, he was a man of originality of mind, and differed much from the common herd in his opinions and actions. Yet his peculiarities hardly amounted in any case to eccentricity; they were simply little marks, which caused him to be the observed of all observers—the outward and visible signs which indicated that genius which was more amply developed upon near and closer intercourse." 
" Mr. Porson once remarked, that Dr. Parr would have been a great man, but for his trade, his wife, and his politics." The greatest " fault alleged against him was an infirmity of temper, though tried by early disappointment and difficulty, by pecuniary distress, and by domestic dissension. It is said that he married for a housekeeper, and that his wife married 


ELEMENTARY TEMPERAMENTS. 
54 
for a home. Her dislike to him took every possible form of annoyance. She described herself as having been educated by three maiden aunts, in " rigidity and frigidity, while the doctor had been born in a whirlwind and bred in a storm." 
The truth is, Dr. Parr did not possess a single element of greatness, all that he had was pugnacity and learning—he was only a bundle of little things, which his pugnacity converted into porcupine quills. He was, however, a good illustration of the dry form of this constitution. 
When we have found the lymph present in early youth, it was associated with good health, and we do not know that we ever discovered good health without it. This want of health in youth may so impress the constitution, in many instances, as to prevent its accumulation in after life. This circumstance and the mental irritability, induce us to think it very probable that the presence of the lymph constitutes the normal state of this constitution. 
That it depends upon some peculiarity of the cellular tissue there cannot, perhaps, be much doubt, and to us it seems to consist in part, or altogether, upon an incapacity in its capillary vessels to circulate the red portion of the blood. The skin has an opaque and dough-like appearance—one more indicative of death, than vitality. Mr. Combe says that the skin of this constitution is "clear." He has certainly confounded it with the sanguine lymphatic. 
Upon the appearance of the lymph the head becomes globular and much larger, the eyelids, in a great measure, closed, the cheeks full and ponderous, the nose larger, the lips thicker and the hair longer, finer and thinner. As might be supposed, all the motions of the body are slow and clumsy. The large size and globular form of the head will readily distinguish this from the other constitutions. 
Partly in consequence of the lymph, and of the well-balanced condition of the brain, but mainly for the want of that influence which a highly developed sanguiferous and portal system can impart, this constitution manifests but little energy or enterprise ; nevertheless, in a safe and judicious common-sense, it is not more than equaled by either of the others. 
We saw in Pennsylvania, a female, who was about seven- 


LYMPHATIC TEMPERAMENT. 
55 
teen years of age, so lymphatic that she could not walk, and yet she was rather handsome and very sprightly. 
Many ladies and a few gentlemen are much troubled about their superabundance of lymph. If they will live on dry food, and drink but little fluid of any kind, they will soon reduce themselves to very comfortable dimensions. 
Hogs raised on still-slop become exceedingly lymphatic and unfit for a gentleman's table. All lovers of good ham should regret that our old long-legged, long-nosed, sanguine, and bilious breeds of hogs should ever have been replaced by foreign lymphatic ones, which are fit for little else than lamp oil and soap. 
" Pomponius Atticus, the friend of Cicero, is offered as an example of this temperament, in ancient times, and Charles IV of Spain, who resigned himself almost wholly into the hands of Godoy; Augustus, king of Saxony, who equally resigned himself into the hands of Napoleon, and Ferdinand, of Sicily, who surrendered for the time the government of his people to the British," are given as examples in modern times. 
The above worthies may all have been lymphatic, but as physiologists have agreed, or apparently so, to regard all great men as bilious, so they may have agreed to consider all the passive ones as lymphatic. From the bust we have seen of Socrates, we look upon him as a fine specimen of this constitution; and although he never manifested much enterprise, yet the moral and intellectual excellence of his character is sufficient to redeem the whole class. 
The illustrations which are usually given of this constitution, and, indeed, of the others, are caricatures—libels upon human nature. Van-ta-gin, the Chinese gentleman of distinction, whose portrait is here presented, gives as perfect an idea of this constitution as can be conceived of. In Colonel Washington (American Portrait Gallery), the lymph so preponderates over the sanguine and bilious elements of his constitution as to render him a pretty good specimen. Between him and Van-ta-gin there is a strong family resemblance, although they are of different races. In this constitution mercurials are inadmissible, because of the feeble influence of the portal system; and quinine only in small portions. 


56 
ELEMENTARY TEMPERAMENTS. 
(eev. db. eeinstadt.) 
IV. ENCEPHALIC TEMPERAMENT. 
This temperament was suggested to us, after a close observation of five years, in search of the anatomical foundation of the fourth or melancholic constitution, by seeing a boy, who was about sixteen years of age, in Professor Hall's college in the city of Baltimore. He was as much like Father Reinstadt (a native of Switzerland, a clergyman, recluse, and scholar, whose portrait Lavater introduced into his work on physiognomy, as an illustration of the melancholic temperament), as a boy can be like a father. He had a large and well-formed head, but his thorax, abdomen, cerebellum, muscles, and bones were all particularly small and feeble. 
If the ancients had attributed the melancholic temperament to a great development of the cerebrum, particularly the hemispheres, when compared with other parts of the head, and the head with the general system, instead of the biliary capsules and spleen, they would have been correct. 
When we saw this boy, we could discover no reason why a great endowment of the cerebrum was not as much entitled to 


ENCEPHALIC TEMPERAMENT. 
57 
make its mark on the constitution, as that of any other apparatus. So far as we have read, and we have read everything on this subject that we have been able to find, we are the first to have conceived of such a temperament. 
In the encephalic constitution of Dr. Thomas, the whole brain is referred to ; his view of it, therefore, includes too much—it embraces parts which have but little or no relationship in function—the cerebellum is appropriated to the vital functions, and the cerebrum to the mental; with a high endowment of the former, we always find a corresponding one of the sanguiferous and muscular systems; and with the latter, only mental phenomena. 
The nervous temperament, as hitherto understood, is described as having a small head and a great irritability of the nervous system. Professor Dunglison says, that the susceptibility of this constitution to excitement from external impressions, is unusually developed; and, like the melancholic, it is " seldom natural or primitive. Mr. Combe says, that " the whole nervous system, including the brain, is predominantly active " in this constitution, " and the mental manifestations are proportionally vivacious." 
In our review of the prevailing opinions upon this subject, we showed that the so called nervous temperament was confessedly founded in a pathological condition of the system; we will now add, that it exists essentially in a degeneracy of the vital forces of the sanguine encephalic, sanguine encephalobilious, and sanguine bilious constitutions; produced by sedentary habits, vitiated air, or excessive indulgence of the propensities. It is generally associated with a liability to pulmonary diseases. In fine, it obtains in an entailed preternatural activity of the nervous system and an imperfect and feeble development of the vital; producing, on the one hand, genius; and, on the other,infirm health and premature death. If these remarks are true, it requires no argument to prove that such a condition of the system is not a physiological one, and, therefore, cannot be compatible with life, health, and longevity. 
The third class in Table, page 20, furnishes illustrations of the sanguine nervous and bilious nervous temperaments, according to modern physiologists. 


58 
ELEMENTARY TEMPERAMENTS. 
Between these views of the nervous temperament, and ours of the encephalic, it will be found that there is no similarity. We taught our doctrine of the latter as early as the fall of 1832, in the city of Baltimore, and quite extensively through Virginia during 1833 and 1834, and, in Cincinnati and New Orleans, in 1835, and more or less ever since, in the southwest. 
We claim to have discovered the anatomical source of that fourth element in human physiology, which the ancients and moderns have both recognized to exist, and which the former denominated the atrabilious or melancholic; and we have introduced the preceding circumstances as authenticating the period when we made the discovery and the notoriety which it has since obtained. 
Professor Caldwell,* excellent authority in medical history, has said, that if we could determine the temperaments by the cranium, the discovery was our own, and, to do this, with the combinations, it is obvious that we must have discovered all the material conditions involved in the primitive ones. Notwithstanding all this, if any one will show that he taught these views, at a period earlier than we did, we will cheerfully abandon all claim to them. 
This constitution may be known by its light, long, lank, and fine hair; dirty blue eyes ; thin and rather small nose, inclining upward at the extremity; thin lips, having the inferior one the more prominent; pointed cheek bones, because of the great thinness of the facial muscles; the forehead being large and projecting; the large and somewhat quadrangular form of the head ; the relative smallness of the cerebellum ; the contracted thorax and abdomen ; the small and stingy character of the muscles; the motions being slow and dragging; the skin pale and opaque; the countenance serious, bordering on gloominess, and by the tardily performed functions, both animal and vegetative. 
The most distinctive and readily-perceived indication of this constitution, is the full and expanding character of the hemispheres throughout the whole extent of the parietal ridges and 
* American Phrenological Journal. 


ENCEPHALIC TEMPERAMENT. 
59 
the superior portion of the forehead.* The lateral portions of the cerebellum are particularly feeble and the nervous system is but tardily impressed by external agents. 
One of its remarkable endowments, is the extent and development of the venous system; and it must perform as distinguished a part, as the portal system does in the bilious. 
As there is, in this constitution, but a little action, so there is but little liability to disease. For the same reason, metamorphoses go on very slowly; and hence there exists no necessity for a rapid or vigorous assimilation. But, notwithstanding its feebleness, such is the adaptation of all its parts that it is compatible with health and old age. 
This constitution is compatible with great learning and profound discrimination; but all the mental functions, though accurate, are tardy and feeble, like the animal and vegetative; and consequently no great achievement can be expected from it. 
Dr. Thomas has stated, that when the brain is large, and the thorax and abdomen are small, there is great mental power. "Where does this power come from, if not from the thorax and abdomen ? We have never known a vigorous thinker who did not possess a well-developed thorax and abdomen. Men with small heads and large chests have achieved great results, but those of large heads and small chests have never become distinguished in the active concerns of life, and very rarely in any other. 
This, and the preceding constitution, are very rarely to be seen in their extreme purity; but their combination with the sanguine and bilious, constitutes at least one half of society. The encephalic element in the constitution of Hon. Edward Livingston, the Hon. Lewis Cass, and Dr. Franklin, is remarkably conspicuous. Men of the encephalic constitution are few, and these have not become distinguished, hence it is difficult to obtain ample illustrations. We have seen several well marked cases of it, some of which were as good as Father Reinstadt, whose portrait is here presented as a fine illustration. 
* A small admixture of it, in combination with the other constitutions, can t* >\m 


ELEMENTARY TEMPERAMENTS. 
60 
Dr. J. Mason Good regards Tasso Torquato as a specimen of this constitution, but I think it more than probable that he was bilious encephalic, with the latter element predominating. He had what is common to the encephalic, a precocity of genius. At the early age of seventeen years he was honored with degrees in the four branches of canon and civil law, and theology and philosophy. He wrote many poetical works, but finally became too much deranged to be useful. He was sparing of words, sedate and grave in manner, and in conversation displayed but little of the fire that animates his works. All this is highly characteristic of this constitution. 
In consequence of the great feebleness of the vital forces, this constitution becomes almost incapable of an effort by or before the meridian of life. Yery many of our most intellectual lawyers and divines, being highly encephalic, begin, by thirty, to feel their feebleness, and then resort to ardent spirits to obtain that force which nature had denied them, but which they might have acquired by early and constant exercise ; but as they have no desire for action, they live in inactivity, not apparently knowing that without a strong body they cannot possess effective minds. 
In the scholastic walks of life, there is a constant tendency 
to the degeneracy of the vital forces, with a corresponding increase, either positive or relative, of the encephalic element, of all the combinations in which it obtains. Those who possess it should therefore make it a law of their lives to blend with their mental pursuits some variety of muscular employment. This is a good doctrine for all persons, but more especially for the encephalic classes, to whom it is especially addressed. 
We have deeply commiserated many lawyers and divines, who had become learned and manifested intellect and accurate discrimination, but who had no resource for that life-moving eloquence without which the masses of mankind cannot be effectively influenced. They had no corps de reserve for that reinforcement of their minds upon important emergencies. The truth is, we have many farmers and mechanics who could quell a mob by the energy of their voice or, a penetrating glance of their soul-stirring eyes, while many of our erudite and intellectual lawyers and divines would utterly fail. Is not 


ENCEPHALIC TEMPERAMENT. 
61 
this humiliating, more especially as they have brought it upon themselves, or promoted it by a neglect of that law of God's kind providence which he intended should make them men and not women ? As an illustration of this important principle, we will introduce a case. 
While traveling through Tennessee, a young lawyer called upon the author for a phrenological opinion of himself. He was bilious encephalic, with a great preponderance of the latter element. We told him that he had a very fine head, but, unfortunately, he could apply it to no useful purpose. This surprised him, and caused him to demand of us an explanation of our meaning. We told him that his vital forces were too feeble to throw his brain into effective motion. " Then," said he, "what shall I do to be saved?" We answered, "Follow, sawing and chopping wood, walking and running, but, above all, fencing and dancing." 
Ten months after this, we met with him, and such was the enlargement of his neck and thorax, that, at first, we did not recognize him, but when we did, we gave him our hand, remarking at the time, " You must have taken our advice ?" " Yes," said he, " I have not omitted it a single day—I have labored, and I have a black fiddler who plays for me, and I make the young negroes dance with me when I cannot do better." He is now, we have learned, on the bench. 
Did this young man do too much to make an effective man of himself? If our talents are not worth improving and our lives preserving, then certainly, they are not worth the having.* 
* If the fact is not universal, it is as least very general, that those who die of phthisis pulmonalis before the forty or forty-fifth year of their age, have not a large head—the cerebrum is not remarkable for its size, even in relation to a comparatively small cerebellum. And we showed, when treating of this viscus, that the phthisical constitution consists in a disproportion of development between the medulla oblongata and the cerebellum. In the encephalic constitution, the cerebrum is large, but the medulla oblongata and cerebellum are Doth small, and upon this condition depends the venous or anti-phthisical condition of the encephalic constitution. 


62 
BINARY COMBINATIONS OF 
CHAPTER III. 
THE COMBINATIONS OF THE ELEMENTARY TEMPERAMENTS. 
INTRODUCTORY REMARKS. 
In approaching the consideration of the combination of the temperaments, it may be truly said, that we are venturing upon an uncultivated field. Nothing definite or descriptive has ever been written on the subject. If we consult authors on the primitive ones, we obtain nothing that can enable us to infer the combinations; indeed, all that they have given us amounts to about this: the sanguine man is a toy for the ladies—the creature of folly, extravagance, and dissipation;— the bilious man is the only great one, and he is so, simply because he has a great liver; —the lymphatic man is a disgusting sack of humors ; —-and the melancholic man is a poor, gloomy, miserable, liver-diseased wretch, whom it would 1 be a mercy to dispatch. 
If we shall then mix with the profession in the discharge of its active responsibilities, we shall obtain no additional light, and yet, all of them feel the great importance of the subject. The primitive temperaments are but rarely met with, hence it is impossible that one physician in a thousand can have any knowledge of them, and from what has been written, the combinations cannot be distinguished, hence it must be conceded that an accurate description and illustration of them cannot be an unacceptable service. 
I. BINARY COMBINATIONS. 
I. THE SANGUINE-BILIOUS TEMPERAMENT. 
In this constitution the head is smaller and the brain more dense than in any other variety of the species. A sight of the skull, at once, gives the idea of compactness. The poste- 


THE ELEMENTARY TEMPERAMENTS. 
63 
rior lobes of the cerebrum are more developed, relatively, than in the sanguine, and the anterior ones are usually more perpendicular than in either of its elements ; and this, we think, results from a less development of the perceptive powers. The superciliary ridge is, perhaps, invariably less marked—less prominent than in the sanguine or bilious. The forehead is never expanded ; the nose is usually straight on the dorsum ; the lips are moderately thin and of equal prominence; the cerebellum is never so developed as to lead to brutal excesses; the chest is round; the abdomen is slender but in a fine relation to the chest; the person is very erect; the muscles are slender, but very compact and strong; the bones are relatively well developed ; the motions are all prompt; the skin, where excluded from the light, is very white, quite unlike the sanguine or bilious ; the hair is coarse, thickly set, and black, or between a light and a red; the eyes are of a deep blue or bluish grey ; the skin of the face and hands, if much exposed, becomes of a light tan or a red tan color. In cases where the sanguine element preponderates, the hair may only be brown or sandy; and if the bilious element preponderates, it will be black or red. 
The vegetative functions are usually performed with great energy, and, comparatively, but little liable to derangement. The tenacity with which this constitution clings to life, has no parallel. We saw a negro woman, who was exhibited in Cincinnati, several years since, as a curiosity, on account of her extreme age—one hundred and twenty-seven yeara —and from documentary evidence presented, the statement of her age was probably correct. She was said to have been a nurse of Gen. Washington. She had totally lost her eyesight, but her hearing was good. 
No other temperament can endure as much fatigue and exposure—it seems to have been intended for muscular action. In consideration of these capacities it is well adapted to a military life, to which very many of this class are much disposed. 
Men of this class are principally adapted to mathematical, astronomical, chemical, and military sciences. They have not, however, that power of plan and system of movement, requisite for such positions as were filled by Bonaparte, Washington, and Scott. For subordinate positions they are 


64: 
BINARY COMBINATIONS OF 
perhaps the best. For mental toil, under responsible and vexatious circumstances, they are not adapted—they become irritable and then rash. A capricious temper, is, so far as we have observed, a universal attendant upon this constitution.* 
Powell, the London pedestrian, was a fine specimen of this constitution. In the English "Boxiana" there are several fine illustrations, and among them is Bill Neat, the English champion. The battle he fought that gave him his title of champion, was with Thomas Hickman, commonly called the Gaslight-man. Hickman rested his hopes upon his science; Neat, though not without science, placed his hopes upon his muscular strength and activity. 
Men of this constitution are generally so light, that their strength is usually underrated, more especially by those who have large muscles. It was in this way that Hickman was deceived in Neat. When he first saw him, he said, in allusion to the contemplated fight, " Oh ! I'll take the shine out of him in seven minutes." Hickman is not the only one who has been thus deceived. 
Illustrations—Daniel Boone and General Jackson. 
II. THE SANGUINE-LYMPHATIC TEMPERAMENT. 
In this class of our race the skin is white and clear, and apparently translucent, with a delicate glow of the rose in the cheeks; the expression of the eyes is generally soft and agreeable; their color is but little above a sky-blue ; the hair is light, rather thin and soft; the lips rather thick and of equal prominence ; the nose rather short and straight upon the bridge or dorsum ; in this respect a variation in the proportion of the elements will make a difference in favor of the element having the preponderance. 
The outline of the person is full, plump, and soft; the motions of the body are rather slow and waddling ; the back of the neck is broad, and so is the entire base of the head; the temples are highly filled; the corona is round but not expanded ; and the whole head is nearly as round as that of the full 
* A knowledge of the therapeutic compatibilities of the primitive temperaments will be a guide in the combinations. As we have done but little medical practice since becoming conversant with this subject, our readers have a fine field for discovery in the relation that exists between it and therapeutics. 


THE ELEMENTARY TEMPERAMENTS. 
65 
lymphatic, but not usually so elevated. In the eyes of lean and dark-complexioned men, the females appear to be peculiarly beautiful. 
We infer from a bust we have seen of Nero, that he belonged to this class—his character certainly harmonizes well with its criminal and degraded extremity. William Wirt, deceased, of Maryland, was of this constitution, with a slight preponderance of the sanguine. The "Boxiana" does not furnish an illustration. The tendency of this constitution is not to fight, but to kill. 
As an illustration of this temperament, we refer our readers to the portrait of Judge Story, who, as a jurist, stands, we have no doubt, deservedly high'—higher, we conclude from his organization, than he could possibly stand in any other position. He is constituted to reverence the law, and to possess, more generally than most men, an unbiased judgment. His head is more elevated than we have before seen in this constitution ; and though elevated, it does not present the least indication of possessing a particle of the encephalic temperament. Compare it with the sanguine encephalo-lymphatic, the only constitution with which it can be confounded, at the parietal level of the head, and the difference becomes marked and obvious. In the decline of life his lymph appears to have been absorbed. 
III. THE SANGUINE-ENCEPHALIC TEMPERAMENT. 
In this temperament, the hair is light and rather fine ; the eyes are of a pale blue; the lips are of moderate thinness, and the inferior one slightly the more prominent; the nose is slender and straight on the dorsum, when the elements of the constitution are well balanced ; the skin is fair, but less clear than in the sanguine lymphatic ; the person is light and slender; the muscles are thin and flaccid; the bones are small and have but slight muscular impressions. The lateral portions of the cerebellum are feeble, and therefore the neck is thin and small; the posterior lobes of the cerebrum are frequently much developed ; the temples are even or depressed; the forehead is nearly vertical and superiorly full and expanded ; the superciliary ridge is very slightly developed ; the lateral portions of the head are flattened, and the superior, at the parietal 5 


66 
BINARY COMBINATIONS OF 
ridge expanded; and a line drawn from the condyles of the occipital bone to the inferior extremity of the superior incisores, will be very nearly parallel with the top of the head. No function of the system, whether animal, vegetative, or mental, is performed with energy. 
This temperament, like one of its elements, is not adapted to the practical conflicts of life ; nor is it fitted for the development of science. It is measurably confined to schools, colleges, and the three professions. The less gifted class of them never take rough and rugged trades — they are jewelers, tailors, etc. 
Among the individuals of this class may frequently be seen learned and literary men, and occasionally a painter or a poet. They are usually conservative, because they have not sufficient constitutional force to brook the thought of, and much less to contend with, revolutionary movements. We express this only as a general fact, to which of course there are exceptions. 
Illustrations—W. White, D. D., formerly of Philadelphia, Cowper, Ghanning, and Yoltaire may be cited as illustrations, and they constitute a literary constellation. 
In this constitution, mercurials and venesection should never be used; and quinine and morphine with much prudence— the former having much power to materially injure and even to destroy the sense of hearing 
IV. THE BILIOUS-LYMPHATIC TEMPERAMENT 
In this class of men the lateral diameter of the head is less, and the occipitofrontal is relatively greater, than in the sanguine lymphatic. Like all the varieties of the lymphatic, there are no sharp angles about the head, face or person. The face approaches an oval; the superciliary ridge is well defined, but not so prominent nor sharp as in the sanguine or bilious ; the superior sentiments are usually well developed, giving a handsome finish to the top of the head. The forehead usually recedes, but less than the bilious; the posterior lobes are of medium length and tolerably broad; the cerebellum is well developed, but laterally, not so much so as in the sanguine lymphatic. The person is full, plump, and round ; the nose is respectable for size, and though usually straight on the dorsum, it is sometimes aquiline, and sometimes pugged. The 


THE ELEMENTARY TEMPERAMENTS. 
67 
lips are tolerably thick, and of equal prominence ; the hair is fine and brown, or it is fine and yellow or sandy, attended with sandy whiskers; the complexion is brown with a tinge of red, or it is reddish and freckled; the eyes are brown or bluish gray. The females of the dark variety are generally regarded as beautiful. Such beauties are said to be quite common in Mexico. Many of them occur in our southern states. 
Not many of this class become distinguished, indeed, it may be said, that they constitute an unambitious class — seeming to care but little for notoriety or distinction. No class of men possess a clearer or sounder judgment, or more simple or artless manners. Yery few of them visit the penitentiary, but too many of them do the beer-shop. 
The English " Boxiana " furnishes one who became distintinguished for his pugilistic abilities. From this reference it will be perceived that the constitution is not without muscular power and activity. 
As illustrations of this class, we may cite the following: Raphael, General Nathan Greene, W. Pinkney, Rev. L. L. Ilamline, Aaron Ward, ex-member of congress from New York, Alexander W. Buel, member of congress from Michigan, and President Filmore. 
This class bears mercurials and quinine much better than any of the sanguine varieties, nevertheless, when there is lymph, we should be cautious. 
V. THE BILIOUS-ENCEPHALIC TEMPER AMEN T. 
This is, emphatically, the temperament of philosophy. In this class is to be found some of the most distinguished philosophers of every age. By a union with the encephalic, the impatience and irritability of the bilious is removed, and a large development of the front lobes is secured. It is incomparably more favorable to the development of a highly masculine character than the sanguine encephalic. 
In this constitution we find heads which have their occipitofrontal diameter as high as eight and a-half inches. Laterally, they are flattened ; the anterior and posterior lobes are highly developed in length, but it is not common for them to be highly expanded at the base. The cerebellum is not, laterally, highly endowed—not so highly as to incapacitate for 


68 
BINARY COMBINATIONS, ETC. 
sedentary habits, to any required extent, and not so feeble as to deny to the possessor a respectable share of muscular ability. When the encephalic preponderates, as it very frequently does, then the cerebellum is feeble, and so are the animal and vegetative functions. No constitutional class of the species furnishes such extremes, in strength of character. Some are guides to the species, while others have scarcely force enough to maintain existence, and yet intellectual. 
In this class, the whole forehead is fully developed ; and, as in all who partake of the encephalic, the parietal or superior lateral portions of the head are quite prominently so. The intellectual and moral capacities of this class so preponderate over the propensities, that they are but seldom seduced into gross vice or crime. 
Those who shall become familiar with the bilious head, will have only to add to the superior portions of the frontal lobes, and the superior lateral portions of the hemispheres, to distinguish this from any other. 
The hair is fine and brown or sandy; the skin is dark or bilious, or it is reddish, without much apparent life, or it is such as contra-indicates much cutaneous circulation. The eyes are brown or bluish gray ; the nose is unusually straight on the dorsum, or a little aquiline, or a little of the opposite curve; the lips are of moderate thickness and usually of equal prominence, but the inferior one commonly turns a little out at its upper edge. There is a difference between* the brown and the red varieties in this respect: the former are inclined to the physical sciences, and the latter to the abstract. 
Mercurials, quinine, and morphine are as compatible with this constitution, as with any other. We have never seen but one man of this constitution in states' prison, and he was in for counterfeiting a bank-note plate — he was an able engraver. 
The " Boxiana" furnishes one specimen of this constitution—Tom Owen, the conqueror of Bully Hooper. He was true to his constitutional predisposition : he gained his battles by his science. Few boxers, it is said, have fought more battles than Tom Owen. In the character of a second, he was inferior to no one on the list. 
As illustrations of this constitution, we may cite Lord 


TERNARY COMBINATIONS, ETC. 
69 
Bacon, Professor Caldwell, the late Chief Justice Marshall, and Professor James Jackson. 
It is in this constitution, and the encephalo-bilious lymphatic, that the mistake of attributing all the great men of the world to the bilious temperament, originated. If, however, they had been placed in these classes, it would have still been a great error. 
VI. THE ENCEPHALO-LYMPHATIC TEMPERAMENT. 
We have never seen a specimen of this constitution, nor can we conceive it to be possible that such an one could be produced in this country. By inference, we conclude that it may exist. In the study of thousands of prints we have seen but one that we could not place under some other head. As the character and person of this temperament can be inferred from its elements, and as twenty millions of inhabitants do not probably produce an illustration, it cannot be considered to claim further attention than we have given it—a place in our classification. 
As, however, the sanguine encephalo-lymphatic is frequently met with, even in this country, it is highly probable that in Holland the encephalo-lymphatic elements may so predominate, in some instances, as to constitute such a constitution. 
II. TERNARY COMBINATIONS. 
I. THE SANGUINE BILIOUS-LYMPHATIO TEMPERAMENT. 
This combination produces a greater variety than any other. Illustrations of it abound plentifully in every walk of life, in every grade of society, and in every degree of virtue and vice—and always practical. 
The individuals of this class, while living, are very distinguishable from all others, but the differences between the crania of this and some others are much more easily perceived, by a practiced eye, than described. The skull, however, cannot be mistaken when it is at all balanced, for that of any one \Jt the lean varieties; because it is not so angular. It is 


70 
TERNARY COMBINATIONS OF 
neither so large nor so round as the lymphatic, nor is it so round as the sanguine lymphatic; the posterior lobes are more, and the middle lobes are less, developed; the cerebellum is developed downwardly more, and laterally less ; the glabella and superciliary ridges are much more rough, and the general texture of the bone is less close and compact. 
The person is full, and usually has the appearance of considerable solidity. The muscular movements are much more active and ready, than we would, a priori, imagine, and in the abstract, inferior to no other in muscular strength. 
The complexion is about that of the sanguine bilious; the hair is coarse and brown or reddish ; the eyes are of a bilious blue or bluish gray; the lips are tolerably thick and of equal prominence, but never, or very rarely, beautifully denned ; the nose is rather short and straight, or it is pugged, and sometimes aquiline, depending upon the preponderating element. Apoplexy frequently occurs in this constitution. 
The "Boxiana" furnishes about twenty specimens of this constitution, and Jack Broughton stands at the head of the list. He maintained the championship of England for eighteen years. In the prisons of all of our states a list proportionally as large as the preceding, can be found. They are a busy set of fellows in mobs and riots. They are very generally courageous, gregarious in their attachments, and generous in their deportment. 
As illustrations of this constitution, we may cite> among the distinguished, Baron Larry, Professor Hare, Stephen Girard, Pope Leo X, Major-General Henry Knox, Dr. Spurzheim, and Lawrence Kearny. 
II. THE SANGUINE ENCEPHALO-BILIOUS TEMPERAMENT. 
This constitution, like the preceding, in consequence of comprising three elements, produces a great number of shades or varieties. At one extreme, we find a high grade of the encephalic, and on the other a close approximation to the sanguine or the bilious, but more frequently to the sanguine bilious. It is far more fibrous and enduring than the sanguine encephalic; more intellectual, that is, more expanded or various than the sanguine bilious, but less tough and less tenacious of life. When once seen and designated, in the white race, 


THE ELEMENTARY TEMPERAMENTS. 
71 
it will very rarely escape detection. It possesses usually, a higher degree of susceptibility than any other constitution. It is really the most nervous, and when pretty equally balanced, it is highly vivacious. 
In this constitution are to be found many of the masters of the fine arts—it might, with considerable propriety, be called the artistic temperament. Some of the finest specimens of the race are found in it, and if the information we have received be correct, it comprises a large proportion of the Caucasians. 
Although the crania of this variety are readily distinguished by a practiced eye, yet it is difficult to describe it so accurately as to designate all the shades of difference. The head, however, is usually about the size of the sanguine encephalic, possibly a little larger, but more compactly formed—not so long but rather broader; the cerebellum is more developed laterally; the parietal ridge obeys the common form of the encephalic, but is more angular; the forehead is usually quite vertical and square, sometimes, however, it is full and round ; the superciliary ridge is very generally more transverse than with other crania, and the glabella is rather narrow but rough, like the sanguine bilious lymphatic, but not so prominent; the temples are usually depressed, while the head expands above them. The hair is brown or sandy and of moderate coarseness ; the iris is of a clear darkish blue, or bluish gray ; the skin is like that of the sanguine bilious; the nose is of moderate length and size, and straight on the dorsum; when well balanced ; the lips are tolerably thin, with the inferior one a little turned outward—an almost uniform characteristic of the encephalic and all of its combinations. 
The " Boxiana " furnishes one specimen of this class, who was highly esteemed for his courage, and, as a boxer, had considerable reputation. He never, however, obtained the championship. 
The president elect, General Franklin Pierce, is the only individual of this constitution, who has ever figured in the official stations of an army, so far as we have been able to learn. 
Yery many individuals of this class are the victims of consumption. Those in whom the encephalic predominates much, 


72 
TERNARY COMBINATIONS OF 
seek positions in schools, churches, etc., while those who par take largely of the sanguine bilious are found in the more practical concerns of life. 
As illustrations of this constitution, we may cite John C. Calhoun, Professor Daniel Drake, T. R. Beck, M. D., and G. A. Mantell, L. L. D., F. E. S. 
III. THE SANGUINE ENCEPHALO-LYMPHATIC TEMPERAMENT. 
This constitution is but seldom met with in this country, that is, it is not seen every day, even in a large city ; but in Holland it is of frequent occurrence. It is far from being an active condition of the system, but it is, perhaps, unequaled for industry and patience; consequently, men of this class frequently accomplish more, in the course of life, than others of a more forcible and active nature. 
There is just enough of the sanguine in it to maintain a moderately vital action ; the encephalic furnishes a high order of mental organization, and the lymph saves it from irritability. The head is large and rather quadrangular; the posterior lobes are very broad in densely populated countries ; but in this, where they are cultivated by a necessity for goahead or forward movement, in the prosecution of business, they are considerably longer but not so broad ;* the anterior lobes are elevated, prominent, and broad; the sides of the head are flattened ; and the parietal ridge is prominent, but not sharp ; the cerebellum is broad; the superciliary ridge is but little developed ; the skin is of a pale white, passing into a slight translucency ; the person is full and soft, and though abundant, the muscles appear to be stingy; the flesh hangs loosely from its attachments ; the iris is of a moderately pale blue ; the nose is moderately thick, rather short, and straight on the dorsum; the lips are not so thick as in the other forms of the lymphatic. 
Many of the German scholars and philosophers are of this constitution ; but generally they are more distinguished for their learning, than for their discoveries or originality. 
The justly distinguished Dr. B. Franklin is an illustration 
* These remarks apply to all temperaments, but their truth is less obvious in the lean and dense varieties. 


THE ELEMENTARY TEMPERAMENTS. 
73 
of this constitution : also the late Dr. Troost, of the university at Nashville, Tennessee, Major-General Lincoln, and the Hon. Lewis Cass. 
IV. THE BILIIOUS ENCEPHALO-LYMPHATIC TEMPERAMENT. 
The head, in this constitution, is more dense than in the preceding, and therefore not so large. The posterior lobes are about as in the previous temperament, except that in the former the parietal projections are large or more prominent, and so is the superior portion of the forehead, but in this constitution the forehead is more round, and apparently more compactly put up ; the corona and the hemispheres are not so elevated nor so much expanded; the cerebellum less broad, but more developed downward. The hair is fine, brown, or auburn; the eyes are brown or bluish gray; the nose is straight, aquiline, or pugged; the lips are of tolerable thickness, and most generally defined handsomely. 
This temperament is admirably calculated for the developof great subjects, but not so ready or instantaneous as many others. The men of this class are more than ordinarily liable to the use of unnatural stimuli, and by this means the usefulness of many of them is greatly abridged. 
It is not a very difficult matter for those of the sanguine constitution, and its combinations, to quit the use of tobacco, coffee, tea, and even ardent spirits; but the reverse is the case with those of the bilious and its combinations; hence those varieties should be careful how they indulge, unless they intend to contract a permanent habit. 
As illustrations of this constitution, the Hon. Daniel Webster, Peter the Great, and Dr. Gall. 
The portrait of Mr. Webster, as seen in the American Portrait Gallery, was taken at a period of life too young for a full development of the lymphatic element; and in his old age the lymph appears to have been absorbed.* 
If we have been correctly informed, this combination is of 
* It may be as well for us to remark, that as we have to be governed by the published portraits of distinguished individuals, it follows that if they bo very inaccurate, we may err—and in this way we may have erred. 


74 
QUARTERNARY COMBINATIONS, ETC. 
frequent occurrence in Persia. The females are very beautiful, and the men fine looking and commanding. Of this constitution and the preceding, the "Boxiana 1 ' gives us no illustration ; nor does it of the one that follows. 
III. QUARTERNARY COMBINATIONS. 
Jr. SANGUINE BILIOUS ENCEPHALO-LYMPHATIC TEMPERAMENT. 
This is possibly the most favorable combination that can happen in the species, with reference to the highest order of achievements. The sanguine gives force—the bilious, motive and durability of impression—the encephalic, mental apparatu —and the lymphatic equalizes them, or prevents waste by preventing useless motion; or, in other words, it prevents that irritability of the fibrous tissues which so rapidly hastens that metamorphosis which wears out and exhausts the lean varieties. Under this condition, and that species of absence from all animal wants, which the encephalic imparts, it is, that men of this class can excel all others in doing without food, sleep, and repose. 
The head is above the average size, and developed in all of its aspects, and yet preserves, considerably, a quadrangular form, particularly when the intellectual lobes are not promi- developed. The hair is brown or sandy and of moderate fineness ; the eyes are of a dark blue or bluish gray ; and the face, how shall we describe it ? No part, unless it may be the forehead, appears too large or too small, and yet there is not that blending and losing of one part into another that generally characterizes the human face. Each part looks as though it had been separately made—finished and then fitted to its place. In fine, a sui generis abruptness, a right-angleness marks, not only the face, but the whole body. 
The person, though full, is nevertheless quite firm and compact, and the complexion, beside having the blue tint common to the other combinations into which the sanguine and the bilious enter, has a shade of brown, or it is fair and rather florid. The former variety darkens greatly under the influ- 


CONCLUDING REMARKS, ETC. 
75 
ence of light. As this constitution does not obtain frequently, many distinguished illustrations of it cannot be given, but Napoleon Bonaparte, Caius, Julius Caesar, and Mr. Whitney, of Pacific and Atlantic railroad notoriety, may be cited. 
CONCLUDING REMARKS. 
In the application of this subject to national crania, except to some of the nations of Europe—their descendants in America, our negroes, and some of our native tribes, much difficulty will be met with in consequence of cranial deformities. That an artificial deformity of the head can become permanently congenital, we have the facts to prove beyond the possibility of a doubt. And that considerable deformity can be, and is, produced by slight and even unintentional causes, we have as little doubt. 
The Osage Indians are known to have the occipital portion of the head broad, flat, and generally deformed, so that the occipital foramen approximates very closely to the posterior basis cranii. We believe that the cause of this is to be sought in the fact that they strap a board to the backs of their children. The occiput is continually in contact with the board— bound to it by a strap passing over the sinciput. We have seen German, Polish, Swiss, and Tyrolese crania flattened, more or less, like the Osage, and we think it probable that each of them is referrable, remotely, to some similar cause. 
A portion of the Choctaw tribe of Indians have a congenital deformity of the cranium—the result of artificial deformity which was produced by their remote maternal ancestors, the Shockshumas. Of this fact, we have a chain of evidence, with illustrations, that cannot be invalidated. 
In cases of cranial deformity, the want of harmony between their several parts, will usually determine whether they have, or not, been deformed, and by restoring these relations, pretty correct conclusions may be arrived at by careful examination. 
It is possible for an individual to become so conversant with our doctrines of the temperaments, as to apply them with great facility and accuracy to the population of one country, 


76 
CONCLUDING REMARKS ON 
and fail with reference to those of another, unless he shall have given an extensive attention to those of other countries ; because different conditions in human society very materially modify the human head. In old and densely populated countries, it is broader and shorter than it will be found where the population has for centuries, or even for several generations, been subject to a contrary state of social existence. These remarks are intended to place students on their guard when studying foreign crania. 
The several races, and even different branches of the same, present considerable differences of external configuration, and it is worthy of remark, that those of the latter are equal, at least, to those of the former; and the constitutional marks, a3 we have unfolded them, are as clearly indicated upon savage crania as upon the civilized. There is, however, one difference—the triple combinations with the encephalic are never met with, and even the binary is so rare as scarcely to deserve a notice. 
The encephalic constitution appears to be a result of civilization—a product of moral and literary culture—the work of many centuries. It is founded in a higher development of the cerebral hemispheres than is necessary to the savage mode of existence. 
With a higher development of the hemispheres is associated diseases to which the savage is a stranger —this we believe to be particularly the case as regards phthisis pulmonalis and its kindred affections. But each constitution has its physiological, pathological, and therapeutical peculiarities, and the inhabitants of each country differ, in these three respects, from those of others; and a neglect of these conditions has done very much to retard the advancement of pathology and therapeutics. Remedies that succeed in certain diseases in one country, in a great measure fail in another, because of the difference of constitution. How should it be expected that the most effective remedies upon the sanguine and sanguine lymphatic constitutions of the north, in which the skin and kidneys are the great depurators, should succeed with the bilious and bilious lymphatic constitutions of the south, in which the portal system and the mucous lining of the intestinal canal are the great depurators ? 


THE ELEMENTARY TEMPERAMENTS. 
77 
We have not time, nor is this the place, to do more than to briefly hint at the importance of a knowledge of the human temperaments ; and if every circumstance favored such a purpose, we confess ourself unable to do it justice, nor do we pretend to have discovered all the facts that are involved in it, nor to have properly applied all those which we have discovered; and yet, the success that has, for many years, attended our demonstrations, would seem to prove that we have succeeded in establishing a foundation that will sustain the discoveries, in this connection, of all future ages. It is for others, therefore, to finish the edifice. 
If any one had suggested to us, twenty-two years ago, the possibility that a time would come when physiologists would be able to read, from the naked skull of a Caucasian, the color of his hair, eyes, and skin, and the details of his personal condition, we would most certainly have regarded him as exceedingly visionary; and if he had gone further, and added, that they would also do the same with facility and ease from chirographic marks alone, we would most assuredly have concluded that he was insane. 
We are not, therefore, surprised that people now should be as skeptical as we were then. We are not surprised that even Professor Caldwell should have suspected us of being guilty of a mere " pretension," but we were surprised that he carried his incredulity as far as he did, knowing that such a " pretension " was not in contravention of any established law—that we had the same immutable laws of animal organization to guide us, that guided Cuvier—the two subjects being only parts of the same, and about equal in magnitude and difficulty. 
It is known that differences exist between all the individuals of society—and will any one affirm that these differences are not impressed upon the solid parts of the system ? Will any one affirm that it is impossible to classify these differences ? The great wonder with us, at this time, is that the discovery was not made a century or two since, because the subject has had the attention of physiologists ever since the dawn of the profession. 
As all the facts or conditions involved in the subject exist in abundance, we may certainly conclude that no one is stupid 


78 
CONCLUDING REMARKS ON 
enough to assert that they cannot be arranged, and if they can be arranged, then our " pretension " is possible, and being possible, it does not involve an impossibility. 
But, says one, u thus far I have some faith in your pretension, more especially as Cuvier did as much in another department of the same great subject, but you have gone far beyond him in asserting that you can distinguish the temperaments by chirographic marks." Yery true; and what are marks made with a pen but acts of the individual, in any given case ? And will any one assert that a man with a round head, will use his pen like one who has a long head ? The very idea is preposterous. If differently shaped heads did not dictate differently shaped marks, and if certain parts of the same head did not produce marks that differed from those of other parts of it, we should have never made such a pretension. But as the contrary of all this is true—that is, as each organic form makes its own peculiar mark, we are enabled, by seeing the marks a man makes in writing a letter, to arrive at a knowledge of the form of his head, which determines his temperament—yes, and his character too. 
Such is the amount of public incredulity upon all new discoveries, more especially if they relate to humanity, and still more especially as regards our " pretensions," as Professor Caldwell has been pleased to regard them, that we hope to be excused for attempting to sustain our own declarations, by adding the testimony of others. We do not do it, however, with a view of convincing any one—such conviction is useless—but for the purpose of preventing any rash action w T ith reference to them—to induce all to withhold an expression of opinion until they shall investigate the subject; and, as far as possible, to induce others to examine it. 
If we have, unaided, made such progress, it would seem to be an easy task, with the aid of our instructions, for others to advance beyond us—some of our pupils, in some practical respects, are now in advance of us. Out of the many certificates we have, confirming the validity of our " pretensions," we shall present but two ; one from the Hon. Judge Chalmers and Dr. Reed, testifying to the accuracy of our discriminations upon crania; and another from a number of medical gentlemen, who testify to an equal accuracy upon chirographic marks: 


THE ELEMENTARY TEMPERAMENTS. 
79 
"Holly Springs, Miss., December, 1840. 
" "We presented the skull of Loper to Dr. Powell, before his audience, which was large, to test his ability as a phrenologist, but more particularly to test his pretension of distinguishing temperament by the denuded skull. We are sure he had no information with regard to Loper—we guarded our own secret. He informed the audience that the skull he held in his hands indicated a sanguine bilious lymphatic man—that his person was full and round, not too lymphatic to be both strong and handsomely shaped—that he had had darkish blue eyes, and dark brown hair. In the above remarks he was peculiarly correct; and so far as is known, he was equally correct in pointing out his character. 
Jos. W. Chalmers, 
Will. S. Reed, M. D." 
The following certificate is equally conclusive: 
"Memphis, Tenn., February 24, 1851. 
" We, the undersigned, gave to Professor Powell, at the close of one of his lectures, about thirty letters, from gentlemen who were known to us, but unknown to him. In each instance he gave the complexion of the hair, eyes, and skin, make of person, shape of the head, and the mental character of the writers ; and with a precision that could not have been surpassed by their personal acquaintance. 
T. B. Burnet, M. D., S. R. Jones, M. D.,Phys. Prof., Geo. Salmon, M. D., J. King, M. D., Mat. Medica D. S. Mills, M. D., Prof., J. A. Powell, M. D., R. S. Newton, M. D., Chirurg. 
W. G. Weathersby, M. D., Prof., 
N. D. West, M. D., J. B. DeWitt, M. D., A. L. Gray, M. D., G. J. D. Funchess, M. D., J. A. Secord, M. D." 
There remains to be considered two applications of the temperament —one of which is, perhaps, only interesting, but the other is of paramount importance to society. We allude to the parental likeness of progeny, and to the degeneracy of the species by a union of incompatible constitutions in marriage. 
It has long been known that the intermarriage of near relations, in consanguinity, will produce degeneracy in the 


80 
CONCLUDING REMARKS, ETC. 
species; but so far as we have learned, it has not hitherto been known that the union of incompatible temperaments produces a more fatal degeneracy of the vital forces, than any variety of that which attends those of consanguinity. The results are so strongly marked and so particularly fatal, that we cannot imagine how it should have so long escaped the attention of physiologists. A tolerably full consideration of this subject will be found in the next Book. 
As regards parental likeness, we have to observe, that it is an old opinion that the sons who resemble their father or his family, and the daughters who resemble their mothers or her family, are inferior to their parents, respectively. "We believe this opinion to be founded in truth—in an organic law that governs all animal existence ; except when the parent or family, so resembled, is of the sanguine constitution. With this exception, the following observations will be found to be generally true. The reason of this exception may be inferred from what we have said upon the sanguine constitution. 
Sons should resemble their mother, and daughters their father, and when they do, the fact is indicated by the full, round, and symmetrical forehead; and when the contrary is unfortunately the case, the front of the forehead is flat, indicating a shortened condition of the front lobes of the cerebrum — the face and forehead appear upon the same plane. Bonaparte and Washington are fine illustrations of maternal resemblance. Among the distinguished we know of no illustration of paternal resemblance. 
Those of a mixed resemblance, who have inherited the best elements of both parents, are superior to them; but, on the contrary, those who have inherited the inferior qualities of both, are inferior to both —possibly idiotic. In either event, the middle or relative range of the forehead is more or less depressed. According to this law we can comprehend why it is that we sometimes find the two extremes of mental ability in the same family of children. As illustrations of such a mixture, we may cite the Hon. J. C. Calhoun and Chief Justice Marshall. 
This Book now closes, and as it is, in a great degree, the work of one mind, an exemption from error is not claimed for it; and yet its fundamental truths are demonstrable. 


BOOK II. 
PHYSIOLOGICAL CONSIDERATIONS IN RELATION TO PARENTS AND THE TREATMENT OF CHILDREN. 
6 




INTRODUCTION. 
When we contemplate the inferior departments of animated nature, we cannot rationally conclude that disease and premature death were ever intended to constitute, necessarily, a part of God's physical providence, with reference to man. Sickness and premature death are much more common to man than to his inferior domestic animals; and more common to them than to the wild and undomesticated. They are also more common to man in his civilized than in his savage state. 
These sentiments being admitted as facts, the conclusion seems to follow, that those conditions which are indispensable to health and longevity are more frequently violated by the former than the latter. Civilization creates motives which are very frequently stronger than his unperverted instincts, and his domestic animals are rendered highly artificial by the restraints, he has imposed upon them. But in the wild state, both men and animals live in greater conformity with their inherent appetites and instincts. 
Sickness and premature death may then, in civilized society, be far more properly attributed to his sins, or infractions of the laws which his Creator impressed upon him, than to him— his agency, or his providence, as they too frequently are. 
Disobedience to the laws of his organic nature, may be said to have commenced with the dawn of his existence, and an enlarged edition of it with that of his civilization, and the inequilibrium it produced in his organization, rendered it incapable of repelling many of the various causes of disease. This inequilibrium has so multiplied, if not increased, that it may be safely asserted, at this time, that not the half of one per centum of children, now born, possess an organization in such equilibrium with the climate and the existing modes of 
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84 
INTRODUCTION. 
living, as to be exempt from frequent disease and death before the attainment of threescore years. 
In view, then, of this existing state of society, it becomes proper, in a work professedly treating of the Diseases of Chil dren, that we should first treat of those who are, or rathei who should become parents; because a very large proportion of the diseases, not only of children, but of adults, have their remote causes in them. So true is this, that it would be just as rational to look for pippin apples on crab-trees, as happily constituted children from unhappily constituted parents. 
The vegetable kingdom furnishes, analogically, a satisfactory illustration of the truth of this doctrine and the importance of the attention we are about to bestow upon it. It is now well known to horticulturists that so much depends upon the perfection or stamina of vegetable seeds, that while some produce vigorous and healthy plants, others cannot sustain their existence to maturity—some dying very young —having, nevertheless, equal advantages of soil and season. 
In human society, it may be safely assumed that one-fourth of the annual mortality consists of children under one year of age; that about one-half consists of children under five years of age; that three-fourths consist of those under forty-five years of age; six-eighths under sixty; seven-eighths under eighty, and a few live to be one hundred and upward: and this difference of longevity, in the main, depends upon a corresponding one in the original constitution—in that vital force which the original germ received from the parent. 
In our frequent travels on the Mississippi river, we have frequently witnessed, in the young cotton wood forests, a beautiful exemplification of this principle in the aggregate of human life. The spring deposits of alluvial mud, throw up a dense forest of young cottonwood plants—during the first season one-half of them die; during the next season one-fourth of the remainder; and thus the reduction goes on, until but few, perhaps a dozen, are to be seen, where there were millions in the beginning. A wise provision !—those of unsound seed are not permitted to live to bear seed ; and so it is in human society. This Book is, therefore, devoted to the improvement of the seed and the culture of the plants. 


CHAPTER I. 
PARENTAL CONDITIONS CONSIDERED WITH REFERENCE TO CHILDREN. 
INTRODUCTION. 
In the condition of parents, and the manner in which they respectively discharge their functions, exists the health and the happiness, or the disease and the misery, of individuals and society, in a higher degree, than upon any other two circumstances connected with human existence. 
The very idea of sex is pregnant with that of progeny, and in the union of the sexes, or marriage, is founded the provision for the perpetuity of the species; and for the security of this provision, it was placed under the government of laws, without which the animal world would have exhibited as great a confusion—as complete a chaos, as a mere mechanical aggregation. No particular type of body or mind could have been secured to progeny—every variety of monstrosity would have prevailed—there could have been no division of the animal world into classes, orders, genera, and species, but an inconceivable commingling of the whole. 
By these laws, then, when strictly obeyed, parents have Becured to them, their own vital stamina, their own virtues and talents, and also their own infirmities, vices, and crimes, or rather, inherent proclivities to them. By these laws, parents may hope to the full extent of their obedience to them, but no further. They must never expect to find in their children amiable dispositions and sound constitutions, when they themselves have not got them—children cannot inherit that which the parents have not, and they must and will inherit that which they have, be it good or bad. No man of common sense and observation expects to produce on thorn-bushes, fine 
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86 
PARENTAL CONDITIONS, ETC. 
apples—each tree may produce its own kind, in both size and quality, and human parents can do nothing better. 
What a motive do these laws present to a reflecting and ambitious mind ! What must be the depth of the degradation of that parent whose soul would not be frozen with the thought of bringing into existence a progeny to suffer from the frowns and restraints of civil authority, to live in constant and conscious degradation—to be a practical curse to their race, and multiplying, in every generation, to the end of time, without some fortunate event should occur to turn the tide of such a deepening, widening, and blackening scroll upon the face of time ! 
How ignorant of, or indifferent to, the certainty and immutability of these laws must existing society be, if we may judge from the incompatible alliances and the violations of domestic and social duties which are perpetrated every day, and almost in every walk of life! 
Do we not see men and women hazarding the consequences of an alliance with consumption, scrofula, cancer, intemperance, insanity, epilepsy, their own cousins, and incompatible constitutions ? Can they have an abiding faith in the integr rity of God's ordinances ? We see, furthermore, scolding, brawling, and fighting within the domestic precincts of the bed-curtains—the sanctuary of the procreating genius. Is not such conduct a wicked braving of the ordinances of heaven ? Can they expect that such uncompanionable dispositions will not be entailed upon the fruits of their intercourse—do they never reflect that they are laying a foundation for their own degradation, through the crime of manslaughter in their children ? 
If we turn our attention to even the most intelligent portions of society, we shall find inconsistencies of a more glaring and mischievous character, than those w r e have been exposing. We find both men and women who are socially and perhaps morally unexceptionable—such as are very particular in doing right, and to the best and most useful end, all that they do. Should we not look to such people for good, happy and useful children ? But are we not sometimes greatly disappointed ? When they desired progeny to smile upon them in their old age, and to ornament and prosper society, 


MARRIAGE ELIGIBILITY. 
87 
did they observe the same care that they manifested in their other concerns? Did they pause to consider whether their own bodies and minds were in a proper physiological state to justify so responsible a function? Was he in good health — was his mind relieved upon every other subject ? Was her mind and body in a similar condition ? If all this were so, look back, in due time, and the result will occasion no regret. But if conditions of a contrary character obtained, shed a tear of pity for the result, and another of contrition for the imprudence. Blame not the author of the laws—he has only promised success for obedience. 
The great end and aim of marriage was progeny, and consequently, we do not expect any very signal improvement in society until the organic laws that govern the marriage function shall be better and generally understood, and as generally obeyed. 
SECTION I. 
MARRIAGE ELIGIBILITY. 
Much has been said about the periods for the consummation of marriage by the two sexes respectively; and yet considerable contrariety of opinion prevails. The ancient Germans did not allow their young men to marry before they were twenty-four or five years of age ; and in Wirtemberg, at this time, it is illegal for a man to marry before he is twenty-five, or a young woman before she is eighteen. This statute is, in every instance, an outrage upon organic law, but probably not upon that condition of society which has resulted from the artificial influences of an imperfect civilization. 
Professor Dewees fixes the time of marriage for the male at a little over twenty-three years of age, and the female at a little over nineteen, in this country. But he teaches, "that no precise or absolute rules, based upon the lapse of years, can be laid down; since the body of both male and female may be precociously expanded, or may be unusually and morbidly retarded. In the first instance, the period we have assigned may be anticipated with safety ; but in the second, it would be wise to extend it. Thus, oftentimes in India, females 


88 
MARRIAGE ELIGIBILITY. 
become mothers at ten; while in Lapland they rarely give evidence of womanhood until eighteen; consequently, the women of India would be on the wane, did they wait for the limit at which it would be proper for a Lapland woman to marry: and the Lapland woman could not support the contingencies of marriage, did she attempt to regulate it by the usage of India." 
Dr. Dewees is the advocate of early marriages, cceteris paribus, nevertheless, he attributes to them evils, which we think should be referred to other and very different causes; such as " diminished vigor and shortened life of the male; faded beauty, blasted health, and premature old age of the female;" with an entail upon the progeny of " diminutive stature, debility of body, imbecility of mind, and a predisposition to consumption, rickets, scrofula," etc. 
" It has frequently excited the surprise," he observes, " as well as provoked the reproach of foreigners, that the females of this country lose their beauty so early, especially when compared with the females of Europe, and particularly those of Great Britain. The cause of this hasty decay must be principally sought for in our very early or premature marriages ; but we confess that climate has also a certain, though more limited, agency." 
Upon this subject, it really appears, that there has been a very general want of accurate observation and philosophical discrimination ; —to attribute an early loss of either beauty or health to early marriages, is, in our opinion, equivalent to charging our Creator with unwise provisions—to referring our misfortunes to him—to his " mysterious providence," instead of our disregard and disobedience of his institutions. 
It has now become a well ascertained fact, that our capacities are not simultaneously, but successively developed ; the first faculties manifested by children are those which preside over physical development, and those that take cognizance of surrounding objects ; then come those animal ones which preside over our relations, both affectively and intellectually; then our moral and reflecting; then those which are usually denominated the religious; and lastly, the sexual, or those which preside over the perpetuation of the species. 
It would now be exceedingly unreasonable to conclude that 


MARRIAGE ELIGIBILITY. 
89 
it was the intention of our Creator that either of these classes of powers should be developed, before their functions should be manifested. In such a design there would be no utility, hence no wisdom. We allude to what appears to be the law of the race, and not to exceptions, or instances of precocity, and therefore of morbid or abnormal development. 
With the undomesticated animals we find uniformity and harmony in the manifestation of their functions—as soon as the sexual capacities of the females are developed we find them to be successfully manifested, and that too without any stinting of the species. 
The same is true of all people whose mode of existence is primitive. Even twenty years since it was particularly the case with our Creek Indians, and yet the men were not diminished in either size or vigor, nor were the females faded in beauty, blighted in health, or visited with premature old age ; nor did they entail upon their progeny a predisposition to consumption, rickets, or scrofula. What is true, therefore, of one people may be true of all others, under similar circumstances. 
Dr. Dewees regards marriage with females, at a little over nineteen, as being early—it is the period at about which the female body receives its final " expansion." Now, inasmuch as her sexual capacities are developed from three to five years earlier than this, we should, with as much justice and propriety, assert that the manifestations of her intellectual, moral, and religious capacities should neither be trusted nor tolerated until about the same period of life, or until the body receives its final " expansion." 
Philosophically considered, there is just as much propriety in the one position as the other, because it is not to be supposed that the Creator would implant in her mind a desire, and in her system a capacity to conceive, without the ability to execute, in good faith, the function. We cannot, therefore, attribute the early decay of beauty in the American women, as compared with the English, to premature marriages—we deny that they do, in the abstract, take place prematurely, so far as age and the development of the sexual system are concerned. Nor are we disposed to attribute our troubles upon 


90 
MARRIAGE ELIGIBILITY. 
this subject to any peculiarity of our climate, but to our artificial modes of existence. 
Our own observations have confirmed the truth of those expressed by foreigners ; and to show that the evil is not attributable to premature marriages, w r e have but to compare our single women, over the age of twenty-five, with those of England. These appear vigorous, youthful, and healthy, while those are as generally lean, pale, wrinkled, and prematurely old in appearance. In American society, single women, at the age of twenty, or thirty, are, in point of beauty and healthy appearance, inferior to the married women or mothers of the same age. 
We must, then, attribute the premature decay of our women, so far as the fact may exist, to some other cause than premature marriage. 
English women, as well as men, can, and always do, find time to eat, to laugh, to rise early, to be cheerful, and to take exercise in the open air, while the American women, we allude to the young ones, have no time for early rising, no appetite when they have risen, no time to be cheerful, except in spasms, or upon exciting occasions, and no time to take exercise in the open air. English women delight in walking four, five, or six miles at a time ; but American women fancy that such walks w r ould kill them. English women aim at red cheeks and well-turned limbs; American women aim at shriveled limbs and blanched faces. The consequences are that the English women, wdiether married or single, maintain a healthy appearance, while those of America, in either condition, soon arrive at premature old age. Marriage, with such American women is premature, no matter at what age it takes place. 
These remarks, of course, apply mostly to our city society, but not entirely. If our readers will compare the neck and thorax of our English women with those of American women, especially as we find them, very generally in our cities, and then appeal to our expositions of the cerebellar functions for an explanation of the difference, then they will discover that early marriages have not done the mischief complained of. 
We have never known an American woman to marry too 


MARRIAGE ELIGIBILITY. 
91 
young, but we know very many who should not have married at all. As there is but little, if any, tendency in females to marry before the development of the sexual system has caused them to desire to do so, there is as little danger of their marrying too young. The question then, should be one of health, of constitutional stamina—and not one of age. The natural laws command early marriage, with sound and healthy individuals, and no marriage at all with those of a contrary character ; and such is our faith in the wisdom of these laws that we urge obedience to them. 
We have not made observations upon society in Europe,"nor in the eastern portion of the United States, but we have in the western, and hesitate not to affirm that the first children of early marriages are as sound and as intellectual as those of riper years. The difference which we have observed appears to be in their favor—they are more impulsive, sprightly, and enterprising, and to us the reason is obvious : they were conceived or produced under the prevalence of the greatest activity of the physical and mental faculties—when the parents felt themselves to be bound together by no other bond than that of love, and at the period, too, of their greatest and most expanding hopes. 
As physiologists we should not look to old and densely populated countries for normal manifestations of human nature. There, poverty and position, on the one hand, do not engender the inspiring influence of hope—the mill-boy there, only makes a mill-man, and not the owner of land or the governor of a country ; and on the other, among the affluent, marriage is too much a matter of commerce, to produce, generally, enterprising genius. But in this country, hitherto, society has been as free as the undomesticated animals of the forest, and hence all the human functions have been manifested in the order and at the time intended —no complaints have been heard about the misfortunes of early marriages. 
This appearance of premature decay that has been spoken of, as being peculiar to this country, is not confined to the females—the males are also marked with it to a very considerable extent. For this fact, as it applies to both sexes, there is another cause far more fruitful in mischief than early marriages have been. 


PARENTAL CONSTITUTION. 
92 
In England, Ireland, and we believe in Scotland also, it is, in good families, the practice to set a separate table for the children, which is provided with such food as is thought to be the best for them—such as is simple and of easy digestion. In this way they are removed from the temptations of the adult table, which is adapted to adult constitutions. This practice, modified more or less by the circumstances of families, is no doubt practiced by all classes of society. 
How stands the case in this country ? As soon as they can sit, and even before, they are taken to, and fed from, the adult table, and fed with such food as it may contain—with the remark, "if the poor child cannot have substantial food it will not become strong." In this practice, through gastric derangements, we can certainly discover the premature loss of teeth, and with them departs the rose of health and the bloom of beauty. 
SECTION II. 
PARENTAL CONSTITUTION. 
It is a very prevalent opinion among the unprofessional that those persons who are the most fresh and rotund in appearance possess the best constitution. As these appearances very frequently depend upon plethora, we have the reason why so large a proportion of fine, healthy-looking persons die during the prevalence of severe epidemics. Women with such constitutions, though well and health} 7 looking, have usually but few children, and they are of an inferior quality. 
On the other hand, very many feeble and infirm women have many fresh and rosy-looking children, but their appearance is deceptive—their condition is one of obesity—a constitutional weakness of the vital forces, which has been entailed upon them. 
The rich, or those who live high, are too plethoric *to bo fruitful, and hence such people have usually few children. The poorer classes, or those who have enough, such as it is, consisting mostly of vegetables, are much more prolific, and the children have the best promise of health and longevity. But the most prolific women, for the time being, are those who 


PARENTAL CONSTITUTION. 
93 
are laboring under some slow, chronic, but certainly fatal, disease, as consumption. This appears to be a law of the vegetable and animal kingdoms, that in proportion to the danger of the species becoming extinct, so far as the individuals are concerned, is the increase of fecundity. Fruit trees, so battered and bruised that they must die in a year or two, are certain to have a full crop of fruit the year before they die. 
"Women thus circumstanced should not marry, and if, after marriage, they should become so, they should cease to become mothers. 
The amount of disease and premature death that is entailed upon society by the marriage of unhealthy persons, is such as to demand, on the part of society, the enactment of some protective ordinance. If the consequences were confined to the parties themselves, or even to their children, the evil would be comparatively small; but the multiplication of it is so rapid, that, in a few generations, a very large extent of country becomes similarly afflicted. Because a man or woman has acquired a predisposition to consumption or some other form of disease, it does not follow that the privilege should exist to entail it upon others. 
There is scarcely an individual in society who has not witnessed the deplorable consequences of the marriage of those who have had entailed upon them a predisposition to consumption, to insanity, to apoplexy, etc.; then what should we think of those who, knowing themselves, by what they know of their ancestors, to exist with such predispositions, place themselves in such a situation as to visit the mischief upon unborn hundreds, perhaps, thousands ? We must conclude that they have never seriously thought upon the subject, or else, that they are superlatively selfish or inexcusably dishonest. 
There has become, broad-cast, in our country, a predisposition more mischievous than consumption, insanity, or any other form of disease that now occurs to us, though not so certainly and speedily fatal—it is intemperance in the use of ardent spirits. A drunkard is almost sure to be the grandfather of drunkards, through the female part of his children, and it is probable, that he may also be the father of them. 
A practical phrenologist rarely fails to detect this predispo- 


94 
PARENTAL CONSTITUTION. 
sition. Indeed, it may be truly said, that all predispositions to disease, as well as to crime or moral depravity, are advertised upon the outside of the head. 
All predispositions may be removed by appropriate physical and mental education, and by judicious marriage alliances; but who is to direct these % All that we can do is to announce their existence, and to admonish all young people against forming an alliance with them. 
There is yet another predisposition, which has hitherto, so far as we know, entirely escaped the notice of physiologists, and yet it is one which every person should avoid, in a marriage alliance, and every one would avoid it, who entertains ambitious hopes of his children, if they knew it. We allude to those women who very closely resemble their mothers, and in consequence of this entail upon them, they will entail their own likeness and constitution upon their daughters, and those of their husbands upon their sons. Such children never equal their parents, respectively—the fact indicates that the work of degeneracy is in progress, and if continued will result in physical infirmity and mental imbecility. To this law there is possibly an exception in the sanguine temperament. 
The Arabians seem to have understood this long since—they maintain that the blood in any species of animals is transmitted through the female; hence they will cheerfully sell their stallions to foreigners, but not their mares. 
As a very general Jaw with all classes and species of animals, man included, males inherit through the mother, and females through the father. Daughters, though inheriting the mental peculiarities of a father may never manifest them, because of their more restrained position in society, but her sons will. The character of the sons may be inferred from that of the maternal grandfather. 
These rules are always applicable, except when the elements of both parents are blended in the children, which is frequently the case. 


IMPROPER MARRIAGES. 
95 
SECTION III. 
IMPROPER MARRIAGES. 
It is universally admitted, but not always avoided, that consanguineous marriages are gross violations of the laws of procreation. Physical deformity or mental inferiority is certain to appear in some of the descendants of such alliances. The unfortunate consequences of such marriages upon society are so notorious, and have been for centuries, that it is a matter of surprise that penal statutes have not been enacted against them, by all civilized countries. Conventional statutes are enacted to enforce obedience to very many of the organic laws which are very far inferior to this, in their importance, or in the consequences of their violation. Organic law has as positively prohibited marriage alliances between blood relations, as it has murder, theft, and falsehood ; and the individual who contracts such an alliance, knowingly, is just as guilty of crime—of an outrage upon society—of disobedience to his Creator, as if he had stolen his neighbor's horse. 
As an illustration of the magnitude of this increasing evil, in some of the old states, we extract the following history of one family from the Fredericksburg "News:" 
" In the county," says the editor, " in which we were raised, for twenty generations back, a certain family of wealth and respectability have intermarried, until there cannot be found in three of them a sound man or woman. One has sore eyes, another scrofula, a third is idiotic, a fourth blind, a fifth bandy-legged, a sixth with ahead about the size of a tin-cup, with not one out of the number exempt from some physical or mental defects of some kind. Yet this family perseveres to intermarry with each other, with those living monuments of their folly constantly before them." 
Who can say that, ultimately, this family connection will not become a heavy expense to the state ? When they shall so degenerate that they cannot take care of their property, then the state will have to provide for them. It is even now a question whether one-half of the adult males are fit for military duty; and when a people become too degenerate to defend themselves, w T hat are they but Hindoos — unfit for 


96 
IMPROPER MARRIAGES. 
anything but the most stupid and degrading idolatry. In the very face of this enervating and dehumanizing practice, legislators look on, with their arms folded, and say, " well—this is none of our business—our country is free, and they have a right to marry whom they please." This false notion of liberty, unfortunately, exists in every part of our country; when in truth, no one ever had a right to do wrong. 
There is another alliance that frequently happens, which, if possible, is more objectionable than the consanguineous, so far as regards the immediate progeny, but not so far as concerns society at large; and for the reason that they do not live to propagate. We allude to the union of individuals of the same temperament or constitution. We are now acquainted with intellectual, energetic, and healthy parents whose children are all dead, or else possess so little stamina that they will not reach maturity. This law obtains with all the temperaments, except the sanguine, but more particularly with the triple and quadruple combinations. So marked are the consequences of these marriages, that it may be regarded as a matter of much surprise that it should, up to this time, have entirely escaped the notice of physiologists. 
Such parents, having fine health, deem the cause of the early loss of their children, as entirely inscrutable. They never imagine that they have violated an ordinance of their Maker, and that in the loss of their children they are suffering the consequent penalties. 
In consideration of the existence of this law, let all persons be admonished to avoid a marriage alliance with those who have their own complexion and habit of person. 
This topic is too important and too little understood to be passed over with a mere mention of it; and therefore we will illustrate it by the introduction of two cases out of the many we have. 
In Mississippi, we boarded two or three weeks with a very excellent man of the sanguine bilious lymphatic constitution. He was large, and had a large and finely-proportioned head— in fact, he was an excellent specimen of this constitution. His wife was large, and as fine a specimen of the same constitution as he was. The cerebellar and coronal portions of both their heads were fully developed. 


IMPROPER MARRIAGES. 
97 
At this time we had not discovered this law, and from the healthy and fine appearance of the parents, we expected to see fine children. Now, imagine, if possible, our disappointment! They had six children, and a description of one will answer for all of them. The head was large but the cerebellum was exceedingly small, and, consequently, so were the neck and chest, and, indeed, every other part of the body. The parents had beautifully rounded and elevated coronae to their heads, and therefore capable of all the more elevated feelings of our nature; but the head of each child was very nearly as flat as the table on which we write. They were all highly encephalic, with the exception of the superior portions of the hemispheres, which were too flat and defective, to constitute normal specimens of it. The complexion of all of them indicated great feebleness of the respiratory and circulatory functions. It is not our opinion that either of them could have lived to the age of ten years ; but we do not know what has been their fate. 
Upon a recurrence to the facts in this case, we shall find that the mischief was two fold. First—Both parents had the vital forces large—the children had them too feeble to sustain them to maturity. Second—Both parents had large religious and moral organs—all the children were as defective in these as in the vital forces. The children, then, of this marriage suffered, immediately, both vitally and mentally. 
Now, we think it very probable that our readers are as much puzzled as we were, to comprehend the intention of the law that governed in this case; but do not doubt the wisdom of it —all of God's laws—the natural laws, are pregnant with wisdom and the good of the human race. We were six or seven years laboring to discover its intention, but in the meantime we discovered many similar cases—enough to convince us that the law of procreation governs in the premises. 
We will disclose it. Suppose the children had inherited from their parents the combined strength of their vital forces, would not the consequences have been monstrous ? Suppose, again, that they had inherited the combined strength of the moral and religious faculties of the parents, and they should, in turn, obtain wives like themselves, and that their children again should do the same, does it not become obvious that 
7 


98 
IMPROPER MARRIAGES. 
the most lamentable monstrosity of mind would be the result ? 
Now, what is the law which was violated by this gentleman and his wife ? It was this:—The husband and the wife must be the compliment of each other. They were not, but were like each other. If the moral and religious faculties had been the compliment of each other, then the children would only have suffered in their vital systems—reverse the case, and then they would only have suffered in having very feeble emotions of morality and religion. "When, therefore, this law is violated, the extent of the consequence will depend upon the character of the violation. If it be in relation to the vital forces, then the law cuts off from life, the acquisition of the outrage, which is the child. 
Can any one reflect upon this law without being forcibly penetrated with the wisdom and philanthropy of it ? In the criminal walks of life, the mischief-doing propensities are strong; now, suppose that this law did not exist, how frequently would children inherit the combined strength of them in both parents ? And suppose they did ; what would be the extent of the theft, burglary, robbery, piracy, murder, and arson, inflicted upon society ? 
One morning, a large, fine-looking, sanguine bilious lymphatic gentleman, who had heard us the night before upon this subject, called upon us, and commenced thus: "My wife, sir, was in many respects like myself; her hair, eyes, skin, and general make of person were like mine; her head differed from mine about the front, it was not so wide, particularly about the top, but her neck and the back part of her head were like mine: now, what would be the character of our children ?" 
"We answered: "In the first place, it is possible that you had none; but if you had, it is very probable that you did not preserve one to maturity." He replied : "We had six, and all died before they reached their tenth year; and I never had any idea of the cause until I heard your lecture last night, for both of us were healthy, and we lived on a healthy place, and our young negroes have all done well, which seems to show that there was no cause for such a fatality, except the one you have given. Finally, the mother of these children died, and 


IMPROPER MARRIAGES. 
99 
I married a lean, dark-skinned woman, and we have now three promising children." 
The marriage of old men with young women is not an uncommon occurrence—too common, indeed, for the happiness of the parties or the political good of society. Although more males than females are born, yet, in consequence of the greater exposure of the former, the latter prevail in all old communities, which is comparatively a social or political evil; and as it is usually increased by such marriages, they are objectionable. When such marriages produce sons, they are usually of an inferior quality. 
It is contended by some that it is better, on all accounts, for a young woman to marry a sound, and, in other respects, unobjectionable old man, than an unsound and debauched young one. We admit this, but contend that it would be better for her and for society, as a general rule, to avoid both. 
Professor Caldwell says, and Mr. Combe has indorsed it, that " old men should in no case contract marriages likely to prove fruitful. Age has impaired their constitutional qualities, which descending to their offspring, the practice tends to deteriorate our race. It is rare for descendants of men far advanced in years to be distinguished for high qualities of either body or mind." 
In this quotation there are two errors—one of principle and one of fact; and we are surprised that either of these distinguished gentlemen should have committed them. Our Creator, in fixing the constitution of the female, so arranged it that she should not have children when she became too old to entail upon them vigor both of body and mind ; and no reasonable man can doubt that he would have similarly constituted the male, if, in his arrangements, there had existed the same necessity for it. To allow to man the power of performing a function, in connection with a strong desire to do it, and yet deny to him the privilege of doing it, would be just cause for the impeachment of his wisdom. 
Young women have as fine and as vigorous daughters by old men, as they could have had by any other class of men. By such husbands they were never intended to have sons, and when they do, it is in consequence of some fault in their own constitution. The sons of such marriages should have been 


100 
IMPROPER MARRIAGES. 
daughters, and in being daughters, they should not have been at all. It is true, that old men but rarely, or never, have distinguished sons, but they have what is more valuable, daughters who may become distinguished through their sons. 
There is yet another and frequent alliance, particularly in our cities, which is still more incompatible than either of the preceding, because it is very generally attended with the premature death of one of the parties, with the nonproduction of issue, or, if produced, they possess a feeble constitution and but rarely fail to meet an early grave. We allude to an extreme difference in the strength of the sexual desires of the parties. The man or woman who possesses an extraordinary strength in this respect, is a monster—as much so as the other extreme. Both extremes are fruitless. Judicious and wellinformed parents would sooner yield their daughter, who has a delicate person with an extremely small neck, to an executioner, than in marriage to a man who is firm in muscle, and withal has a neck enormously developed in a backward direction. She will not only prove barren, but by worse than any known brutality, be forced into a premature grave. A lady in Maryland, some years since, obtained a divorce from her husband, on this ground, and never was there a divorce more justly granted. 
There are many incompatibilities of less magnitude, which however, produce much mischief in society. One of them is an incompatibility of temper or disposition. If the injury did not extend beyond the parties themselves, and cast its shadow far in the future, we might excuse legislators and judicial tribunals for refusing to grant divorces upon such a plea. But when we contemplate the fact that unhappy parents can produce neither healthy nor happily constituted children, the apparently small and insignificant incompatibility becomes one of enormous dimensions. Leaving out of the account petulance and capriciousness of temper, if we could furnish the statistics of manslaughter and suicide which have resulted from this incompatibility of temper between parents, it would be contemplated by the popular mind with wonder and astonishment. 
Powerful illustrations of the truth of these remarks are frequently to be met with in the cotton and sugar planting 


PRESENT HEALTH AND QUALIFICATIONS. 
101 
districts of our country. The negro children on those plantations which are governed by kind and discreet overseers, are playful, healthy, buoyant, and cheerful; while those whose parents are under the government of heartless task-masters, appear to be sour and careworn—taciturn and unhappy—so destitute of both physical and mental energy, as to become the legitimate food of the first epidemic that visits that quarter. 
Could any better fruit than this be expected of a mother who receives a cowhiding in the morning, sees her children whipped through the day, and her husband at night ? Parents, then, who cannot live in peace and happiness with each other, should, for the good of society, separate; and as the well-being of society is paramount to every other consideration, no obstacles should be interposed to prevent those from separating who do not desire to live together. Our divorce laws are doomed to undergo a total change when the constitution of the human mind and the influence which parental discord has upon the health, happiness, and usefulness of progeny shall become to be properly understood. 
SECTION IV. 
PRESENT HEALTH AND QUALIFICATIONS. 
By present health, the condition of the parents at the time of marriage, is to be understood. It might, a priori, be reasonably concluded that no one would venture or presume to contract a marriage alliance under any variety of permanent or greatly incurable disease; such as either gout, cancer, apoplexy, scrofula, consumption, occasional insanity, or secondary syphilis; but such is the state of human depravity, that through selfishness, recklessness, or thoughtlessness, the utmost care is sometimes practiced to conceal the presence of existing disease. 
We have not yet presented the most depraved view of the picture. Marriage is frequently contracted when the existence of such disease, in one of the parties, is known to the other. This may sometimes happen through an ignorance of 


PRESENT HEALTH AND QUALIFICATIONS. 
102 
the laws of hereditary descent, but it most generally does happen through a highly culpable and equally degrading sacrifice of the prospective health and happiness of progeny at the shrine of fortune and influence. 
We had, a few days since, from a very intelligent lady, the history of a case that is worth relating, and one that came under her own knowledge. 
An Irish lady was addressed by an officer of the British army —she declined his suit on the ground that she possessed a scrofulous constitution. He assured her that this should be with him no objection ; but she persisted in refusing to become the wife of any one, for the reason before assigned. At length he informed her that his condition was that of hers, and convinced her that such was the fact, by showing her the unmistakable evidence that he had, at an antecedent period, been intimately acquainted with the "King's evil." At length she consented to have him—they were married—had many children, and all of them died at an early period, after much scrofulous suffering. As hereditary diseases are held in more abhorrence in Europe than they are here, the consequences of such an alliance were well known to them. Knowing the complying character of woman, when she loves, we can excuse her, but what must we think of him ?—a man, too, capable of defending his country in an official capacity. 
There is yet another condition which is entirely incompatible with marriage, and we introduce it because there are very few young physicians who know anything about it; indeed, there are but few of any age, who have had experience on the subject. 
A medical gentleman, who had had an extensive practice in the city of New York, and with this general practice he had much of that which is known as "private diseases." He assured us that he was never able to cure a child (under the age of one year) of a man who had practiced, to much extent, self-pollution. He, of course, associated the previous practice of the sire with the fate of the child, in the relation of cause and effect; but this may not be correct, or it may bo only in part so. 
Let it be remembered, and we think that we have probably 


PRESENT HEALTH AND QUALIFICATIONS. 
103 
made the remark somewhere else, that those who are organically disposed or forced to self-pollution, have generally that division of the vital forces which was intended for the perpetuation of the species, in high endowment, while those upon which their own existence depended, are generally very feeble. The case of Kennedy, page 20, is an illustration of this condition. The unviable condition of the children, may depend upon the feeble endowments of the father, or upon his abuse of them, or upon both. 
In our large cities, men are probably more guilty of fornication, and women of masturbation, but both injure the constitution and defeat the expectations of marriage. 
But, beside the existence of either of the diseases abovenamed, or even a predisposition to either of them, there are moral manifestations of morbid action which should as certainly be a bar to marriage—such as gambling, the tippling use of ardent spirits, and dissipation in general. They are very nearly as incurable as consumption and are as transmissible. 
In both sexes there sometimes exists physical disqualifications for the principal function or object of marriage. It is truly astonishing that either sex would enter into such an alliance, under such circumstances, when the merest commonsense cannot avoid assuring them that if made, it will and should be broken. r 
Early in our professional life, a. gentleman of polite and liberal acquirements, a few days before the appointed time of his marriage, called upon us and submitted his sexual apparatus to our inspection, for a professional opinion. The testes were contained in two separate and independent sacks, and the urethra terminated, anteriorly, between them. The original track of the urethra was a hardened cicatrix, which, acting as an unyielding cord, drew the penis into a little more than a semicircle when erected. As might rationally be supposed, we advised him to abondon forever all idea of placing himself in the position of a husband, and he agreed to break up the marriage agreement he had contracted ; but, nevertheless, in three days he complied with his engagement to the lady, and in a few weeks after she left him. From a gentleman of engaging and courtly manners and enterprising habits, 


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he became, from this event, a bloated sot, and died most disgustingly scabious. 
Beside an equal disability on the part of females, there are other conditions which should sometimes cause them to prefer celibacy to the hazards of matrimony. Women much advanced beyond the usual period of matrimony, of a dry, dense, and fibrous system, can but rarely become a mother without the cost of her life —her paturient apparatus absolutely refuses to perform the function for which it was intended. 
On the other hand, there are many young women of stinted development and feeble stamina, with whom every particle of life is expended upon the parturient function, and even then a failure not unfrequently results. The cost, then, of becoming a mother, a probable event, should be well calculated by these two classes of women before venturing to become wives. 
Professor Dewees, speaking of the parturient difficulties that attend early marriages, asks the question, "Do not these facts emphatically declare there is a time best for marriage? This time we shall fix at nineteen for the earliest, and thirty for the latest periods." 
Every girl, who feels that she has arrived at womanhood, will be facetiously disposed to inquire what right he had to fix the age at which she should marry, when her Creator had fixed it at a much earlier period ? 
We cannot make war upon nature's institutions, but we do upon the violations of them. The proper question for girls and parents to consider is fitness, for the functions of a mother.* 
* We are, upon this subject, much disposed to agree with an aged and reverend gentleman whom we knew in Pennsylvania. When called upon to consummate a marriage, his daughter would say, " Why, pa, she is too young ;" then he inquired, " Is she large enough V and upon being informed that she was, he would remark, " Then she is old enough." Upon other occasions, she would say to him that the bride was too small, and then he inquired if she was old enough, and upon receiving an affirmative answer, he would remark, " Then, she is large enough." This is our opinion, presupposing that the organic laws, which govern in the premises, have been obeyed by her ancestors and by herself. 


CHAPTER II, 
INFLUENCE OF MATERNAL CONDITIONS ON THE FETUS. 
INTRODUCTION. 
If it be true that the impressions made upon the maternal mind or body can affect the fetus, the fact should be placed beyond controversy, because, such is our faith in the wisdom of all the natural laws, that their discovery and establishment must contribute to the improvement of the human race; for if such a possibility exists, it is to the advantage of the species, while the injurious consequences fall only upon individuals. 
If such a possibility exists, it can be the recipient of favorable impressions, as well as those of a contrary character. It is, therefore, all important to settle the question, as one of fact, because women, in general, seem not to know or believe that any impression can influence their offspring, except one of fear or apprehension. This general conviction should be eradicated, and the profession should be active in trying to effect it. 
Such is our conviction of the affirmative of this question, and such our estimate of the value of truth, that we beg our readers to excuse us, in the event that we shall prosecute the subject to an extent beyond what they may deem necessary. 
The question is one of inference from facts, and to acknowledge it as such, displays no exercise of credulity, it is a mere acknowledgment of coincidence, and upon the same kind of evidence that we admit the conclusion that the brain is the instrument of the mental functions ; and the phenomena are as explicable in the one case as in the other. 
(105) 


PSYCHOLOGICAL INFLUENCE OF 
106 
SECTION I. 
PSYCHOLOGICAL INFLUENCE OF THE MOTHER ON THE FETUS. 
The opinion that impressions made upon the mother's mind may, and very frequently do, affect the fetus, is regarded by some as being, in point of fact, true; and by others as false and delusive. The former, under the conviction that all truth should be known and defended, do not hesitate to avow their convictions; while the latter, no doubt from equally honest motives, deprecate the doctrine as being greatly mischievous in its influence upon the female mind. One thing is certain, that so far as we know to the contrary, it is as old as the human race, and almost universally believed by all nations, both civil and savage. 
It has been our lot to become convinced, that however much we may decry the philosophy of the ancients, we are bound to respect their observations. They did not possess our advantages to become learned, and, consequently, having to rely almost exclusively upon themselves, their observations were directed with more careful attention; and to be correctly informed that Galen and Hippocrates maintained the opinion, as one of fact, is sufficient to secure our respect for it. 
Those who contend for the negative, refer us to the existing anatomical relations between the mother and her fetus. They assure us that the connection between them is entirely through the circulation—that no nervous communication has ever been detected—that there is no direct communication of any kind; and hence, they conclude that it is impossible that any arterial or nervous condition of the mother can affect or influence those systems of the fetus. 
It appears to us that the man who can, on this account, reject the doctrine, and all the facts that sustain it, is capable of rejecting a fact because he cannot explain it. Our knowledge of human dynamics would be reduced to a very small compass if we were to reject everything for which the anatomist has not detected an appropriate apparatus. Upon this principle we might deny that the brain is the apparatus of thought and feeling—that there is any difference between the 


THE MOTHER ON THE FETUS. 
107 
nerves of motion and sensation, and reject the whole doctrine, that the agency of the male is requisite in the work of procreation. 
Notwithstanding the almost independent existence of the mother and fetus from each other, it is admitted on all hands, even by those who deny the doctrine under consideration, that the existence of the fetus produces nausea and vomiting in the mother—that it produces a " longing " or desire for unusual, and frequently, for the most filthy species of food, as putrid fish and " bacon skin from a soap kettle." If the connection between the mother and fetus is so indirect and insignificant, that impressions upon the former cannot affect the latter, how does it happen that the latter can so powerfully affect the former ? In all other known instances a rule will work both ways. 
Dr. Dewees, who repels the doctrine, says, "Nothing contributes more certainly to the safety and future good health of the child, than cheerfulness of mind ; or, at least, equanimity on the part of the mother: this fact was well known to the ancients ; and they acted upon it accordingly, by giving great attention to the little wants of the pregnant women." Again, he says, "It would appear that the woman has an important duty to perform, during the whole period of utero-gestation ; that her offspring may not suffer, in either body or mind by her imprudence," etc. Again, he continues, " She may entail [by neglect of duty] a frail constitution of body, or perpetual feebleness of mind, or even fatuity itself." 
Now, suppose a person, who is ignorant of the anatomical relations in question, to read these extracts, would he not conclude that the connection between the mother and her fetus was peculiarly, direct and intimate ? 
Of all the tasks that men are called upon to perform, that of being consistent in the defense of error is the greatest — truth will occasionally peep through the fogs of error with the brightness of the sun's rays through broken clouds. In our judgment, the confessions contained in the above extracts are fatal to his defense of the negative of the question under consideration. 
We are not contending that hopes, fears, and frights pro- 
duce all the calamities that are known to happen to fetuses, 


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any more than we contend that utero-gestation is the cause of all the nausea, vomitings, and longings of the mother; and when it is admitted that a fit of anger may produce abortion— that irritability and petulance of disposition may greatly injure the future health and mind of the child, the substance of the whole question is conceded. 
There are other phenomena in the human economy much more obscurely connected with their cause, than the facts contended for in the premises. The connection of the semen masculinum, in the vagina, with the ovum is as obscure and indirect as that between the mother and fetus, and yet, through this double difficulty—this double obscurity, fathers entail their present and accidental condition upon their children. As an illustration of this truth, we cite one case, out of many which are at our command. Mr. George Combe (Constitution of Man) informs us, that " a man's first child was of sound mind ; afterward he had a fall from his horse,, by which his head was much injured. His next two children proved to be idiots. After this he was trepanned, and had other children, and they turned out to be of sound mind." 
But even such cases as these do not prove or illustrate the entire strength of our position. It is now a well known fact, that both men and the males of the inferior animals transmit to their progeny their acquired habits and peculiarities. The English fox-hound was crossed with the Spanish pointer, and the progeny trained to stand at game, and after being thus trained, their puppies were seen, untrained, to stand at swallows and pigeons. 
The whole subject of human impressibility is closely allied to the one under consideration; indeed, the latter is only a fragment of the former, and therefore illustrations of the one are equally applicable to the other. 
Intellectual and educated men at the present day do not pretend to believe that amulets and other kindred means can exert an influence either in the cure or prevention of disease, or in anywise affect the human solids or fluids ; and yet, they admit themselves to be greatly puzzled with the coincidences w T hich they have been forced to observe between the assigned causes and certain obvious results. 
An old gentleman, highly educated in some of the exact 


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sciences, very unimpressible and incredulous, was afflicted with rheumatism, and upon complaining of it in the presence of some gentlemen, one of them told him that if he would carry, in his pocket, constantly, a buckeye nut, he would not be afflicted with the disease any more, and as he concluded his prescription, he handed him one. He has carried the buckeye ever since, says that it is light and of no inconvenience to him—professes no faith in its influence—laughs at the idea, but admits that he has not been afflicted with the disease since. 
The writer, while a student of medicine, had a large wart on his ring-finger, and shortly after he engaged in practice, a young lady asked him why he did not remove the " ugly wart" from his finger; he answered that he intended to do it when the weather became a little warmer. She then told him that if he would agree to cure her of the ague the next fall, she would remove his wart. He, of course, assented to it. She obtained a bit of chalk and rubbed the wart until it became white, and then made a mark on the back wall of the fireplace, remarking at the time, that when the mark became obliterated the wart would be gone. He laughed at this as a bit of girlish mischief, and thought no more of it at the time. Some two or three weeks subsequently, he was dressing his finger-nails, and happening, spontaneously, to cast his eyes upon the wart, he discovered, with considerable astonishment, that it was nearly gone ; and in a few days more no trace of it was to be seen, nor has it ever reappeared. 
A gentleman in Memphis, of a high order of intellect and respectable acquirements, but constitutionally very impressible, informed the writer that when he was a schoolboy, it was a prevailing opinion among the boys that if the water in which eggs have been boiled happen to get upon the human skin, it would produce a crop of warts; and, one morning when at breakfast, he offended his little sister, who, for revenge, threw some tea on his hand, telling him that it was egg-water. In a few days his hand was covered with small warts which grew to Buch a size as to render his hand a disgusting object. Subsequently a boy told him that if he would wash his hand in 
the first stump-water he found, they would all go away; and 


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he did so, and in a few clays, comparatively, they were gone, and he had had none since. 
A lady, in Cincinnati, the handsome widow of a late wealthy merchant, had a wart on her hand, and being in the store attending to some business, a country woman came in and observed the wart, and remarked, " You have an ugly wart on your hand." " Yes," answered the lady, " and I would give a good deal to have it off." " I will take it off for you," said the woman. " If you will," said the lady, " I will give you the handsomest silk dress in the store." The woman pricked the wart with a needle until it bled, she then stained a boss thread with the blood, inclosed it in some paper, and walked off. The lady, as in the case of the writer, had no faith in the remedy, and therefore thought no more about it. Some weeks afterward the woman called again at the store and remarked to the lady, " I see that your wart is gone." The nature of the remark caused the lady to remember the circumstance of the wart, and to recognize the one who had relieved her of it, answered, " Yes, and I owe you the best silk dress in the store," and forthwith cut it off for her. 
Now, in these instances, and hundreds of others of a similar character of which we have been credibly informed, not knowing anything of the modus operandi of the assigned cause, we do not know that the one depended upon the other in the relation of cause and effect. We must confess, however, that they place us in a dilemma out of which we cannot escape. If we deny that the effect was produced by the assigned cause, it may be inquired why the effect was produced in the time that would have been expected from a known and adequate cause ? If we affirm that the assigned cause did produce the result, then comes the question, how did it effect it ? In the first position, we cannot deny; and, in the second, we cannot explain; the first, therefore, is sustained by the greater probability, for the reason that a given cause may effect a given result, although we cannot comprehend its modus operandi. 
In the same category of incomprehensible phenomena must be placed the fact that some species of snakes capture birds by impressing their minds. Some people, however, deny this, but as the writer has seen it, and shot a black snake in the 


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act of taking a small bird into its mouth, it is not probable that he will be convinced that they do not do it. 
The assertion of Dr. Hunter that he could not authenticate a single instance in two thousand cases in a lying-in hospital in which impressions upon the mother's mind had marked the child, proves about as much as the denial of the late Professor Harrison, of New Orleans, that the white substance of the brain was fibrous, after we had made such an exhibition of it that every one present, but him, saw it. 
As no mother can know whether her child has been injured or marked before she sees it, it is not to be expected that every one who entertains such apprehensions should find them realized ; and, on the contrary, it is not to be expected that every mother who has received an impression should either remember it, or found upon it apprehensions of something disastrous to the child. In the present state of our acquaintance with human physiology, we cannot, and dare not, without presumption, assert that a very slight apprehension, made upon the mind under favorable circumstances, may not produce upon some part of the system a very marked result. 
A gentleman, about fifty-five years of age, highly intelligent and of a sanguine bilious lymphatic constitution, called upon the writer in his cabinet, and exhibited to him a highly aggravated case of parenchyma of the thumb, stating that he desired for a little while, the use of a piece of loadstone, or natural magnet, to reduce the swelling and inflammation of his thumb with. We gave him a piece very strongly charged, which weighed about a pound and a-half, and not having any faith in the virtue of such an application we desired to witness the operation. He carried it over the thumb, but close to it, from the extremity toward the elbow, and then by a semicircular movement brought it back again. He continued this operation about an hour, in which time the thumb became much reduced in size, and from a deep florid color it became nearly white. Now, the question is, were these effects produced by the magnet or by his faith in its application ? We must admit the one or the other, and when admitted we are as much in the dark about the modus operandi, as we can be about the psychological influence of the mother on her fetus. 


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1. Mrs. G., who was well known to the writer, upon going home rather late one evening from a neighbor's house, became frightened at a mole. The circumstance inspired her with fearful apprehensions, which upon the birth of the child were discovered to have been well founded, for its hands were turned outward like those of a mole. It lived but a few days. 
2. A friend of the writer, a Scotchman, lost his mother in the act of his birth; shortly after this event his father came to this country and never returned; but twenty years after, his son came to this country, and when they met the following dialogue took place: 
Father. " You say that you are my son; please to tell me how you know it ?" 
Son. " I do not know it, but I was so informed by my connections in Scotland." 
Father. " But how do you know that I am the identical individual of whom your relations informed you ?" 
Son. " I do not know it, but I have inferred it from circumstances connected with you." 
Father. " What are those circumstances ?" 
Son. " You appear to be about the proper age—you have the person which I expected to see, and I have found you living where I was instructed to go, and you have the proper name." 
Father. " Such evidence may satisfy you, but it will not do for me. Take off your coat; now take off your shirt; now turn your back to me—you are my son!" and he threw his arms around him, and kissed him, and wept upon him. When he had so far recovered from his joy, he proceeded : " I will now tell you how I know you to be my son. When I married your mother, she would not eat eggs, but sometime afterward, w T hen she was carrying you, I was approaching my door, unobserved by her, and found her standing in the door picking the shell from a roasted egg. 'Ah !' said I, to her, 'you have come to that, have you?' at which she threw the egg at me, and I caught it in my hand, and as I raised my arm to throw it back at her, she turned her back to me, and I hit her in the middle of it, and here is the splash it made upon your back." 
The writer has no doubt of the truth of the above state- 


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ment —he has seen the mark, and knows of nothing but an <jgg that could have made such a splash. 
3. Mr. F., a good scholar and able mathematician, thirtyfive years since a teacher of the writer in mathematics, was very greatly deformed in his body; when down, he could not get up, nor could he do more than get the points of his fingers to his face or any part of his head. "When he moved, he did it by the aid of a long stick which he would project and plant before him, and then drag his body upon the points of his toes, with a serpentine motion after it. The last joint of each fore-finger had the shape of a snake's head, and always had, to the balance of the finger, the position which a snake's head usually holds to its neck. He was very strong in his neck and jaws, and when angry he desired to bite. He could neither mount nor dismount from a horse, and yet he traveled much on horseback; and when his horse would run away or become unmanageable, he would pitch himself headforemost upon the ground. He was the most talented and enterprising member of the family. 
The cause assigned by his mother for his condition was the coiling of a snake around her ancle. The writer has heard her narrate the circumstances of the event, and the conviction it produced on her mind that it would prove unfortunate to her child. ' 
4. "Esquiral, a celebrated French medical writer, in adverting to the causes of madness, mentions that many children whose existence dated from periods when the horrors of the French revolution were at their height, turned out subsequently to be weak, nervous, and irritable in mind, extremely susceptible of impressions, and liable to be thrown by the least extraordinary excitement into absolute insanity."— Combe's Constitution of Man. 
5. "A lady of considerable talent wrote as follows to a phrenological friend: ' From the age of two years I foresaw that my eldest son's restlessness would ruin him, and it has been even so. Yet he was kind, brave, and affectionate. I read the Iliad for six months before he saw the light, and have often wondered if that could have any influence on him. He was actually an Achilles.'"— Combe's Constitution of Man. Cs. The following case, by S. Sleeper, M. D., is reported at 
8 


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more length than was necessary to our purpose, and hence we have availed ourselves of its important facts only. 
Mrs. B., aged about thirty-four years, and of more than ordinary strength of mind and cultivated intellect, in the sixth month of gestation, with unusually good health, for one in her situation, and buoyant spirits at her prospects of issue, which she much desired, was compelled to see and hear frequently a young bear from California, which was housed upon a lot adjoining her residence—it made what she called an " unearthly noise," but one that much resembled that which a lunatic brother of hers made while a member of her family. This noise gave her much trouble, she strove against it, but to no appreciable effect. She never saw the animal without having her mental equilibrium much affected. Her health declined, and before the full period of gestation arrived, she had all those troublesome symptoms that the gravid uterus frequently produces, and in the most aggravated forms. 
Finally the child was born, and lived about twenty hours. Dr. L. Sleeper and Dr. Darland then examined its physical conformation, and the following is their report of it: "The feet and ancles resemble talipes vulgus —the soles of the feet are flat, and the heels project beyond the usual length; the thighs are flexed upon the abdomen, and the flexor muscles so contracted as not to admit of full extension, without violence to the tissues involved; the same is the case with the superior extremities, they could not be raised above a right angle with the body; the wrists turn outwardly; the fingers overlap each other ; the nails are elevated on the dorsum and quite pointed—much resembling claws; the arms, legs, and back are covered with a fine hair, from three to six lines in length, and of a dark brown color, and so abundant as to strike all with astonishment; the skin on the back and extremities was remarkably rough; the face and head appeared natural."— Medical Examiner. 
The gentleman who can separate this monstrosity from the assigned cause of it, must have a very pliable imagination. 
7. By B. F. Hatch, M. D. " Six years ago my brother had in his employ, as domestics, a young married couple, who procured a turtle about the second month of her pregnancy, with which she used to amuse herself by placing a coal of fire 


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upon its back, to witness its struggles for relief. In this case there was no fright: but for some weeks a daily recreation. The birth of the child clearly evinced the folly of the mother. Its deformity was frightful in the extreme. The upper jaw was entirely wanting, there being nothing to fill the space between the lower jaw and the nose. The nose was merely a fleshy flap with a tooth protruding from its end. Its head was so greatly deformed as hardly to be considered human ; it fortunately died in about two weeks." — Boston Domestic Journal of Medicine, Vol. 1, JVb. 8. 
8. By M. J. McCormack, M. D. " The first case I will allude to is a near relative (an uncle), who presents a very extraordinary mark all down his thigh and leg, which (strange though it may seem, is nevertheless true) is much more vivid and prominent during the summer season than any other time. The appearance it then presents is that of a red currant tree branch in full fruit; the fruit being regularly raised and standing out of the cuticle, having a bruised appearance, with the juice squirted all over the limb. Now, in connection with this is the circumstance of his mother, when not more than six weeks or two months pregnant with him, being engaged (as the ladies of that period were in the habit of being) in making some preserves from red currants; and while in the act of squeezing the muslin bag containing the fruit, it burst and covered her whole face. Being a woman of strong presence of mind, and being fully impressed with the prejujudices of that day, of the effect the mother's mind had on the child, instead of putting her hand up to her face, at once passed it down the thigh and leg; at the time she did so she declared it was to prevent her offspring being disfigured ; the result was as above described. I may further add, that the party alluded to is now a very distinguished officer in her majesty's navy, and I have myself often seen the appearance of the leg, which in summer is very startling."— London Lancet. 
In this case the mark seems to have resulted from the circumstance, but its location was from her volition, and this peculiarity renders the case more confirmatory, but at the same time more mysterious. 
The three following very interesting cases we extract from the New York Scalpel: 


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"A few years since, we were requested by Dr. Moore Hoyt, a gentleman whose powers of observation and veracity will not be questioned in this city, to examine an infant of a few months' age, and to bring with us our pencil and a bit of Bristol board, as he designed to publish a description and drawing of the case he wished to submit to our notice. "We found a very healthy child and mother; the former presenting an eschar directly across the patella—or knee-pan, as it is called by the people—of each knee. They were of irregular form, as if made by the scratch of a nail or pointed instrument, and from two to two and a-half inches in length. The doctor was much astonished to observe these wounds at the birth, as there was no instrument or hard substance near, and the labor was perfectly natural. On careful examination of the eschars, this astonishment was greatly increased, by observing that the wound on one knee was half united by a recent cicatrix. This was sufficiently defined to put its character beyond a doubt. No one in this city who knows Dr. Hoyt will question the accuracy of his conclusion, or his want of sufficient interest in so remarkable a case, to induce a thorough and critical examination. It was then evident, that this state of the knees had been produced within the womb. But how ? The mother had spent, for a number of days, some hours daily on her knees, leaning over a cradle, and nursing a sick child. She complained of pain on arising, but did not anticipate any deformity in her child. When we saw the eschars, they were completely healed. This process, Dr. Hoyt informed us, went on without interruption. 
" The next case occurred in our own practice. A lady of great equanimity of temper, and extremely delicate constitution, during the second month of gestation was presented by her husband with a pair of earrings. These she was exceedingly desirous to wear the same evening to a party, but found it impossible to insert the hoop into one ear, as the hole had partially grown up. The attempt was therefore abandoned, with some disappointment, and the expression of apprehension that her child would be marked. We were consulted on this point, a few days after the event, and asked if such things were ever true. We unhesitatingly answered, no ; for at that time we treated such stories with ridicule. Judge, then, of 


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our surprise on observing one of the ears of the child present, at birth, a hole in the center of one lobe of the ear, so nearly perforated, that, on stretching it slightly with two fingers, the unperforated part proved so thin as to be absolutely diaphanous ; a deep cleft running downward for a quarter of an inch from the center of the hole. 
" But these cases, astonishing as they are, are far surpassed in interest by one, which, from its very peculiar nature, it was impossible for us to authenticate by personal inquiry and observation. The high respectability of the parties who were our informants, and the circumstances under which the case was related to us, leave no other course than to give the facts, however wonderful, our entire belief. In narrating it, the parties must be nameless, as all, so far as we know, are living. "We trust they will perceive our intention, and impute it solely to our desire to post up a matter of intense interest to humanity and science. 
"Mr. A., of the northern part of this state, married, some forty years since, a lady of an adjoining state. Pecuniary circumstances, at the time of the marriage, rendered offspring undesirable. Within a year, however, it became evident to the wife that their wishes were no longer to be realized ; on expressing this belief to her husband, she was, at the moment, quite shocked at the dissatisfaction with which he received it. Taking his hat shortly afterward, he left the house, and was absent for nearly an hour. He was distressed, on his return, to find his wife in tears. He assured her immediately (for they were devotedly attached) that he was rejoiced to learn the probable realization of her announcement; that he was now satisfied with the condition of his pecuniary affairs and convinced of their stability. 
" The wife dried her tears, but soon expressed her conviction that, in some way, her expected offspring would suffer from her agitation. The husband endeavored to remove her apprehensions, by gentle and affectionate ridicule. But her fears continued at intervals during her early months, and gradually increased as gestation advanced. The relief of the parties was great, at the birth of a healthy and well-formed boy. No peculiarity of conduct in the child was observed, until several moniis had elapsed, and then their fears were renewed, by its 


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extreme unwillingness to approach the father. This gradually increased, until its dissatisfaction was manifested by loud and continued screaming when brought near him. As age advanced, the most persevering efforts were made to overcome this repugnance; the utmost degree of persuasiveness and ingenuity, diversity of childish gifts and sports, all were tried in vain, and the attempt was abandoned in despair. The feelings of the father may be judged by parents, for he was, and is, an exceedingly affectionate man. 
" This continued, and at the time of our receiving the information from a near personal relative, the son, then an active and rising member of the bar, had never been able to speak a word to his father, though the most painful efforts were made. 
" "We give this case as we heard it from a lady and her husband, whom to know is to revere. It was told us by the lady just arising from what we all supposed would be her deathbed, and an offer was made at the time to introduce us to the parties. We now regret that our years induced us to decline the proffered introduction. We did not feel willing, at the time, to make any personal inquiries in a matter that had been productive of so much distress, and that time had somewhat alleviated. 
" The next case was related to us by Dr. Cox, now practicing at Williamsburg, Long Island. Dr. Cox is certainly authority that few who know him will doubt. His urbanity and truthfulness are known. A lady constantly attended upon her dying father; his disease was a cancer on the forehead, and required repeated daily dressing: this was done by the daughter, who was in the early period of pregnancy. In a few months the father died, and the daughter was delivered, at the full period, of an infant disfigured by a large tumor on the forehead. This, the doctor assured us, became an open sore, in all respects similar to the one of which its grandfather died. It resisted every application, and soon terminated the child's life. No one, Dr. C. observed to us, could have told it from a cancer." 
The preceding cases present an illustration of each possible class of psychological impression—in some, fearful apprehensions were entertained, from the previous mental shock; in 


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one the fetus suffered from the mother's amusement, where no apprehension existed; in another no apprehension existed, but the fetal injury was directly referable to the mother's uncomfortable situation at a given time; in another the fetus was marked on the leg instead of the face, and the choice was determined by the mother's volition ; in another the fetus suffered through the mental agitation of society ; in another the mother's repugnance to the father, at a particular moment, was entailed upon the child for life, to which a very similar case now exists in Cincinnati. 
In some of these cases, the cause embraced no object—it was mental, and therefore it could only affect the fetus, mentally ; while others of them had direct reference to the fetal body, and it alone suffered. 
Finally, all of them hold such a natural relation to their assigned causes, as to render it far more difficult to doubt, than to believe. 
SECTION II. 
INFLUENCE OF CHILDREN ON A MOTHER BY A FIRST HUSBAND, WITH REFERENCE TO CHILDREN BY A SECOND. 
This subject, if possible, is more mysterious than the former, and probably not less important in its intended influences upon society, and therefore its discussion and establishment, beyond doubt or equivocation, will have that influence which is extended to all the organic laws, that admonish us with reference to all that is near and dear to us in life. 
The conclusion contended for, under the circumstances, is, that a mother's constitutional identity becomes merged in that of her first husband, and consequently her children, by a second husband, will not resemble their father nor inherit his qualities, necessarily, nor her own, but those of her first husband. 
In support of this law, there is not wanting an abundance of facts—enough to arrest avaricious parents in the sale of their daughters to old and debauched rakes for property, under the expectation that they will soon die—enough to convince 


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young women that just as certain as they shall have one child by such a creature, her own constitution becomes as base as his—nay, more, that she has bartered for property or some other unworthy consideration that power which she originally possessed, to render justice to a second husband (through his children), whom she may wed through love and affection. But to the facts. 
It is now an undoubted fact, a fact admitted by every one conversant with the subject, that a mare, after having a foal by an ass, will never after bear a colt by a pure-blooded horse that will not possess qualities and resemblances of the ass ; and among stock raisers, no one can be found who would put a mare, no matter how excellent her blood, to the best or any other blooded horse, after she has once had a colt by an ass. 
"When the writer was a student of medicine, Professor Caldwell, in support of his doctrines of sympathy, introduced the following well known fact: Lord Morton had a finely blooded mare, and, by an accident, a quagga (which is a variety, possibly a species, of the wild ass of Africa) found an opportunity to cover her once, and after the due term of pregnancy she had a hybrid foal which in very many respects, bore strong resemblances to the quagga. In the proper season of the three succeeding years, she was covered by a black Arabian horse, and she had three foals, all of which, however, bore strong resemblances to the quagga. These facts may also be found in a late number of the New York Scalpel. 
To the same point there is another fact which we add: 
"A mare belonging to Sir Gore Ouseley, was covered by a zebra, and she gave birth to a striped hybrid. The year following, the same mare was covered by a thorough-bred horse, and the next succeeding year by another horse. Both of the foals thus produced were stripid, i. e., partook of the character of the zebra."— Soalpel. 
In the preceding cases, it is proper to remark, that the males were of species widely differing from their own, consequently other evidence becomes requisite for the establishment of the proposition : but this can be easily done. 
Mr. McGillivray states, that u in several foals, in the royal stud at Hampton Court, got by the horse Actseon, there were unequivocal marks of the horse Colonel—the dams of these 


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foals were bred from by the Colonel the previous year. Again, a colt, the property of the Earl of Suffield, got by Laurel, so resembled another horse, Camel, ' that it was whispered, nay even asserted at Newmarket, that he must have been got by Camel.' It was ascertained, however, that the mother of the colt was covered the previous year by Camel."— Scalpel. 
Facts like the preceding are well known among all growers of cattle, hogs, and dogs; but, while upon the subject, we may as well present two or three more facts from the same excellent authority, Mr, McGillivray, 
He says: "It has often been observed, that a well-bred bitch, if she has been impregnated by a mongrel, will not, although lined subsequently by a pure dog, bear thoroughbred puppies in the next two or three litters." 
" The like occurrence has been noticed in respect to the sow. A sow of the black and white breed (known as Mr. Western's breed) became pregnant by a boar of the wild breed, of a deep chesnut color. The pigs produced were duly mixed, the color of the boar in some of them was very predominant. The sow being afterward put to a boar of the same breed with her own, some of the produce were observed to be stained or marked with the chesnut color that prevailed in the former litter; and, on a subsequent impregnation, the boar being still the same breed with the sow, some of the litter were also slightly marked with the chesnut color." 
"A pure Aberdeen heifer was served with a pure Teeswater bull, to whom she had a first-cross calf. The following season the same cow was served with a pure Aberdeenshire bull; the produce was a cross calf, which at two years had very long horns, the parents both hummel. A pure Aberdeenshire cow was served, in 1845, with a cross bull, i. e., an animal produced between a first-cross cow and a pure Teeswater bull. To this bull she had a cross calf. Next season she was served with a pure Aberdeenshire bull—the calf was quite a cross in shape and color," 
To settle this question, pretty conclusively, we have presented facts enough from the inferior animals, but as man has ever, if not philosophically, at least practically, considered himself an exception to all the laws that govern the former, 


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observations enough, bearing upon the same subject, have not been made upon human society to produce an equal conviction ; we have, however, a few, which are much to the point. But we do not believe that they so frequently occur, and for this opinion our reason is this: The females of the domesticated inferior animals have no choice as to the males with which they shall have connection, constitutional incompatibilities, though of good blood in the abstract, may frequently be brought together; but with man there exists an inherent sympathy or affinity between individuals of the two sexes, and this affinity is generally in accordance with organic law, and hence this law is more frequently infracted through mercenary motives than any other. We do exceedingly doubt whether such phenomena would result from constitutionally normal marriages. To convey more clearly our opinion, or rather suggestion, we will present cases to illustrate it. 
Suppose a bilious woman should marry a bilious man, or one of the compounds of the bilious, and more particularly one of the lean ones, as the bilious sanguine, or bilious encephalic, she would most clearly violate one of the organic laws which was intended to regulate the function of procreation ; and by so doing she has contaminated her own constitution—she has almost as greatly violated a law, as the mare which has a foal by an ass —such a man was not her choice—• she sacrificed it at the shrine of some other consideration; but she has done it. Now, suppose her to take a second husband, and in doing so makes a normal selection, possibly a sanguine, or sanguine encephalo-lymphatic one, her children, as in the case of the mare and the horse, after the former had had a mule, would partake more or less of her first husband. But, in supposing her to have made, in both instances, a normal alliance, it does not appear to us that her second children would partake of the marks and qualities of her first husband ; and for the reason that she violated no law, and in conforming to the law, she did not lose her own constitutional identity. 
We do not know that this reasoning is valid, yet we think it deserves attention in the investigation of this subject. So long as a woman obeys the organic laws of procreation, we 


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can conceive of no reason why she should lose her own constitutional identity. Our suggestion in the premises is partly the result of one case which we have observed. 
In the interior of Kentucky, a bilious encephalic lady married a bilious gentleman of the florid variety, and had children, but we never saw any of them ; subsequently she married a bilious lymphatic, though not entirely normal, was far less objectionable than the former, by whom she had one daughter. Now, let it be remembered that the first husband had reddish hair and grayish blue eyes, and the second had brown hair and eyes, and so had she. The daughter had the features of her father, one eye and the hair of one side of the head had the color which was common to both of her parents ; but the other eye was bluish gray, and the corresponding side of the head was red—marks peculiar to her mother's first husband, between whom there existed an organic incompatibility. 
In further confirmation of this subject, we have two cases by Dr. Harvey, who states that the first was communicated to him by the Reverend Charles Combie, of Tillyfour, minister of Lumphanon, in Aberdeenshire, and the second by Professor Simpson, of Edinburgh. 
" 1. Mrs. , a neighbor of Mr. Combie, was twice married, and had issue by both husbands. The children of the first marriage were five in number; of the second, three. One of these three, a daughter, bears an unmistakable resemblance to her mother's first husband. What makes the likeness the more discernible is, that there was the most marked difference in their features and general appearance, between the two husbands." 
As " there was the most marked difference in their features and general appearance, between the two husbands," it is much more than probable that they were of very different temperaments, because, between individuals of the same temperament there is something of a family likeness, invariably. In conformity, then, with our suggestion, her first husband, at least, may have possessed a constitution incompatible with her own. 
"2. A young woman, residing in Edinburgh, and born of white "(Scottish) parents, but whose mother sometime previous 


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CHILD'S INFLUENCE ON A MOTHER, ETC. 
to her marriage, had a natural (mulatto) child by a negro manservant, in Edinburgh, exhibits distinct traces of the negro." 
This case is in precise conformity with our suggestion. 
The two following cases were communicated to Dr. Harvey by Dr. George Ogilvie, and Professor Pirre, respectively: 
1. "A woman was twice married, and had children by both husbands," and those of " both marriages were scrofulous, although only the first husband had marks of this diathesis j the woman herself, and second husband, being to all appearance quite healthy." 
2. " Mrs. H., apparently, perfectly free from scrofula, married a man who died of phthisis. She had one child by him, which also died of phthisis. She next married a person who was to all appearance equally healthy as herself, and had two children by him, one of which died of phthisis, the other of tubercular mesenteric disease—having at the same time scrofulous ulceration of the under extremity." — Scalpel. 
These cases are strong, interesting, and instructive, but as they do not show that they did not originate in a violation of constitutional law, they do not really establish any new principle in the animal economy, because it has long since been conceded that mischief will forever succeed the violation of organic law. We are not informed as to the constitution of the mothers, and we can only approximate to that of the first husbands. Phthisis, idiopathically, occurs most frequently in the sanguine encephalic and sanguine encephalobilious constitutions. Now, the mothers may have been one of these, or a sanguine bilious, or a bilious encephalic. 
There is yet another question involved in this subject. We have suggested that the impression made on the female by children of a first husband may possibly result from a temperamental incompatibility between the parents; now, the question is, may not an unsoundness in the first husband constitute an organic incompatibility—such as should affect her constitutional identity ? It must certainly be a violation of organic law for a woman to have children by a man who possesses a mercurial or syphilitic disease in an occult form, or a hereditary predisposition to cancer or phthisis. 
It must now, we think, be quite obvious, that before these nice questions in physiology can be satisfactorily settled, we 


CHILD'S INFLUENCE ON A MOTHER, ETC. 
125 
must know more about the subject of the human temperaments. Nevertheless, the facts as they stand, by the exercise of proper discretion, may be rendered inservient of important consequences. They should make women prudent as to whom they take for a first husband, and men more prudent as to their marriage with widows. They should at least learn whether her first husband was mentally a villain, or corporeally a putrid mass. In either event she has probably, either through ignorance or willfulness, rendered herself unfit for a future mother. Under such a circumstance, she would much more promote the good of society by living a widow, than by becoming the mother of either social pests, or the victims of early disease and premature death. 
We have before us a case of a directly opposite characterone that has been a matter of surprise to many individuals in the community where it exists. A white man in the vicinity of Covington, Ky., had eight or nine children by a dark mulatto woman—all of the children, of course, had impressed upon them unmistakable indications of the black race. The mother of these children died, and the father married a white woman, by whom he had two children, which are now living, and which bear as indubitable marks of the black race as do many of the first children. 
We shall not attempt to found upon this, or any other one fact, a principle, and yet we may indulge a little in speculation. It will scarcely be denied as being possible that he may have absorbed, by his cutaneous surface, some of the elements peculiar to the negro constitution, by sleeping in contact with one thirty or more years. It is, further, well known that the surface of the negro emits a peculiar odor, and therefore is it not possible that he may have received, through his lungs, some of the elements of the negro constitution ? Finally, is it not possible that he may have lost his constitutional identity by sleeping and otherwise living with a colored woman for so many years ? 
Another modification of this subject comes up for a passing consideration, before we conclude. When an aboriginal female has had successful intercourse with a white man, can she afterward conceive by one of her own race ? 
By the Scalpel, we are informed that Dr. Harvey says : — 


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CHILD'S INFLUENCE ON A MOTHER, ETC. 
" This question is suggested by an observation made, in various parts of the world, by the excellent Count de Stuzelecki." That they will not, he says, that " Whenever such intercourse takes place, the native female is found to lose the power of conception on a renewal of intercourse with the male of her own race, retaining only that of procreating with the white man." 
We have been much among our south-western Indians, and although we never made any observations with reference to this question, yet we feel confident that if the fact had so existed among them, we would have heard of it. It is certainly not the case with our black women. There is now in the city of Covington, a black woman whose first child was by a white man, and yet she had, afterward, several children by a black one. 


CHAPTER III. 
OF MATERNAL DUTIES IN RELATION TO HER CHILD. 
It is not our purpose, at present, to treat of female diseases, but the duty we are endeavoring to render to children, makes it, as it has thus far been obligatory upon us, to involve the mothers in our remarks during the period that their well-being shall especially depend upon them. 
The life, health, and proper development of the child, depend upon the quality of its food, which should consist of the mother's milk, and upon indispensable attentions to its person ; consequently she should now, in a great measure, cease to think of drink, food, rest, or exercise, except in relation to the well-being of her child. Her wants should now originate in it, and not in any of her own personal desires. 
Under the influence of such a responsibility, she will carefully avoid, after the delivery of her child, every variety of drink or food which is suspected to possess a fever-producing influence. She should not attempt to sit up too soon, nor too long at a time when she does. Her chamber should admit of sufficient ventilation, and be maintained, at a comfortable temperature. Stimulating diet and drinks should, in a great measure, be avoided—the wisdom of officious old ladies to the contrary, notwithstanding. Last, but not least in point of importance, she should see but little company. To sustain this injunction, we are aware, in some sections of the country, is very difficult. The lying-in chamber is too frequently regarded as the proper place for the neighboring women to assemble for the purposes of talking and feasting. We have seen women more troubled about the accommodation of their guests than about themselves and children. As the attending (127; 


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MATERNAL DUTIES 
physician is held responsible for the proper recovery of his patient, he should protect his responsibility by ejecting from the house all those who had no other business there but to talk and eat. 
If she did not commence before the birth of her child, she should not now lose a moment of time in guarding against a common calamity, to both mother and child, known as " sore nipples." As soon as she recovers from the fatigue of parturition enough to admit of it, the child should be applied to them, and this application should be repeated as frequently as every three, four, or five hours, unless contra-indicated by some important contingency. This duty is imperious, if she would avoid the suffering to herself and the injury to her child, which are inseparable from sore nipples. We say imperious, because we regard the affection as being produced by the effort of the child to draw the milk from the greatly distended milk-vessels in a state of incipient inflammation, produced not only by this distension, but in part by an inspissated condition of the milk, which has partially obliterated the vessels themselves. In this condition of the nipples, the efforts of the child to obtain its proper nourishment, draws the skin from them, which terminates all her comfort in suckling the child, and all certainty that it will be regularly and sufficiently fed. 
As such attentions to the nipples and breast as will tend to prepare them for their important functions should not be postponed until the moment of impending danger arrives, she should, about the close of the seventh month of pregnancy, have them drawn two or three times a day by one of her children, a servant, a puppy, or a lamb. By this practice they become accustomed to the process, the cuticle is rendered pliable and delicate, the skin becomes fit for its function, and inspissation of any secretion that may happen and consequent inflammation are prevented. 
Many lotions have been recommended for hardening the nipples. Such a thought is ridiculously mechanical. Who ever knew any portion of the cutaneous surface to become hardened by washing ? By friction the epidermis is hardened and the skin rendered more healthy to a certain extent. This, in the absence of an agent to draw them, the woman can do 


IN RELATION TO HER CHILD. 
129 
for herself, by the use of her fingers and a little flour paste and warm water. This process will also keep them clean and prevent the deposition of cuticular matter in the superficial follicles, which, when it happens, never fails to irritate and inflame. For this purpose, the use of soap and water have been recommended, but soap is as incompatible to the nipple as to other parts of the surface—paste is much better, and after the use of the napkin, they should be allowed to dry in both air and light. 
When we compare the entire compatibility which nature has established between the milk of all healthy women and the development of their children, it can be regarded as but little less than criminal for her to delegate to any other woman the privilege of nursing or suckling her child. This important duty, it is true, under some contingencies, may be contraindicated, but as a general rule, even when the mother's health is far from being good, her milk is its most compatible food, for at least several of the first weeks of infancy. Furthermore, she should not allow it to be fed with anything, while very young, unless she cannot possibly support it at the breast. Careless and inexperienced nurses frequently do implant irreparable mischief in the cleansing, dressing, and undressing them — hence these offices should be scrupulously attended to by herself. Furthermore, she should not allow it to remain either wet or cold, under any pretext. 
As soon as practicable, she should take moderate exercise in the open air, but only in dry weather, and she should participate in such society and amusements as may contribute to the b faithfulness of her secretions, avoiding every species of dissipation. Furthermore, she should carefully resist the importunities to eat that which is improper, or too much of anything, under the plea that she has her child to support; because the milk of a plethoric woman will prove as mischievous to the child, as that of a partially starved one. Nature has been careful to provide for both her and her child under the observance of the strictest temperance in all things. 
Finally, every woman, after having called to her aid the services of a physician, should consider herself bound by every moral consideration, and also by every selfish one, that has s the well-being of herself and child for its object, to 
9 


130 
MATERNAL DUTIES, ETC. 
implicitly carry out his instructions, and to enforce this duty upon her nurse. If she have unfortunately employed a blockhead, it is not to be supposed that she was more discriminating in the selection of her nurse ; consequently, it is to be presumed that the advantage is still in his favor. 
And yet, it must be confessed, that there is in society, even among the well informed, an astonishing amount of credulity and a superstition that would scarcely deserve toleration in a savage community. We have known wealthy and intelligent gentlemen to employ, as a physician, a man so stupid and dull that he would not have employed him to groom his horse, and for no more cogent reason than that he was a seventh son, or had been among the Indians, or for some imagined reason, that he must possess a pathological and therapeutical instinct. 


CHAPTER IV. 
OP PHYSICAL INJURIES TO THE CHILL, 
SECTION I. 
NECESSITY OF A FOSTER MOTHER. 
Phrenologists well know that there are many women who have an insuperable aversion to the care of their own children—are always pleased to find some one—any one, who will relieve them of this responsibility. The crime of infanticide proves the existence of such women. It always gives us pain to see any one, but more especially a woman who has an aversion to children. We, of course, do not blame them— none of us can avoid our likes and dislikes —they are most generally entailed upon us; but it is very unfortunate to a man to have such a wife, and equally unfortunate that such a woman should become a mother. 
That it is the duty of every mother to suckle her own child no one will doubt, except when by so doing her life or that of the child is endangered. We are taught that no woman should be relieved from the discharge of this duty, through a mere aversion to it, nor through the plea of ill health, unless confirmed by the judgment of an intelligent physician. 
Hundreds of women, who have but a feeble sense of moral obligation or duty, possess, nevertheless, such an attachment to their children, that they would almost as soon part with life, as to surrender their infants to the care of others. When, therefore, the child has no other ground of hope and protection than its mother's sense or feeling of moral duty, its chance for a continued existence is very precarious. Now comes the proper question for the consideration of the husband and his 
131 


132 
IMPROPER NOURISHMENT. 
friends—which offers the best chance for the well-being of the child, the mother who has no affection for it, or a wet nurse who may or may not be dutiful ? 
We repeat that the mother's milk is the best for the child, other things being equal, and it should not be deprived of it for any trifling consideration; but it must be remembered that objectionable food is not the only cause of fatality among children ; consequently a mother who entertains an antipathy for her child, or even views it with indifference, may by negligence destroy it. (We here remark that such a woman should not be permitted to become a mother a second time, for the reason that she will probably, according to the laws of procreation, entail her own mental constitution, in this respect, upon her daughters, and thus spread the evil upon society.) 
We will now suppose that every fact and contingency, so far as known, has been duly weighed, and that it has been decided, either on account of the disability of the mother to nurse her child, or on account of an unwillingness to do it, or perhaps from some insuperable objection to her doing it, to employ a wet nurse for it. It should now be remembered, that, as a general fact, a wet nurse holds about the same relation to a good mother, that an artificial tooth or leg does to a natural one—even under the most favorable circumstances a poor substitute—but it is the only alternative, whether it does or does not destroy the child. 
SECTION II. 
OF IMPROPER NOURISHMENT 
The old adage, " tricks in all trades but ours," applies with as much truth to wet nurses as to any other class of individuals. They serve for a consideration, and like those of other professions, they will never fail to represent their own pretensions in the most favorable light. 
If the child of the nurse shall be living, she is more to be suspected and watched than otherwise, because it is not to be supposed that she will, even for wages, neglect or endanger the health of her own child; and although she will probably 


IMPROPER NOURISHMENT. 
133 
represent herself as having an abundance of milk for both, and she may have so prepared appearances as to indicate the same, yet the mother should exercise over her services an unsleeping vigilance, for in the event of her not having enough of milk for both, she will not starve her own, but will clandestinely feed the other. Young and credulous mothers are frequently imposed upon in this way. 
Vigilance, however, will soon detect any fraud that may be practiced, for if the child be sustained by other food than suitable milk, fretfulness and various manifestations of pain will attend it. The nurse may, as she frequently does, parry all this by the use of laudanum and such personal address as will make the mother believe that nothing but a little "colic" ails it. 
But the time is not far distant when the cheat will become obvious—the mother will perceive that her child is not growing—that it is stinted, and presently diarrhea appears, and then she sends for her physician, whose investigations detect the fraud—possibly in time to save the child, and possibly not. 
Thus, it not unfrequently happens that when parents have, as they believe, provided in the best manner for the nourishment of their infant, they lose it through the clandestine use of improper food. 
On the other hand, the nurse may be honest and faithful— she may provide plenty of milk, and she may give it to the child, and yet it may not be nourished. Her milk may be as mischievous to the child as the improper food above remarked upon ; and all this may result from the ill health or improper feeding of the nurse. If she live upon gross and indigestible food, or if she indulge in the use of ardent spirits, or if she be dyspeptic, or is laboring under a tardy condition of the liver, and if so, many gross and even poisonous elements, which should have been disposed of by the agency of the liver, are eliminated through the milk. Her skin or kidneys, or both, or the uterine system, may be at fault, and effete matter is vicariously cast off through the mammary secretion. 
It is also well known that a capricious temper, more especially paroxysms of anger will render a woman's milk poisonous to a child. 
That a mother can maintain, so far as can be ascertained, * ' 7 


134 
INFECTIOUS POISON IN THE MILK. 
even sonnd health, and fatally poison her offspring, and all other animals that partake of her milk, is a fact well known in this country to those who are familiar with the disease known as the " milk-sick," which is communicated by the cow to her calf and to those who use her milk. This single but well known and established fact, should teach every mother to be careful as to what she eats. 
No matter, however, what has given the nurse's milk a diseased or bad quality, the fact can be detected by a close attention to the manifestations of the child. It does not sleep like a well child; it starts and cries as though penetrated with severe pain, and almost as suddenly falls again into unrefreshing slumber. When awake, it is uneasy and fretful, and the milk it receives is soon after rejected, or it excites alvine action, and passes through the bowels with rapidity and painfulness. The stools are of a pale green color with offensive odor and frequently mixed with milk curd; they are not generally frequent, but aqueous and copious, which, consequently, rapidly reduces and weakens it. Its flesh is flaccid, and skin pale. It does not continue long in this condition, before it suddenly emaciates and exhibits an alarming illness of both head and bowels. 
SECTION III. 
INFECTIOUS POISON IN THE MILK. 
Although we have no direct evidence in support of the opinion conveyed by the heading of this article, yet we have enough, of an analogical character, to render all parents careful and vigilant upon the subject. 
It will not probably be denied by any medical scholar of the present day, that a father possessing occult or secondary syphilis may transmit the disease in an active form to his child through the sperm that brought it into existence. No doubt but that it sometimes has a different effect, and produces some other form of disease. If this disease can be so obscurely communicated, as through the semen of the father, may it not be communicated through the milk of a nurse ? 


INFECTIOUS DISEASES. 
135 
But suppose it cannot; may it not produce some other, but unrecognized, form of disease ? and may it not be applicable with reference to porrigo, herpes, psora, etc.? 
These last remarks are, perhaps, practically useless, as no parent would employ a nurse who was afflicted with either of them, in an active form, and it is not known that they exist in an occult one. 
There is, then, at least, analogical evidence that such a transfer of syphilis is possible, whatever reason there may be against it; at all events, no discreet person will employ a nurse, if avoidable, who is thus afflicted. 
Whatever may be the fact, touching the communicability of syphilis through the milk of a nurse, we can scarcely doubt that scrofula can be and has been. In confirmation of this opinion, we present a case that occurred in our practice: 
Miss 0., aged sixteen years, was, when only a few weeks old, in consequence of her mother's inability to nurse her, placed in the care of a wet-nurse, whose health at the time was supposed to be sound and vigorous; but before the time arrived when it was thought advisable to wean her, suspicion arose that she might not be, as the child did not flourish as much as all had reason to hope; when an investigation of the condition of the nurse was instituted, it resulted in the discovery that she possessed a scrofulous diathesis, and was therefore discharged. The child came under our treatment at the time, and has been, more or less, up to the present. Her ailment is evidently scrofulous, but manifests itself in a local, rather than a constitutional, form. We have been long and well acquainted with both of her families, and are sure that such a diathesis does not exist in either. 
SECTION IV. 
INFECTIOUS DISEASES. 
The introduction of strangers into a family, to fill any domestic position, is always attended with some danger from infectious diseases. We have known white members of a family, as well as black ones, in the south, to contract 


136 
INATTENTION" TO CHILD'S NECESSITIES. 
secondary syphilis from a house servant; and we have known the same misfortune to happen in the free states, through the instrumentality of hired white ones. 
If a wet-nurse should have this disease, or either of the infectious ones of the skin, we may well suppose that the child, of which she has the care, will contract it. Such occurrences are said to be frequent on the continent of Europe, less frequent in England, and still less in the United States. However this may be, we know not; but sure we are that the propagation of syphilis into American families, by domestics, is not infrequent. 
SECTION V. 
INATTENTION TO CHILD'S NECESSITIES. 
To attribute a mother's attentions to her child, to benevolence, a feeling of moral obligation, or to reflection, as the metaphysicians have done, is to mistake very widely the provisions of our Creator for the care and protection of our infancy. If the protection of progeny had been confided to the care of the superior sentiments, the population of the earth, at this day, would have been very small, compared with what it now is. Under such an ordination we would have had no savage races, nor degraded and brutal classes in civil society. No, the author of our being did not leave the helpless period of our existence to the vicarious functions of facul - ties which may or may not have even an appreciable existence. The feeling that binds a mother to her new-born babe, exhibits more passion, more enthusiasm, than her own love of life could exhibit—the only other feeling that can equal it, is that which constitutes the religious martyr. During the early infancy of her child, when it can interest no one else, she betrays for it a care, a vigilance, a self-denial, and a devotion that baffles all conception. We have often thought that a mother is amply compensated for her pains and privations in child-bearing and nursing by the pleasure she finds in her child—witness her pleasurable emotion at its very smile—it is now the exclusive object of her worship. 


INATTENTION TO CHILD'S NECESSITIES. 
137 
We have dwelt thus long upon maternal attachment, to enable our readers to fully appreciate the hazards to which a child is exposed, in being separated from its mother, even as regards its physical existence. If a mother's attentions are frequently insufficient to save the tender infant, how precarious must its chance for a continued existence be, with even the best of other women, and how much better its chance would be with them, than with those hirelings into whose hands they are generally cast. 
The first and great care due to a child is the regular and timely application of it to the breast, that it may not be injured by hunger or over-feeding; the second consists in a vigilant attention to cleanliness ; and the third, in cultivating regular habits, as regards its evacuations, exercise, sleep, and airing. 
These attentions, to secure their accomplishment, must be urged by a much stronger feeling than that sense of hired obligation, which alone, in most cases, actuates the wet-nurse ; and yet it must be confessed that a neglect in either respect may stint the child, impair its constitution, or terminate, prematurely, its existence. 


CHAPTER V. 
OP MENTAL INJURIES TO THE CHILD 
SECTION I. 
THE VITAL FORCES. 
We found the preceding chapter all important to the physical well-being of the child ; and if, as we believe, life was given for usefulness and enjoyment, it will, a priori, be admitted that these two great ends as much depend upon a proper training of the mental faculties, as upon the good health and strength of the body. 
The faculties in this class which fall under the care of the nurse, are those which preside over voluntary motion and the sensibility of the body, particularly to the skin, to the impression of surrounding bodies. Upon the proper cultivation of these faculties depend, in a great measure, the future usefulness and happiness of the adult* A lounging and idle man is never happy or useful, nor has he that mobility of muscle, or expansibility of lungs, which fit him for those occasions that peculiarly require the exertions of a man or woman. Their existence is mostly vegetative. This subject, although important, has hitherto claimed no part of the attention of either parents or nurses—accident has alone governed. 
The idle man or woman is eschewed by every useful citize —then, why should a child be permitted to be idle, however young, when it is not asleep ? As we indulge the body, so we develop the mental faculties which hold a relation to such indulgence. The great wish of most parents, and all nurses, is that the child, even when awake, shall lie still and be quiet; if it do these, it is called a " good child," —yes, and 
138 


THE VITAL FORCES. 
139 
such children, without some unanticipated revolution, make good men, but the goodness is of that kind which we denominate good-for-nothing. 
Some children are said to be cross—that is, when not asleep they are crying, and wherefore, for they are neither vicious nor sick ? It is usually because of that condition of the system which demands motion as the.only means of relief, and relief they usually obtain by crying, which gives exercise to the lungs and most of the muscles of the body. When they have cried enough to produce the necessary amount of fatigue, they again fall to sleep. 
When a child is cross, it is usually appeased by giving it the breast, and through a desire of something to do, rather than through a want of food, it sucks. The practice of feeding children to quiet them, is attended with serious mischief. The stomach being frequently filled to repletion, at length becomes to require that distension which repletion produces, and thus the digestive function becomes impaired, and speedily following it is an impairment of the general health. 
This repletion, furthermore, if it should fail in producing disease, by making a heavy demand upon the nervous system to dispose of it, produces sluggishness and an indisposition to motion, and finally plethora, and with it an aversion to motion, with dullness of mind. 
To aid in manufacturing out of active and sprightly infants stupid men, the cradle was invented, which by the lulling influence of its motion, keeps the child quiet, promotes obesity and an indisposition to voluntary motion. In all our own reflections upon living organized structures, we should remember that nature always secures an adaptation between all the parts which are in anywise dependent upon each other. Hence, if we train the child to rest, to an indisposition to motion, all of the other faculties become adapted to this state of things ; and nothing less than some extraordinary and continually active, or revolutionizing motive can effect the necessary change. A new order of development, in solid parts, and new modes of action must become established. 
If we are understood by our readers, it will be clearly perceived by them that the old proverb, "Bring up a child in the way he should go," is as applicable here as in any portion of 


140 
THE VITAL FORCES. 
a child's education. Instead of being trained to inertia, it should be trained to motion ; therefore, as soon as it wakes it should be taken up, and kept up, until the proper period arrives for rest, and while it is up it should be carried about that the various objects in the chamber may become addressed to its senses. This motion of carrying it about, while an infant, will give it, in a sensible nurse, all the motion it may require, and its mind (which, for our present purpose, is only the motion of the brain) will obtain all the action that may be requisite. 
By this mode of training, the faculty of motion will become active, and more developed—motion will be demanded for its gratification—this motion will promote a favorable development of the pulmonary, arterial, and venous systems, and nearly all the mental faculties, and greatly diminish the chances for consumption and general feebleness of health. 
Now, what does it matter to a hired wet-nurse whether her charge shall finally be an idiot or a Webster ? She is hired to give it nourishment and to take such care of it as circumstances may force. The more the child will sleep and the more quiet it is, the more time she will have for amusement or her own selfish purposes. If the child be fretful and indisposed to sleep to stultification, she will, as they frequently do, clandestinely give it laudanum. 
Under this head there is another subject, which is highly important, but perhaps less so than the one we have just concluded ; we allude to that mental faculty which, when properly endowed, forces us to personal purity or cleanliness in all things. The child that is brought up in filth has the delicate and healthful sensibility of the skin greatly obtunded. If its training is commenced by keeping its skin and clothes clean, it will, in a short time seek the cleansing process for the pleasure it affords it. By this attention the faculty will be improved, the skin maintained in a delicate and healthful condition, and in future life, it will give evidence, by personal cleanliness, that it was educated under civilized influences. 
By a reference to our closing remarks upon the functions of the cerebellum, it must be perceived that now is the time to commence the development of the lateral portions of the 


THE DEFENSIVE FACULTIES. 
141 
cerebellum, particularly with such children as may have a small chest, because upon this depends their exemption from consumption in future life. 
By a proper attention to the skin, the organ of animal sensibility is developed ; and by a proper exercise of the body the organ of muscular motion is developed » and under a proper development of both, there is no danger of consumption, of passive congestions of the brain, etc. 
If, therefore, infants and young children be exercised until they become fatigued, they will not require a cradle to put them to sleep. We rejoice that in our exposition of the functions of the cerebellum, we have placed the necessity of early and thorough exercise beyond the reach of debate or possibility of doubt. Every intelligent parent can comprehend how it is that the life, health, and usefulness of his child are made to depend, not upon the rest, sleep, and fat of the infant, but upon as thorough attention to exercise as to food or rest. 
Finally, neither infants, nor older children, should be allowed to become fat—it is not a condition of healthy nutrition, and a little interruption to it, is pretty certain to develop cutaneous or other diseases. If its fat cannot be kept down by exercise and a diminution of sleep, diminish also its food ; but this reduction can generally be effected by exercise and waking. By this early training, a vital system may be produced adequate to health, age, and usefulness. 
SECTION II. 
OF THE DEFENSIVE FACULTIES. 
Resentfulness, fretfulness, harshness, and capriciousness of temper never fail to render their possessor, and those associated with and dependent upon them, unhappy, to say nothing of murder and manslaughter, which are sometimes their extreme results. A nurse, then, who is not particularly fond of children, or who is irritable, impatient, and fretful, may ruin the disposition of a child for life. If it cry much, it is scolded and perhaps spanked, and these are the remedies for 


THE MORAL FACULTIES. 
142 
all its acts of disobedience, of willfulness, and of accident. She sometimes calls them directly into improper action, as, when the child hnrts itself, it is taught to strike the object for retaliatory satisfaction. 
There is, perhaps, no quality in a parent or nurse so essential to the future happiness of children, as patience —forbear- and amiability of temper. Children should be taught self government —and to this end the nurse must manifest it. To suppose that scolding or whipping will put a child in a good and pleasant humor, is about as consistent as to suppose that an animal government can improve the moral faculties. A child should never receive from a nurse, and much less from a parent, a cross or angry word, nor should it ever hear such words between its parents. 
With all these objections, it is better that the child should be sustained by a bottle, than by a wet-nurse whose mental faculties have not been properly disciplined. 
When children are taught to know that they can obtain no gratification by crying for it, or by any exhibition of ill-temper, they learn to effectually govern themselves. It but seldom happens that either adults or children are discovered to persist in a course of conduct that yields them nothing but disappointment. The christian sect known as Friends or Quakers, succeed better than any other people with whom we have become acquainted, in teaching their children practical selfgovernment. 
SECTION III. 
THE MORAL FACULTIES. 
The moral faculties of children are manifested at a very early period, and any obliquity imparted to their action while young, is but too apt to follow them through life. We have frequently heard parents say that they would whip the faults of their very young children out of them, when they got older. Such an attempt as this would display as much ignorance of the laws of the human mind, as an attempt to whip out of them 


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the color of their hair or eyes, would an ignorance of the physical. 
In our southern states, a gentleman selects his most intelligent and faithful servant to groom his horse, and usually the most lazy, awkward, stupid, and lying maid he has to take care of his children, simply for the reason that she is good for nothing. 
In the free states the case is no better—most generally no inquiry is made about her parents, or about her own moral dispositions, but, is she able to carry the child, and can she be had for her food and a scanty wardrobe. 
This subject is too important to be dismissed with only a passing remark ; therefore, we beg leave to enforce its claims upon the attention of parents, by two illustrations out of the multitude we have. 
In traveling through one of our southern states, we called at a village hotel for dinner—the usual dining hour had passed, and our only company was the landlady, a most amiable and excellent woman. Upon entering the dining-room, we saw a servant girl, about nine years of age, with a child on her hip—she had, strongly marked, the head of a murderess. We turned to our hostess and addressed her thus:— " Madam, do you wish to have your children murdered ?" She looked at us with astonishment, and answered, "No, sir!" " Then, take that servant out of your family." With amazement, she remarked, " That brings to my mind what has happened." " What has happened ?" we inquired. She replied, "About two weeks ago my little son fell out of the second story window; he says that this girl pushed him out, but I thought he must be mistaken, because I could not imagine any one so cruel as to do so ; and a few days ago my little girl came to me wet all over, and said that this girl put her in the creek and tried to hold her under the water ; but the servant, when challenged about it, said that the child fell in, and this seemed to me to be the more likely, because I could not believe any one to be so heartless as to drown a child." We afterward learned that this girl was sent to the Louisiana market. 
Under circumstances almost similar, we inquired of a lady 


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in Pennsylvania, if she wished to make thieves of her children ? As may be presumed, she answered in the negative. "Then," said we, "you will discharge that nurse"—a girl about ten years of age. " It is a fact," observed the lady, "she does steal, and I have corrected her for it several times, but I never supposed that that would make thieves of my children." We then remarked, "It is no business of ours, madam; but as the friend of children, we have admonished you." 
No one, who is the least informed upon the subject of human nature can now doubt, that it is a matter of the first importance that those who are to be associated with children, no matter in what capacity, should be constantly under the influence of a chaste and moral mind. 
We do not contend that it must follow that a child which has been under the care of a thief will become one, because it is both possible and probable that its native powers of intellect and moral endowment will prevent it, but we still insist that such influences upon infancy do blunt the moral perceptions—do impress them with an unfortunate obliquity. 
The moral faculties consist of justice and stability, and it is the duty of parents to train their children to a strict discharge of them. Such is the native strength of these faculties in children, that they are easily trained. The procrastination of duties or the evasion of them, should never be tolerated. When habits of honesty and punctuality are established in early youth, they are apt to continue through life. 
SECTION IV. 
THE SOCIAL FACULTIES. 
These, like the moral, are manifested very early in life, and consequently, on behalf of children, they claim our special attention. 
It is admitted, by all writers, that children are very imitative, more especially in all things that pertain to manners and habits. A woman, then, who sits, stands, walks, or dresses 


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in an ungraceful manner, should never be employed in a good family, or trusted with the charge of a child, more especially if a female. What can injure a woman more than ungraceful manners ? And will not female infants as certainly acquire them from their nurse as they do nourishment from her breast ? In truth, the hurse should manifest good taste in everything. 
Furthermore, she should be so well-bred and kind in her disposition that she would, in the child, awaken its sympathy, even in behalf of a suffering worm ; and yet, she should possess no sickly timidity. Worse than all these, is that credulity which delights in ghosts and hobgoblin stories—impressions are thus made which the best subsequent education and the most manly judgment cannot eradicate. Of all the vices of a nursery maid, an attempt to frighten children into obedience is, perhaps, the worst —they may recover from the evils of every other species of mismanagement, but from those which this practice engenders, never. 
In every age of the world, the few have governed the many through the instrumentality of their superstitious fears and hopes. Man has ever been the dupe of his own credulity, and no class of men are so universally unpopular as the fearlessly candid — those who will not condescend to mislead their fellows. 
And, furthermore, it is remarkably strange that not less than seventy-five per centum of men, in the formation of their belief, make no distinction between the possible and impossible; indeed, there are very many, even among the wellinformed, who are more likely to adopt the latter than the former. A mere impossibility, like the "spirit rappings," will more readily find advocates than a new demonstrability, such as those discoveries of Galileo, Harvey, Jenner, and Gall. 
Upon a subject that admits of doubt, the people generally do not search for the truth, but for evidence to sustain some preconceived or selfish notion of it; and under such an influence almost every child in the land is now being educated. As people generally do not wish to see their trickery upon this subject exposed, we shall pass on to an application of the principle to the use of the nursery. 
10 


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If there be a spot on earth in which candor, truth, honesty, kindness, chastity, and forbearance, should supremely reign, it is, in our opinion, the nursery of children ; and yet it is, most generally, the private abode of deception and falsehood. The nurse, and very frequently the mother, for the purpose of securing her government over them, fill their minds with superstitious fears that follow them to the close of life, in defiance of their better judgment. What else has made almost every man in the land a coward in the graveyard? We have seen intelligent men in a graveyard shake with fear, as though they had an ague paroxysm ; and we have seen them run, as though a squadron of hostile Indians were after them. 
A few months since, a servant girl in our own family was told that we had two or three large boxes of human skulls in our cellar ; she came home frightened into passionate crying or bawling at the recollection of having been so frequently exposed to an imminent danger of being devoured or taken to the abode by his satanic majesty by ghosts or hobgoblins. She suffered immensely, and had her constitution been more encephalic, it is possible that she might have been rendered a lunatic for life. 
Some pious and well-meaning parents often injure their children to an irreparable extent. When the child is naughty, they often tell him that unless he becomes better, the " bad man " will carry him off. After a short time he becomes afraid to go into a dark place, lest the " bad man " might be there ; but after innumerable admonitions of this kind, and finding himself to have invariably escaped, he ceases to have any fear of him, though he continues to avoid the dark, but why he cannot tell. 
The child has now become absolutely injured—prepared for a reckless course of evil conduct. Instead of fearing the " bad man," he suspects his parents for having imposed upon him, and consequently he gives no attention to any of their admonitions. 
If they had understood the peculiarities of the infantile mind, they could have, from such a government, anticipated the result. Let it be remembered, then, that a child has not, to an appreciable extent, either hope or fear as to any future— it acknowledges no future tense—it lives, hopes, desires, and 


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iears in the present tense only. The parent, therefore, who talks about a hereafter, another vjorld, etc., has great need of a teacher for his own mind. And such a teacher is now needed throughout the whole land. And upon this principle, if the time which is now devoted to the religious instruction of children, up to puberty, was directed, with the same attention at home and at Sunday school, to natural history and the moral relations of society, we would have, comparatively, but few bad boys, and many more and better christian men. We do not entertain a single doubt but that this doctrine will become universal in practice; but, as we are fully apprised, it will be a long time first—not until teachers, generally, shall understand the juvenile mind, and preachers and legislators, the adult. 
We have said enough to indicate to every parent his duty to his children in this relation, and upon the discharge of this duty, in a great measure, the happiness of the adult and the good of society depend. 
Finally, under this head, a woman should not be intrusted with the charge of a child, unless she manifested good taste, amiable feelings, courteous manners, and a truthful intercourse with the children and domestics. 
SECTION V. 
THE INTELLECT. 
If women, intellectually, were generally constituted like men, we would have much to say upon this subject; but, fortunately, most women know something, while most men have learned something;—we speak, more particularly with reference to the Americans, the Scotch, and Irish. To find a German who does not know something, is impossible, though he may have learned but little—we allude to the function of observation as directed to material things. 
The faculties concerned in this function are the first of the intellectual which become developed—they enter upon their duty, feebly it is true, at birth; and a properly-constituted nurse will avail herself of every possible means to gratify 


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them, as being the best means of employing the attention of a child. Witness the anxiety of infants to gratify their senses of hearing, tasting, smelling, seeing, and feeling. This fact indicates the proper duty of the nurse. 
But women who are defective in these faculties resort to every other possible means to entertain the child, except those indicated by nature. She will sing to them, rock them, but never show them any unfamiliar object. If old enough to listen to her, she will entertain them by a recitation of nonsensical stories. As soon as the child begins to notice objects, it should be trained to love nature, not alone for its happiness and usefulness, but in order that its mind may always find an employment more agreeable than tippling, gambling, or any other variety of dissipation. 
By this early neglect of the perceptive powers of children, they do not become either sufficiently developed or active to save future life from unprofitable abstractions and worthless speculations upon all of the most useful or momentous concerns of life. 
In view of what has been said in the two preceding chapters, what must be the maternal constitution of the woman who could willingly or indifferently resign her child to the care of a wet-nurse ? Will any one contend that a husband should not find, in such a fact, an ample plea for a divorce ? 


CHAPTER VI. 
OP PERSONAL ATTENTIONS TO THE CHILD. 
SECTION I. 
WASHING THE CHILD. 
This duty should be performed by the mother herself, but if she cannot, or should not, she should at least be cognizant of it. The first part of the duty involves two important questions, and we, of course, have a choice in both, and if we fail to sustain our preferences, our readers can adopt the contrary. 
The skin of the child, at birth, is covered with a peculiar (we will not say " impurity," because nature uses nothing that is impure in the construction of her works), which was essential to its mode of fetal existence ; it is tenacious, and of a soft gummy consistence. Now, the question arises, is it best to remove the substance immediately after birth, before it dries, or suffer it to remain, dry upon the surface, and finally scale or peel off? Both opinions have its advocates. 
It is to be considered, that while this substance was essential to fetal life, it cannot be so to a directly contrary mode of existence ; and to render this conclusion still more obvious, we have but to refer to the fact that it interferes with the function of the skin about as much as would a coating of wax. This is not all—it becomes more or less putrid and offensive to the smell. Furthermore, when it is permitted to remain and dry upon the skin it becomes a source of mechanical irritation, and of such an excoriation of some parts, particularly about the joints, as to require medical attention. For these reasons we advocate the immediate and thorough washing of the child before it is dressed. 
149 


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Another question now arises of even greater moment than the preceding; it is, whether this washing should be effected with warm or cold water ? Both opinions have strong advocates. We prefer the former, and for various reasons, which to us are insuperable. 
The second great and indispensable want of a child is heat, as all that it now has, came from the mother, and all that it will have, until digestion and nutrition shall have been effected, must be at the expense of its body, for the oxygen that enters the lungs cannot produce heat without something to combine with. Some infants may have a little fat to spare for such a purpose, and might not suffer any further, under a cold washing, than an unnecessary waste of some of it; but the case is far different with one that is lean, emaciated, and feeble, which has nothing out of which animal heat can be produced. 
The first want of an infant, at birth, is air, and, unless it be immediately had, death ensues ; and, as we have before remarked, the next want is animal heat, and unless that with which it is born, be protected, death is as certain as it is in the first instance; therefore the washing of an infant with cold water, immediately after birth, is a direct effort to destroy it, however contrary the motive for such a practice may be. That death has sometimes occurred to such infants from cold washing we have not a doubt. We are fully convinced that the physician who would sanction it upon any child, but more particularly upon the feeble, does it without the sanction of science. Very young infants rarely take food enough for the production of repair and the development of animal heat, and hence the necessity of taking special care to keep them warm ; consequently it should not be touched with a cold hand or cold air, during the first months of its existence. 
Cold water is used by its advocates to make the child "strong." Cold water, further than a tonic influence upon the nervous system, has no strengthening virtues, and even in this respect, when used out of place, will produce disease. A well child then, has no need of it—would probably be injured by it. In adults, when digestion is all the time producing material for the production of repair and animal heat, we admit it to be frequently useful; but in new-born infants 


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all the facts are reversed—they have no heat of their own, nor material for repair—and yet heat is a sine qua non to their existence. How then is it possible that the abstraction of their borrowed heat, which they have not the means of replacing, except at the expense of their bodies, can strengthen them? 
There is yet another powerful argument in favor of our position. Recent experiments have shown that infants have less power to produce animal heat than adults, in the proportion of 80° to 96°. This fact is illustrated by ti e efforts which all warm-blooded animals make to keep their young warm. The infant has just emerged from a temperature of 97° or 98°, into one of 65° or 70°, and with less power than the parent had by 16° to produce that temperature which is essential to its existence. Under such circumstances, it would require the abstraction of but a few degrees to destroy it. 
It should be remembered that the child has just been removed from a temperature of 98° to that of the mother's chamber, which is much below it—respiration and metamorphosis have been rapidly increased to maintain its existence, in the reduced temperature into which it has been introduced ; consequently, the obvious and most rational conclusion must be, that it should be washed with water at or about blood : heat. 
The advocates of cold water refer us to the practice of savage tribes. What do savages know about the difference between the dynamics of a child and those of an adult ? They know that an adult will not, usually, suffer by an immersion in cold water, if immediately after, he is enveloped in a blanket. But we have shown that there exists a wide difference between the conditions of an infant and those of an adult; for a savage will infer, through an ignorance of this difference, that if cold water will not injure an adult, it will not injure a child. Nor is this all; we have yet to be assured that savage mothers prefer cold water. Those acquainted with savage habits state, that women delivered of children while traveling, wash them with cold water ; but this does not prove a preference for it. Some savage tribes, as soon as an infant is born, straighten it out and strap it fast to a board ; we should do this also, if savages are to be our instructors. 
Having arrived at the conclusion that it is far better and 


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safer to wash infants with warm water than cold, by a reference to facts which we confidently believe cannot be overruled or set aside, we proceed now to the discharge of the duty. 
It has been very generally recommended, that, preparatory to washing, the infant should be " smeared " all over with fine lard, and then with fine soap it should be cleansed. "We admit that a mild soap is preferable to strong soap, but as all soap or alkaline substances have more or less a destructive influence upon the epidermis, we would recommend, in lieu of the lard and soap, fine warm and thin flour paste. This will unite with the fetal substance upon the skin, which can then be removed by the use of warm water, and a flannel rag or a piece of sponge. Much care is requisite to remove all the fetal substance, which is the great object of the washing, from all the folds and flectures of the skin, no portion can be left that will not do subsequent mischief, more especially in the duplications of the skin. 
Some people add to the water brandy or whisky; this is worse than useless—it is mischievous—it produces an irritation of the skin, and as it evaporates with more rapidity than water, it will aid in the abstraction of the animal heat. "We have stated that heat is indispensable to infants, and for this reason there should be no current of air about the child while it is being washed, because it promotes evaporation. 
SECTION II. 
OF THE DEES8 OF THE CHILD. 
The dress of a child should always be arranged and adapted so as to secure its comfort, health and growth, or development, and these ends cannot be answered without a proper temperature, and an entire liberty of motion in every muscle it has. 
The practice of swaddling children, which is still in use in some old communities and countries, for they are always the least progressive, should be entirely abandoned. Dr.iDewees thinks that this practice probably originated in the deformity 


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which rickets produces, mistaking an effect of a disease, for a fault of nature. This opinion, however, we think to be erroneous. For some of our Indian tribes practice it to secure to the child what they conceive to be a proper form, and in Turkey, the midwives swathe the heads of infants into that shape which best suits the turban. No matter how it originated, it is a vile and mischievous practice. If every species of the inferior animals can obtain their proper form without swaddling, what reason can be assigned why the human progeny should not! Is it not very probable that if the young greyhound or buck was so swaddled, when young, that he could not use his limbs, that he would not exhibit that activity and grace of motion which distinguishes him in age ? 
If its inutility, in this respect, was the only objection to it, we might tolerate its use to gratify those simpletons who desire the practice of it; but the mischief it does, beside the suffering it inflicts, is too great to admit of justification in a single instance. Dr. Dewees thinks that, inasmuch as the child was bound up in the smallest possible compass, it ought to have entire liberty after it is born. We admit his conclusion as 1 fact, but we have no sympathy for the child in consideration of the cause he assigns. If the condition of the fetus had been uncomfortable, nature would never have adopted such an arrangement. It may be well questioned, whether the fetus is capable of pleasure or pain—comfort or discomfort—but to the question. 
So far as comfort is concerned, let any one confine his limbs in one position for an hour or two, and he will know something of the suffering which the child must endure before the faculty of motion can become adapted to such a condition of the muscles. But if this terminated the mischief of the practice, it might be suffered. It is well-known that the exercise of the muscles facilitates the circulation of the blood, and consequently, strengthens both the heart and lungs; furthermore, it is well known that in atmospheric or animal life, a part is not developed unless it is exercised, on the contrary, it decreases. A child thus swathed may get fat, but fat performs no function—it is not organic development—it gives capacity to neither body nor mind. 
Exercise, to a child, is as indispensable to its health and 


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development, as it is to an adult; consequently we contend that it should have entire liberty to throw its little arms and legs about, whenever it may be impelled to do so, by its faculty of motion—motion was the means provided by its Creator for equalizing and expending the nervous accumulations of the animal system. Mothers have too much attachment for their infants to deny them this privilege, after having been caused to observe how much they enjoy it. 
After providing for the liberty of the child to kick and scratch as much as it pleases, we proceed to the consideration of its clothing with reference to its comfort and health. Nonconducting substances, such as wool and silk, should always constitute the under clothing during cold weather. Its shirt should be white silk or line white flannel, we say white flannel because it is always softer than the red—because it is warmer, in having less power to radiate caloric, and because, for the sake of decency, the mother will be induced more frequently to change it. 
As flannel and silk are preferable to other fabrics only because of their non-conducting power, it follows that they should be used only when it is requisite to retain the temperature of the child ; but when the weather is warm and the child uncomfortable from a too great retention of its animal heat, the flannel should be replaced by cotton or linen, and, as a medium, between the two extremes of temperature, a cotton fabric, known as canton flannel, is excellent. What the writer has said upon the utility of flannel, has been more upon the authority of others, than from his own convictions, growing out of his experience ; with himself, he has found the cotton fabric, above named, far better for him than flannel, and he is decidedly of the opinion, that it would be better for most persons, and even for children. In the case of infants, however, a woolen frock should succeed the canton shirt. 
Dr. Dewees teaches that when the flannel becomes uncomfortably warm to the child, it should be removed, and that in case the weather changes to a colder temperature, it should be replaced ; in fine, he thinks that it should be used and disused as indicated by the thermometer; we think so too, but not as an under garment. If flannel be used as a shirt, it should bo put on in the fall and taken off between the first and the mid- 


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die of June, and its removal should be in the morning ; but no matter at what time, or under what circumstances it be dispensed with, the child will be liable to take cold. The impossibility of changing the undershirt of a child, without a hazard to its health, constitutes the great reason why we would recommend the cotton flannel—it can be worn all the year, while the comfort of the child can be regulated by a change of its other clothing. 
If fever should supervene during the period that the child wears flannel, we agree with Dr. Dewees, in recommending its removal upon the accession of the fever, and its replacement at the close of the sweating stage ; under such circumstances there is no danger that the child will take cold. 
The following quotation from Dr. Dewees, we think, is pregnant with a flagrant error, and if the duty it inculcates were strictly observed the mischief would be very considerable. He says, " Examine the skin of a new-born child, and you will find it almost constantly cold, unless well protected by clothing made of materials which are bad conductors of heat, and hence the absolute necessity of maintaining this condition by suitable means." 
The remarks apply with equal truth to all women of a rather full or lympathetic habit who are not accustomed to laborious pursuits, and yet they are perfectly comfortable, and the use of such means as would keep their skin warm would render them exceedingly uncomfortable. 
In the month of August, when the temperature in the shade is nearby that of blood heat, when the child would be perfectly comfortable without any clothing, when removed from a current of air, its skin will be found to be cold. This coldness of the skin, then, in neither women nor children, indicates a want of clothing. Such women as we have indicated are rarely seen to perspire, except upon such portions of their surface as are so bound by their clothing as not to admit of insensible perspiration ; and the same remark is true of infants. This coldness, then, results from cutaneous evaporation—the ready means which infants and such women as indicated, have of parting with their superfluous animal heat—it is their means of being comfortable in hot weather. 
Infants do not perhaps, nor in health maintain, a high 


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temperature, but to this end the mother's milk contains more sugar than that of any other recollected animal, and such is the constitution of the subcuticular substance that they readily part with any excess they may have, by insensible perspiration and evaporation, and when they are seen to sweat, the cause exists in fever, in a room insufficiently ventilated, or in too much clothing. 
There is sometimes an unconquerable incompatibility between flannel and the cutaneous surface of some infants; it may be detected by the child's constant expression of uneasiness, and even fretfulness, without any apparent cause, and by an efflorescence spreading over the body, which disappears by a removal of the flannel. 
Up to the time when the child begins to crawl, it matters nothing how long its frocks may be, provided they be not so twisted or tied about the feet as to restrain any variety of motion ; but when they begin to crawl, which is generally about the eighth month, they should be so short as to allow it an entire freedom of its feet and ankles. Long clothes, by causing it to stumble, or by causing a feeling of restraint, beget in it a fear to make an effort, which greatly retards its industry in efforts at motion. A mother's vanity in the appearance of her child very frequently retards its prosperity; but they should sacrifice their vanity upon the altar of the child's utility. 
As soon as it becomes expedient to shorten the child's dresses, its feet and legs should be dressed in shoes and stockings, especially in cold weather. It is of the first consideration to keep the child dry, which, from the nature of its wants, will require very frequent attention. It is true that some people, and even teachers are not very fastidious upon this subject, maintaining that the wet and cold to which the child is exposed by the nature of its excretions, will only tend to strengthen its constitution. Nature's plan for strengthening the constitution is by the use of nutritious and digestible food, and sufficient exercise of the body in the open air, when its condition is neither too hot nor too damp. It is of advantage to no animal to be either wet or cold, except to the cold-blooded. 
A little investigation of this matter will expose its absurdity. We have maintained the propriety of keeping the child warm, for the promotion of its digestion, secretion and devel- 


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opment; now what must be the effect of wet clothes upon it. The damp or wet clothing reduces the temperature of the child by combining with its caloric to the formation of vapor, and thus the clothing is finally dried at the expense of its animal heat. Under such a circumstance the child must be exceedingly vigorous if it do not seriously suffer. The three great functions which are promoted by a high temperature, must become less perfectly performed, and that too, as a matter of course, at the expense of the child. This is not all, the skin of the child may absorb a portion of the matter which it had excreted as unfit for any purpose in its economy. Nor is this all, so long as the wet clothes are in contact with it, insensible perspiration will be arrested, and thus other matter which would have been excreted is retained to answer no other purpose than one of mischief. 
In the face of these consquences of wet clothes upon a child, how is it possible that one would permit a wet diaper or other clothing to remain upon it for a single moment 1 Even hogs will not lie down in their own excretions ; then worse than hoggish must be the decency of those who attempt to justify it in children. In securing the child's clothes to its person tapes should be used in all instances of the usual fastenings, so as to exclude, as far as possible, the use of pins, and more particularly the small ones, for under the best care, they will sometimes prick the child; and being handled and nursed by other children of more age, they are certain to do it, and above all a needle or headless pin should never be used, because of the danger of becoming entirely introduced into the flesh of the child. The serious injuries which young children have received by them should be a sufficient admonition to mothers and nurses for all time to come. 
There is yet, to the infant, an indispensable article of dress which claims from us a few remarks, it is the navel or bellyband : —its use is twofold ; it sustains the walls or parietes of the abdomen from unequal and therefore injurious distension, in paroxysms of coughing, crying, and sneezing; its other importance is admitted by every woman, though she may not very well understand its philosophy. The umbilical cord, consisting of vessels passed from the inside of the fetus through the walls of its belly, and thus connected it with the mother, 


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and through which it was nourished and sustained by her, is divided, and most generally the hole into the belly closes quickly and strongly, but sometimes it does not, and the child is exposed to the danger of rupture of the bowels,or a portion of the caul or omentum, in an effort of coughing, or by some other improper motion of the abdomen. 
To prevent the possibility of this rupture, the belly-band has been used from a time more remote than any written history ; and the more certainly to secure, as it is supposed, the child against this accident, it is generally applied so tight as to create the same mischief through other openings of the belly, as those into the groin, and into the scrotum of the male. 
The belly-band should be worn four months, and even longer, if there be any obvious tendency to rupture at the navel; and to avoid producing a rupture at any other point, it is obvious that the band should not be drawn so tightly as to contract the cavity of the abdomen. In other words, the whole object of the band is to keep the abdomen, in defiance of all the motions the child may make, in its normal condition, and to secure this end, the band should be so elastic as to adapt itself, more or less, to the motions of the belly ; and to answer this purpose a single piece of flannel, and if cut obliquely across its structure, so much the better, maybe applied around the body two or three times. 
A few words more upon changing the clothes of children, and we conclude this Chapter. It is a wide-spread opinion that the frequent changing of dress in children, is detrimental to their health, and in confirmation of the opinion we are confidently refferred to the chubby red-faced children of filthy hovels. It is proper to remark that the appearances of these children do not indicate, to a physiological observer, the existence of a good constitution—their condition is one of grossness—of plethora, and hence their liability to loathsome and fatal diseases. 
The frequent changing of the clothes of children, if they be imperfectly dried and ventilated, will be attended with mischief; but the keeping of children cleanly clad, other things being equal, is indispensable to the founding of a good constitution. But to filthy clothes there are obviously great objections. To make ourself understood, conceive a diaper, 


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which has been wetted five or six times, dried and replaced, and then to the question, is it mechanically fit for the child ? will not its roughness and stiffness irritate and even excoriate the skin ? Let it be further remembered that it is stiffened by substances which were eliminated from the system as being unfit to be used in its further development, and when they are again dissolved by the next wetting the child gives it, they are in a proper condition to be absolved by the already chafed parts to which it is applied. To feed the child upon its own excrements, to use strong language, would not be more improper, because the one is equivalent to the other, except perhaps, as to quantity. 
SECTION III. 
OF FEEDING THE CHILD BY THE MOUTH. 
In the fourth Chapter we have shown, we think, beyond the possibility of a doubt, that there is no food so compatible with the health and development of the child as the milk of the mother, except when contra-indicated by strong and cogent reasons. We have shown the almost numberless dangers to which infants are exposed by being confided to the care of wetnurses, and to the remarks which , we have already made, we will here add, that we hold any mother to be culpable who permits any other mother to suckle her child, even for one time, which is nevertheless a common practice in the round of female visiting. The child of one who is simple in all her habits, will certainly suffer from the milk of one who is luxurious in her habits. But further than this ; how can any one mother know the constitutional peculiarities of another ? In every such instance, though it be one of courtesy, the mother exposes her child to a hazard. 
Notwithstanding all the arguments that can be used in favor of a mother nourishing her own child, it does frequently happen that she cannot do it, and it does as frequently happen, that a wet-nurse cannot be had, and yet every dictate of parental fondness and of humanity declares that the child shall be 


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nourished ; and that too by food, which, as regards the child, may be considered as artificial. 
The lacteal glands of some women do not make provision for the support of the child as soon as it is born, or even within several days. It becomes our duty then, in the meantime, to provide for the child an artificial food, which shall as nearly as possible, resemble the milk of the mother, under such circumstances ; which is done by mixing two-thirds cow's milk, one-third water, and then sweeten with loaf-sugar. Upon this the child can be sustained until the mother's milk shall come, and even afterward, if she do not produce enough. 
Other teachers, under such circumstances, recommend, in view of making the food more nourishing, the boiling of the pulp of biscuits in water or fresh milk. "We object to it, because it and every other variety of farinaceous food, is liable to, and usually does, ferment—become acid, and produce flatulence, colic, the iliac passion and death. Some recommend panadoes and gruels, seasoned with sugar, spices and wine. As there is neither spice nor wine in the milk of the mother, no other argument need to be adduced to prove the use of the two latter to be injudicious and consequently hurtful. 
There are others again, who would so far simplify the food of infants, as to deny to it the use of sugar. "With this prohibition, how is the system of the child to furnish its requisite animal heat ? We desire in all things to make nature our guide,—we have neither the folly, the pride nor the vanity, to believe that we know better than she, as to what is best. She has put into the mother's milk more water and sugar, than she has into that of the cow; and she has made the mother's milk the best food for the infant, hence when her milk is not to be had, we feel commanded by her to make, by the mixing of other substances, as close an imitation of it as possible. We do not pretend to say that the substitute which we recommend, as much becomes the condition of the child, as the mother's milk would —it sometimes produces evil consequences, as flatulence, colic, etc.; but these evils can be greatly reduced by giving a proper care to attending circumstances. 
The most important of these circumstances is, that the milk should be from a healthy cow, and one that is not entirely fed upon slops, nor one that is constantly confined in a close pen, 


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nor yet from one that is greatly reduced from the want of food ; in fine, all the circumstances connected with her should be compatible with health and vigor. All that we had to say about wet-nurses, applies now to the cow. As such milk as we are now recommending can but rarely be had in our cities, we have one great cause of the mortality among city children. 
Furthermore, the milk should, if practicable, be always taken from the same cow, and mixed with warm, sweetened water, and fed to the child fresh from the cow, and it should not be made sweeter than the mother's milk. As these rules cannot always be observed, we will add a few others to meet contingencies. If milk cannot be had fresh from the cow when wanted, it should be kept cool, either by the use of ice or a frequent change of cold water; it should never be skimmed, nor should it be heated over the fire, as there would be constant danger of scalding it, —the one-third water that is to be added should be made hot, which will warm the milk, and if this is not always practicable, a sand-bath should be used. 
It is proper to observe, furthermore, that the mixture should be fed to the child as soon as made, and that no more be made upon any one occasion, than it will take in a short time. If the milk at any time should exhibit a tendency to acidity, it should not be used, for no reliance is to be placed in the prevailing opinion among women, that a little more sugar will correct the evil, while in fact, the sugar, whether little or much, only increases the evil under such a circumstance. So far as the child is concerned, the milk is ruined and cannot be restored. 
There are two practices in society very prevalent, which, though not injurious when the mother is the agent, are nevertheless disgusting, but when other persons are the agents, they may prove highly injurious. We allude to the nurse passing the child's food through her own mouth before giving it to the child, and of blowing upon it to cool it. Time should always be allowed for the atmosphere to cool the food, and children should be taught to await the process. If this were practiced upon all children it might aid the American people in finding time enough to take their meals. 
But to refer again to the disgusting practice above-named, 
11 


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what security can the mother have that the saliva of the nurse will not poison her child ? Safety and decency both demand the abandonment of so filthy a practice. But we are told that the child cannot chew its food. We answer, that whenever its stomach is ready for such food, it will have teeth to masticate it. If people could only learn to observe nature's arrangements what an infinite number of blunders they would avoid. 
We are admonished by highly respectable teachers, not to feed children with food that is too warm, because it may burn the mouth and will relax the coats of the stomach. The first part of the admonition was uselessly given, because there is no nurse so silly as to burn the child's mouth ; and if there be any truth or probability in the second, we should profit by it, and apply cold cloths over the region of the stomach, or give them ice water to promote digestion when it is feeble.( ?) To assert that warm blood in the arteries relaxes their coats, would indicate as much common sense, or as much knowledge of nature's arrangements, as to assert that warm food, or such as a child can swallow, because of its temperature, or of any other temperature below scalding, will relax the coats of the stomach. 
On the contrary, digestion is promoted by warm food and drinks, and by all other means of increasing, in a healthy manner, the temperature of the stomach, and after feeding there is nothing more grateful to the child than the application of a warm hand or a warm flannel and gentle friction upon the region of the stomach. Nor is this all; it is better for the child, after feeding heartily, that it should be kept awake, provided it can be so exercised as to increase its temperature, than that it should sleep.* 
It has been clearly shown by experiment that digestion is promoted by an increase of temperature, over and above that 
* It is better at all periods of life, that after feeding, the mind should be agreeably amused and the body exercised, but not to fatigue. Of this truth we have become convinced from both observation and experience. The writer studies from six o'clock in the morning, in summer, to dinner, no matter at what hour it comes —after dining he follows some kind of manual labor for three hours, and then returns to his study, and even then, in consequence of imperfect digestion, his drowsiness sometimes drives him again to labor, before the close of another hour. He has thoroughly tried both this and the sleeping practice, and has found the former alone compatible with his health and his duties. 


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of 98°, or blood heat, and it is equally well-known that exercise, avoiding fatigue, will elevate the temperature, and that during sleep it will fall to 96°, and even lower ; hence it is obvious, in view of these facts, that it is better to exercise than to sleep after eating. 
It is well known that students of medicine, particularly those who have been accustomed to active habits, find it very difficult to give attention to the afternoon lectures—they desire to sleep, and sleep may be taken by those who have a strong digestive system, but those in whom this system is feeble should not indulge,—they should exercise in something that will amuse the mind, consequently it would be wise in them to unite in clubs and employ a fencing teacher, to exercise them for one hour after dining. By this course they would improve their digestion, their health, and at the same time acquire such a command of a walking-stick, as to defend themselves successfully against dogs and those bipeds who use dirks and bowie-knives. 
Infants at the breast, in general, spontaneously stop when they have fed enough ; but when otherwise fed, they cannot judge so well, and hence they are very liable to feed too much. This circumstance should command the particular attention of the nurse, otherwise the stomach will sometimes be painfully distended, which will most probably be followed by colic or diarrhoea. 


CHAPTER VII. 
THE NURSERY. 
INTRODUCTION. 
The normal activity of the various organs and systems of organs of which our bodies are composed, are followed by agreeable sensations, or constitute what we call enjoyment or happiness, and as this activity promotes the development of all the parts thus active, by adding to their magnitude and strength, and by increasing their facility of action, it follows that every person who is able and properly considers the importance of the subject, appropriates a part of his mansion to the purposes of his children, which is called the nursery. 
In its arrangements, then, it should be adapted to all of the important functions, and their most normal modes of manifestation, as rest, digestion, respiration, circulation, and of course, voluntary motion, domestic, intellectual and moral emomotions, and social amusements. To answer all these indications it follows, that the nursery should not consist of some, otherwise, waste part of the house, nor of any indifferently circumstanced portion of it, but of such a portion as will answer the great purpose for which it is, or should be intended, namely, the production or manufacture of the future mothers, fathers, scholars, soldiers and statesmen of the commonwealth. 
"We never witness the attentions which are bestowed on horses that are intended for the turf or for the perpetuity of the species, without a feeling of shame for the human race. Every natural ordinance that holds relation to his physical and mental constitution is infracted or disregarded in his youth, and yet, in future life, his want of intellect is taken advantage of by the sharks of society, and if his moral manifestations 
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shall discord with the standard of society, punishment is substituted for that training which he ought to have had; and if his physical system is too feeble to discharge its required functions, he is pitied and looked upon as one upon whom his Creator has frowned. 
Every animal pursues that course which was prescribed for it by the Author of its existence, except man and those over which he has exerted his supremacy. He disregards that cause —insults all of its ordinances—suffers in his own person or in that of his progeny, the consequences—repines at his misfortunes, and finally refers them to either an unkind or a very mysterious providence; but never reflects upon his own disobedience to those institutions which were intended to secure to him health, happiness and prosperity. 
SECTION I. 
LOCATION AND CONSTRUCTION OF THE NURSERY. 
Having in the preceding introduction indicated the paramount importance of a family nursery, we shall, perhaps too briefly, treat of its arrangements, and indispensable provisions. 
It should consist of at least two rooms, one for rest and one for exercise. This arrangement has many advantages beside those indicated ; it allows the superintendent the opportunity of having both alternately ventilated and thoroughly cleansed without any exposure of the children to cold, wet, or dust, and the last, is by no means a circumstance of trifling importance to young children, when we reflect upon the great delicacy of the lining membrane of their lungs and their inability to protect themselves as grown persons do, or to help themselves by coughing. The mischievous influence of cold or wet chambers to all persons, and much more to children, is too well known to require any comment from us. 
The floors of these chambers should be very tight, and the house so constructed as to admit of a free circulation of the air under them. 'No matter how tight the floors may be, if damp air and moisture exist under them, the chambers will be rendered more or less unhealthy. They should be tall, and in every respect sufficiently capacious to admit of all the 


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purposes for which they were intended, without crowding or cramping their delicate inhabitants. 
The windows should be large, and so protected by cross-bars that the children cannot get through or fall out of them, and the outside doors should open on a piazza, which will tempt them, in good weather, to play on it in the open air; one on each side of the house would, most of the day, furnish them with a shade as might happen to comport with their feelings of comfort. 
Their walls should be exposed to a clear influence of the rising and setting sun ; the former to dissipate all dampness from the house, and the latter to prevent the early damp of the evening and through the night, by the radiation of the walls and all neighboring objects, of their acquired temperature. On the south-east, south and south-west, the house should be greatly protected from solar influence by shade trees, so trained as not to obstruct a free circulation of the air around and through the house, when desired for ventilation, and to cast their shadows upon the house above the windows. In every hundred house-groves in this country, which might as easily have been rendered beneficial, there are but few which are truly beneficial and healthy. Shade trees should not be so arranged and trained as to heat the house, dampen the air or prevent a free circulation of the air, but to serve, simply, the purpose of a cloud, to keep out the direct rays of the sun ; and also for another and by no means an unimportant purpose, the absorption of the carbonic acid gas thrown off by the children and all other sources of it about the house, and, also, perhaps, other gases, which are not necessary to, but possibly injurious to, animal life. Shade trees and other vegetation, furthermore, invigorate the atmosphere by an evolution of oxygen. 
This appendage of the nursery is too important to be passed over as merely one of its comforts. As it is, on the score of health and life, as important as anything that can be said upon the subjects of food and drink, it is important that we should make it so appear. By medical writers there is much said about miasma, so much that it is now lisped in the streets by those who do not understand even the meaning of the word. 


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We have not the time, and if we had, this is not the place to enter into a discussion about it; nevertheless, it will negatively appear before we have done, that it is as destitute of truth, as the proposition is, that two and three make four. 
We have lived in the south, and while there, our faculties of observation were never idle on this subject; and without entering into the philosophy of it, we will simply make two statements of fact, which we trust will prove sufficient for our present purpose, which is, to induce all persons to plant shade trees, if they have not, and to prevent the felling of the forest, in future, where dwellings are to be erected. 
A brother of the writer settled in one of the best cotton districts in Mississippi, and as far as it was the best, so far was it the more sickly and fatal to both the white and black population. At his solicitation we instructed him to select for his residence and that of his quarter, a dry piece of ground, well timbered, and to pay no attention to the vicinage of ponds or swamps, but to be careful to have a quarter of a mile of timbered land between his residence and his cotton plantation, and not less than one hundred yards between it and his garden ; to remove the under-growth from several acres about his mansion, but to be sure to leave enough timber to shade, thoroughly, the surface of the earth. 
Under these instructions he located his mansion in a quarter of a mile, or about midway between his cotton on the southeast, and an overflowed swamp of several thousands of acres of a lunated form, bounding him on the N. E., north, and northwest. There was a pond of water filled with logs about sixty yards south of his house, which furnished his stock water, and washing water for the quarter. 
Thus circumstanced, he lived seven years, without having a single case of, the so-called, miasmatic disease, while, on all sides of him. sickness and death prevailed every summer and fall. At this time, believing that his quarter had become so acclimated as to be in no danger, and not comprehending the philosophy of our instructions, he felled a hundred acres of his forest to the west of his quarter, and up to the yard fence that surrounded it, and planted it the next spring. In the course of the summer, every negro he had, except one, who was about 


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sixty years of age, was sick, and so much so, that he did not make more than half a crop. 
Now a question: Could none of the miasm get from his cotton field, through the open timber, to his quarter during the preceding seven years ? could it have no influence upon them while working in the field ? could they bring none of it home with them in their clothes ? could no strong winds blow it from the swamp or from the cotton field in defiance of the vigilance and absorbing powers of the forest ? 
In traveling, we put up for a night with an intelligent Virginian, some three miles east of Vicksburg, and as we approached the house we discovered that his quarter was in the midst of the cotton field, and the cotton growing up to the doors of the houses. After some general conversation with him, we inquired, Whether his quarter was not sickly in the summer and fall ? He answered, that it was considerably so, but not more so, perhaps, than other quarters about there. (This was probably the fact, as all the quarters were more or less similarly circumstanced.) But my question interested him—it involved the value of his property, which induced him to inquire why we made the question. We answered, with a full explanation of our reasons, and concluded by observing— " You have a handsome ridge of timbered land on the opposite side of the road, and if you will move your quarter into it, without felling a single tree, unless it should become necessary in planting the houses, you will save doctors' bills and negroes." 
As people generally are so much disposed to regard all such notions as mere speculation, we had very little expectation that he would ever move the quarter. Some three years afterward, while at Vicksburg, we were invited to an in-fair in the country, by some of the friends of the family—we had no idea of the family, nor of their residence; but upon arriving at the house, we recognized the proprietor as the one with whom we had spent a night, and to whom we had given instructions about his quarter. After our introduction, we turned our eyes to where the quarter was, and found that it was not there, but upon turning a little more we discovered it on the ridge, in the timber. Being now anxious to learn the result 


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of the change, we turned to him and said, " I perceive that you have moved your quarter." He answered very indifferently, " Yes." I then inquired, " Have you discovered the change to contribute materially to their health ?" He answered as indifferently as before, "Well, I think it has been an improvement." I again inquired, " Do you recollect to have been advised, about three years since, to move your quarter to the ridge on which you have now got it, by a gentleman who had the benefit of your hospitality during a very unpleasant night j " Rising from his seat he answered, with apparently deep concern, " Yes I do, and I moved it; are you the gentleman?" When we assured him that we were, no one could have manifested more gratitude than he did—we could have been a welcome member of his family for a year. He then went on to remark that the reasons we had advanced, caused him to think that the suggested move might be of some advantage to his blacks, and he moved it, but he had no idea that the advantage would be as great as he had found it; previous to the move, and for one year after, he had employed a physician by the year, at a high salary, to attend his quarter, but that the first year after the move taught him that it was a useless expense, and he quit it; and that during the preceding two years, a physician had not been called to his quarter more than two or three times." 
Now this quarter was separated from the old one by a distance of about one hundred and thirty yards, including a slip of timber about sixty yards wide. Did this slip of timber prevent all the miasm of the plantation from getting to it ? 
In our large cities, it is a very general opinion that the broad streets are more healthy than the narrow ones; and yet while we lived in Baltimore, and also in New Orleans, it became obvious to us that the streets which were so narrow that the sun's rays never touched them, except when on the meridian, and for this reason they were nearly always wet, were more healthy than the broader ones, and the broadest were the most sickly in summer and autumn. 
To say that in the narrow streets there was no evaporation or decomposition to produce miasm, will not do, because, in cities, the streets become the channels of the wind, and it traverses all of them. Our observations upon the south 


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brought us almost to an undoubting conviction, that the white race can inhabit the tropics and work in the sun, if they will take all their rest in the woods. 
It is fortunate, however, that while much can be said on both sides of the question, the facts themselves dictate the proper course to be observed, notwithstanding the disgraceful fact that medical men have recommended, and caused to be destroyed, the shade trees of a city, for the purpose of promoting its health. 
We have said enough upon this subject to show that shade trees, properly trained, are not only an ornament to a mansion, but a protection to the health of its inhabitants ; but if they be so protective to adults, how much more must they be to infants, whose skin and lungs are so delicate ? 
As regards the other boundaries of the nursery, the N.E., north and N. W., the sources of bleak, and not unfrequently disease-bearing winds, we would suggest that, if possible, they should be guarded or protected by other portions of the mansion. 
From some remarks of Dr. A. Combe, on Infancy, some persons might draw conclusions adverse to the doctrines we have here presented. He says that " the close vicinity to the house of trees," should be avoided because they prevent ventilation, produce and furnish humidity. As it is possible for an atmosphere to be too dry as well as too humid, his objection to the presence of trees, when cultivated as we have instructed, is more than obviated. He also prefers an elevated situation; but as we have elsewhere taught, this preference requires many qualifications. In the abstract, it is true in no country, and much less so in the south than in the north. 
SECTION II. 
OF THE TEM PER AT U EE OF THE NURSERY. 
It is recommended that the temperature of the nursery should be regulated by a thermometer, and kept equable and at about 66° to 67° Fahrenheit. We object to this doctrine, because it is unnatural, and consequently must produce mischief. 


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In nature, the atmosphere is not regulated by a thermometer, with a view to equality of temperature; we cannot be made to doubt that the external world is properly adapted to the conditions of our existence. If children are maintained in an agreeable temperature, both their lungs and skin will form a habit —a constitution precisely in relation to it; and therefore, when they become exposed to a lower or a higher one by any casualty, they will suffer. What else is it that makes a northern climate so pinching and even hazardous to a southern man ? There are as many and as marked atmospheric changes south as north, but a cold day in the former, would be quite a mild one in the latter. 
We must suppose that our Creator, in constituting the seasons and the atmosphere, was not indifferent to the well-being of the creatures which were to be subjected to them; consequently, we must suppose it to be beneficial to both infants and adults to be subjected to variations of temperature. Nature has amply provided both infants and adults, with the means of adaptation to variations of temperature. The same number of volumes of atmospheric air, breathed in a cold room, will produce more animal heat than in a warm one, because it is more dense. This would be sufficient, provided they were sufficiently fed, to compensate for all ordinary variations of temperature. 
Among cold-blooded and hibernating animals, (and also with vegetables,) in the winter season, the temperature is always above that of the atmosphere a little, and as the one changes, so does the other. Making nature our guide in this matter as in all others, our conclusion is, that infants and older children, should be accustomed to considerable variations of temperature, but to go to the extremes is not essential, and should indeed be avoided. 
The temperature of 67° is not low enough for the hours of rest, nor is it high enough for the hours of waking, in the winter. The freezing temperature has a happy tonic influence upon adults, if not endured too long, and that of 40° would have a similar effect upon young children. During the hours of waking and exercising there is too much difference between 67° and 98° or blood-heat, to enable the skin to perform some of its most important functions. 
Summer-heat or that of 76° is too low for the comfort of an 


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adult, in a state of rest, it is at least 21° below blood-heat, which is too much to admit of comfort, more especially to children. 
We do not advocate an unnecessary exposure of children through the usual plea of making them hardy, nor through any other ; and upon the other hand, we object to regulatiDg the temperature of the nursery to equability by a thermometer, as we do that of tropical plants. A cold air is not to be particularly feared under ordinary circumstances, but a damp one should be guarded against at all times in cold weather, and by all persons, but more particularly by infants. 
We would suggest that a fire should be made in the sleeping room about sunset and suffered to burn down —it will be warm enough through the balance of the night. During the day, in dry weather, the windows should be raised while cleansing it, and kept up for some time. The morning fire is now presumed to be nearly burned down, and if replenished, the windows should remain up, during the period it may be vacated by the children. The other room should be warmed, cleaned and ventilated in the morning before the children go into it. 
During the season of cold weather, both apartments of the nursery should wear a woolen carpet, because of the greater conducting capacity of wood than wool, it is economy in fuel, and a protection against cold feet and hands and consequently against disease. Strong objections are urged against carpeting a nursery floor because of the great liability to which it is exposed to become soiled and wetted, and the difficulty of drying it. These objections are too easily remedied, to overrule its advantages. No matter how wetted, whether by washing out soiled spots with a brush or otherwise, the drying process is rendered easy by always having on hand a few quires of soft or absorbing paper. The application of a quire of this to a wet spot will speedily so far draw the water out of it, that the temperature of the room will soon dry it. During the summer season the floor may be uncovered or matted as may best suit the taste or wishes of the superintendent. 
As to the best plan for warming a nursery, all things considered, is a question of much moment. An open coal fire, indeed a coal fire of any kind is objectionable, because it is 


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next to impossible, to avoid floating dust and ashes, and occasionally sulphurous vapors, which are injurious to the lungs. An open coal fire is objectionable because the children may fall into it, or have their clothes take fire; all things considered we would suggest a wood fire in a close stove with a capacious evaporating dish on the top of it. 
SECTION III. 
PHYSICAL TRAINING OF THE NURSERY. 
As the preparation for the greatest achievements of our faculties must and should commence in the nursery, its provisions and management should be, to every parent and to every commonwealth , subjects of the deepest solicitude. The neglects or omissions committed here can never be entirely repaired— " early impressions are the most lasting," and, accordingly, early neglects and imprudences are the most irreparable. In view of these fundamental propositions, we shall be particularly careful not to teach anything which is not defensible upon well established physiological principles. 
There is a pleasure in the expenditure of nervous and muscular energy through the waking hours, and there is a pleasure in the restoration of it, by rest, during the sleeping ones, and unless accumulations of it be effected during sleep, for expenditure when awake, the health and energies of the system must sink; the best means, then, of procuring rest, is, in point of importance, inferior to no other provision of the nursery. 
Children should be trained to early resting and rising, and after the latter they should be washed, dressed, their minds amused, and bodies exercised for some time before receiving their food. 
The utmost care should be taken to train them to regular habits—a proper time for rest, for exercise, for feeding and the voiding of their excrements. Dr. Dewees teaches that they should not be indulged in voiding their urine too frequently, as it will beget the filthy practice of wetting the bed. In this opinion, we agree with him, but not for the reason he assigns; it is occasioned by lying on the back, causing too much heat 


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and blood to be accumulated in the cerebellum. "When they become one or two years old they should have a hard pillow, which will force them to lie upon the side—one made of cotton or rags. This practice of lying on the back is attended, at a later period of life, with another evil of great magnitude, the nocturnal and spontaneous emission of the semen, to the ruin of the constitution, if not timely restrained. 
The first and great requisite of a nursery is a mother or nurse who possesses sprightliness, intelligence, and amiability—• one who has so much self-government as never to betray anger in the presence of the children—one whose social and moral endowments render her a proper example to them ; and lastly, one who has such intellectual resources as to be able at all times to vary or modify their amusements and exercises. 
After breakfast, dinner and supper, the play-room should be a gymnasium for an hour, more or less; every practical means should be provided for the exercise of the children, particularly of their superior extremities. This exercise should be made a matter of indispensable duty. When this course shall become adopted throughout our land, consumption and many other avenues to a premature grave, will become rare events in society. The truthfulness of this conclusion no one can doubt, who will carefully consult our doctrines of the cerebellum. 
During the first weeks, in the history of every child, it is too feeble to participate in the sports of the nursery, and yet exercise and airing are as essential to it, as to those of more age. These objects, to a considerable extent, may be effected by carrying it about through the nursery, and this should be regularly and punctually practiced every day. But to the usual manner in which this is effected there are some weighty objections. A vertical position to the body of the child should be carefully avoided, as the feeble spine has to sustain the weight of the chest and head. During early infancy it should be sustained in a nearly horizontal position upon a pillow, and thus carried about, or which is still better, to place it on a pillow in a convenient basket; in this condition it has liberty of motion, and can be carried about by any domestic. 
The time was when no possible means were neglected to build up the animal, machine, and similar means are still 


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resorted to by many of our wild tribes; but now, in civilized society, while the animal is neglected, no efforts are spared to build up the intellectual and religious machine ; thus forgetting that the latter cannot be usefully or happily effected without the former. The attempt is similar to placing upon a column a heavy capital when the foundation is feeble and unsettled. In our country this is the great fault of the age. We have infant schools and Sunday schools and every-day schools for the cerebrum, but no other school than chance, which feeble constitutions are sure to neglect, for the development of the cerebellum or vital forces. In this condition of society we have discovered the great source of consumption, cerebral congestions, convulsions and many other nervous affections. 
SECTION IV. 
MENTAL TRAINING IN THE NURSERY. 
We are now to speak of such training as the nursery should provide, which is to affect and materially to mould the future man or woman. It must be recollected, that the child is introduced into the world entirely helpless, and with scarcely more of what can be called mind, than is possessed by an oyster —barren of a single thought, and yet, as observation has clearly shown, it possesses the rudiments of all the faculties which, in future life, will be manifested. Over these rudiments we have not an unlimited control—we have to submit to an original determination of their constitution—to the fiat of na-. ture, " so far canst thou go, but no further." Within prescribed limits we can do great good or mischief, by retarding or promoting the development of these rudiments, and by properly or improperly directing the manisfestation of their faculties. These faculties adapt him to the world in which he lives, and out of which he is to elaborate his happiness or his misery—his usefulness or his mischievousness. Some of his faculties are precisely in kind with those that govern and impe. the brute creation, commanding him to kill that he may eat, to repel aggression, to shun danger and propagate his kind. As far as he has faculties in common with the inferior orders 


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of creation, so far are his pleasures or enjoyments like theirs— he has pleasure in eating, drinking, sleeping, and in the exercise of his voluntary muscles; and the great calamity in the present state of the world is, that a preponderating portion of the race is satisfied with these enjoyments, and will make no struggle to reach that superior sphere, where the social and moral sentiments, and the reflecting faculties preside, and secure to their possessor a large range of enjoyments, in which the animal world can never participate. They furnish his most exalted, his most refined, and his most impassioned pleasures ; those, compared with which, his animal ones are as dross to pure gold. They introduce him directly to the great and ennobling purposes of his existence—obedience to the institutions of his Creator, and love for his fellow-men. They give him dominion over the earth, by being impelled by his animal wants, and aided by his powers of voluntary motion, to control a part of the stupendous whole that surrounds him, and to adapt himself to the balance in such a way as to render it subservient to his comforts and enjoyments. He can control the horse, the ox, the sheep and dog, and render them subservient to his wants and his pleasures; he cannot tame the lion and the panther, but he can destroy them ; he cannot control the ocean, but by the use of canvas or steam he can ride upon its bosom, command its treasures, and the commerce of the world. 
When children cry because of being uncomfortable or sick, they should be attended to; but when they do it as a means to obtain what they desire, they should never be gratified. If under such a motive, they are gratified in things to which there can be no objection, they look for gratification in those to which there may be serious ones. By teaching them to wait your time and pleasure, you cultivate their firmness and fortitude— they acquire the power of self-government, which is indispensable to happiness, to success, and to good-citizenship. There is in society no fault, no neglect so lamentably attended in its results, as this. 
Every laudable means and useful temptation that can be devised should be resorted to, to make the children love the nursery, they should delight to be in it more than any other place. The common practice therefore, of using it as a kind 


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of prison or place of punishment, is very injudicious—it is far better to practice the reverse—take them out of it for improper conduct, which can be made very effective by a little address. Nothing should ever be done to children, which they shall conceive to be intended as punishment. When such a notion takes possession of them, obstinacy is certain to be engendered. 
The nursery should be regarded as a community of miniature women and men, and should be influenced, as we do our fellow-citizens, by the use of adequate motives. They should never be commanded directly, to do anything, but politely requested. The tone of command is offensive to self-esteem, while a request is agreeable to approbativeness and benevolence, and will very generally secure obedience. But suppose it should not, what then ? Let the parent or superintendent address the offender thus: " We have politely requested you to do us a favor, and you have refused, now this is unkind and ungenerous in you, and a bad example to your sisters and brothers, and through a fear that you will spoil them by your example, you must leave the nursery." This course can be variously modified so as to suit age and other circumstances. It is always better to tell a child that he cannot be good or dutiful, than to tell him that he will not; because of two reasons : under the influence of adequate motives he would have been good, but in the absence of them he was not, and by telling him that he cannot, you create a motive which induces him to show you that he can. It is an impeachment of his capacity, which is worse than a whipping. In the first instance, the sending him out of the nursery for the reason assigned, which was a correct one, you impeach his perfection—he is penetrated with an idea of disgrace, and most generally reformation is the immediate result. By these means, variously varied, one person can govern fifty children, and have obedience and good conduct, provided that that person possess patience, and selfgovernment, and those who have not these mental requisites to a nursery, should never have the care of children. 
As mental education commences spontaneously, at a very early period, and as exercise of all the members of the body is indispensable to health and future usefulness, it is obvious that a nursery should be supplied with inducements and facili ties for the exercise of the intellectual faculties. 
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At an early period, perhaps at birth, an infant manifests consciousness, and soon after a spirit of observation, and as the faculties concerned in this function can neither become active nor developed to a proper extent without early and continued exercise, the nursery should be provided with objects of sense—such as will spontaneously attract attention. To the neglect of this culture, during youth, do we attribute a very large proportion of the vice, crime and idleness of society. This end can be achieved by supplying their rooms with drawings, paintings, and a selected cabinet of natural history. The presentation of one of these objects, will generally arrest that fretfulness which has resulted from animal irritability, whereby it is not only calmed, but instructed and rendered more intellectually able and effective. 


CHAPTER VIII. 
CAUSJES OP INPANTILE MORTALITY. 
In the conditions incidental to infancy, in civil society, must we look for the causes of that infantile mortality which distinguishes many of our cities—a mortality that is not more astonishing, as a question of professional investigation, than lamentable to the philanthropist. In 1818 the entire mortality in Paris, (France), was 22,421, of which 3,942 were of infants under one year of age. In New York, as we learn from the tables compiled by Dr. Lee, comprising a period of sixteen years, one-fourth of the entire mortality consisted of infants under the age above-named. 
In 1851, between the 21st of June and the 18th of July, the total mortality of Cincinnati was 650, and of this number 366 (considerably more than half), were of children under five years of age.* From the usual rates of mortality, as governed by age, we may safely infer that one half the 366 were of children under the age of one year. 
Every writer which it has been our fortune to consult upon infantile forms of disease, enumerates nearly or quite all of the normal differences that distinguish infancy from adolescence, and treats of them as the predisposing causes of disease and death in the former, and thus the greater infantile mortality is accounted for. As a matter of fact, we do not believe this doctrine, and in not believing it, we will not, as a moralist or as a political economist, teach it. 
We have upon several occasions expressed our faith and confidence in the provisions of the physical world for the very best interest of all its creatures. To us, every provision—every 
* Eclectic Medical Journal. 
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law bears upon its face the impress of goodness and wisdom. Under these abiding convictions we are unwilling to admit that any provision of our Creator is faulty, or clumsily adapted to a wise and benevolent end. "With these convictions, we must believe that the infantile brain, its envelopes and their relations to each other, with all the minor arrangements of the wonderful whole must be just as well adapted to health, to life and to an immunity from disease, under the circumstances of its existence, as the similar sum total of the arrangements with which adults are endowed. We cannot then attribute infantile mortality to any peculiarity of God's providence. We do not believe that it was contemplated by it, that any one should die before extreme old age—before the organization wore out, and the existing premature mortality results from the countless violations of its ordinances which have been progressing ever since man had an existence. The average of human life has much increased in the last thirty years, and it will continue to increase so long as there shall be an increase of obedience to the organic laws. 
With reference to the great mortality of children, we must now give our opinion as to the causes. We have elsewhere remarked that all special attention to the development of the animal system has very generally ceased, and in its stead a very general one is given to the mental, which is always antagonistic to the animal, that is, it depends upon the animal for all its force and efficiency of manifestation, consequently onehalf of the children that meet, thus, an early grave, are produced by parents who never possessed a normally physiological condition. Add to this prevailing cause, the morbid condition of mind that distinguishes New York, Cincinnati and many other cities, and the astonishing mortality of infants is accounted for. 
We have but for a few days to observe the manifestations of New York and Cincinnati society, to feel quite convinced that the mental condition of one-half, is in a pathological state, consequently the children of all such persons are born predisposed to inflammation of the brain, convulsions, congestion and all those diseases which can result from an unsound brain, and an undeveloped animal system. Happiness is a stranger to one-half of the community, and pleasure is sought— 


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we mean passionate excitement. Some must go to night prayer-meeting at the hazard of property and children—some must be at the theater—some at the concert, some at the card table, —some at a political club—some at the masonic-hall— some at the odd-fellows hall—some at the tippling shop, and nearly all are impelled by a motive precisely similar in kind— abnormal or passionate excitement. Are parents in this condition capable of producing healthy children ? It would be an unmerciful fate to doom infants thus conceived, carried and brought forth, to live more than one year. Parents who desire children must learn to maintain their systems in a normal state 
—a state of health and happiness, and in no-wise indulge a nervous anxiety for pleasure. If physiologists, philanthropists and moralists desire to reduce the present standard of infantile mortality, they must devote more of their attention to the social state —they must train society to live in conformity to the organic laws. Our clergy and editors, with the help of good citizens, can effect a complete revolution in ten years. But this work cannot be effected by removing evil institutions alone—in their stead must be erected useful ones—such as are devoted to art, science, literature and physical exercise—gymnastics—subjects that produce happiness and usefulness, without passionate excitement. As a morbid excitability is much less prevalent in Philadelphia than in New York or Cincinnati, we would expect a less infantile mortality. 
The three great enemies of human life, in the United States, are politics, religion, and ardent spirits. From the first we have an unstable government, and many unhappy citizens ; from the second, very many unhappy and restless Christians, and from the third, very many unsound bodies. We have, therefore, as a people, yet to learn the temperate use of our advantages. The very freedom of our institutions is pregnant with premature death. In countries less free, almost every individual has, by caste, bounds fixed for the hopes of his ambition ; but here the humblest individual has as large a field for the play of his hopes, and exercise of his ambition, as those of a long line of successful and distinguished ancestry. Every one is born, yes, conceived, in a storm of excited and hopeful expectation and bred in a whirlwind of impassioned exertion. 


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In the American face is depicted irritability, anxiety and care—its pathognomy most clearly indicates that the comforts of life do not constitute the engrossing and all needful purpose of existence. Look at a European face, the Irish excepted, and what does it indicate ? Yery little else than a desire for roast beef and puddings. The natural expression is one of ease—of a fitness to enjoy existence—to make the most of it, and to be satisfied with it. 
The great expenditure of vital force in the mental functions of the Americans, particularly those who populate our cities, so reduces the tone and vigor of their bodies as to incapacitate for producing a vigorous progeny. In view, then, of the existing condition of American society, no one who is acquainted with the organic laws, should be astonished at its juvenile mortality. 
Some may say that this argument is not consistent, because juvenile mortality in European cities is as great as it is in the American ! We admit it, and for the reason that there exists a state of society so low and dependent, that we have none to correspond with it—they are enslaved, ignorant and degraded—but here all are free and intelligent—death from absolute poverty has scarcely ever been witnessed in our country. 
Thus far, in our investigations, we have had almost exclusive reference to children in a state of atmospheric or extrauterine existence, and although there exists almost an entire personal identity between the fetus and the infant, yet they are intrinsically as different as a vegetable and a child; but notwithstanding this difference, mothers speak of their fetus, as their child, and as familiarly too, as if they had seen it or heard it cry; consequently we are called upon to drop a few passing remarks with reference to the intra-uterine children, more especially as physicians are frequently consulted in their behalf. 
Fetal life and vegetable life present many striking analogies ; the fetus is developed from nourishment furnished either by the placenta or the amnion, or both; and vegetables are developed by nourishment obtained from the earth or the atmosphere or both ; the fetus manifests, so far as we can discover, no animal function—it may be diseased, and so may a 


CAUSES OF INFANTILE MORTALITY. 
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vegetable, but neither of them can be sick—both are incapable of suffering. Neither of them manifests an animal sense, nor a voluntary capacity. We may restore a diseased fetus by medicating the mother, and so we may a diseased vegetable, by medicating the soil, which is its mother. 
Philosophically speaking, then, a fetus is not a child, nor can it become one without a greater supply of oxygen than the placenta was ever intended to furnish, but which, normally, is supplied after birth by the respiratory function. We have called attention to intra and extra-uterine life simply for the sake of truth; for the present it is only important for us to know that fetuses are still-born, because probably of disease, and that they are born with varieties of disease, of which they may die, or from which they may recover. 
It is now, we believe, a settled doctrine that fetuses contract disease, of which they either die or recover, and these events may take place in either the intra or extra-uterine condition ; therefore it is not required that we shall support the affirmative by evidence. Nevertheless, the fact that a fetus is diseased, or has been diseased and recovered, we cannot ascertain, unequivocally, till after birth ; and if we could, it would, in the present state of medical science, prove of no therapeutical advantage. 
We may be told by some, that by proper attention to the mother we may, in a great measure, ensure the fetus. We admit this as a postulate; but what are we to understand by a proper attention to the mother ? In one instance a mother has the appearance of possessing fine health, and yet she has a halfdeveloped, sickly-looking and feeble child ; while another, who by the time her child is born, wears out all but the last thread of life, and that yields in a short time after, by struggling against consumption or some other fatal malady, and yet her child is fully developed—a fine picture of health ! In both of these instances we would, a priori, have concluded just the reverse of what happened, and is known to happen frequently. 
In Virginia, large tracts of land are thrown out of cultivation, as being unfit for the production of tobacco, corn and potatoes, but still it produces a thrifty forest of pine-trees. In the abstract, this land cannot be considered as exhausted, but so only, in relation to the vegetables before named. Hence, it 


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so appears, that some women are constituted to enjoy existence, but not to produce children ; while others have but little physical enjoyment, but produce fine, healthy children. "With reference to the land, chemistry has taught us how to remedy the evil; but physiology has not done the same for us with reference to women. As yet the whole subject is enshrouded with darkness and difficulty. If we shall, therefore, do all that is properly indicated for the mother, considering her condition, we shall do all that we certainly can do for the interest of the fetus. 
There is yet another physiological condition with reference to fetuses and children, which we deem too important to be suffered to pass unnoticed, though neglected or never thought of by any one else. It should be constantly remembered that during fetal life no animal function is performed—the fetus only vegetates ; consequently it is possible for one to be born well developed, and in a fine condition, because of a fine organic or vegetative system, but for the want of a more highly endowed animal system, it commences soon after birth to decline ; and thus, to an extent more or less, it happens, that life cannot be prolonged beyond one, two or three years, or possibly, in some instances, to seven. A large proportion of the mortality that happens among infants, during the first years of existence, results from this cause. On the other hand, another fetus has a fine animal system, but so feeble was the vegetative, at birth, as to appear almost impossible that it could live ; but it is soon discovered that atmospheric existence agrees with it, and it soon becomes a child of promise, and finally makes a strong and healthy man. This distinction is important, particularly as it indicates the great importance of early physical exercise to the former. 
We feel entirely satisfied that we have satisfactorily accounted for the existing mortality of children, without any reference to those organic conditions which constitute infantile normality. Such is our conviction, from extensive observation and years of reflection, that all the arrangements of Providence are faultless ; and consequently we are much more disposed to look for the causes of social evils to social violations of the organic laws, than to any oversight or neglect in the plans of the former. 


CHAPTER II. 
OP THE NECESSITY AND UTILITY OP JUVENILE MORTALITY. 
It will, no doubt, appear very singular to many of our readers, that we should advocate such a doctrine as that which must be inferred from the caption of this Chapter, more especially in a work of this kind ; but when they have read it, and reflected upon it, we trust that they will agree with us, that it is neither out of time, nor out of place. 
Our proposition when explained, is, that under existing circumstances of the human race, juvenile mortality, to the full extent of its natural causes, is both necessary and useful. That nothing less could result, and nothing less should result, or be even hoped for, by any good citizen. 
Our readers have not yet to learn, we should think, that we unqualifiedly believe that all the arrangements of God's Providence are adequate to the very best ends of the human race; and consequently, we must believe that disease and death, and both, in accordance with all the circumstances that attend them, are wise and beneficial institutions. Believing this doctrine to be true, and therefore good, we have deemed it proper, as a physiological prophylaxis, to place its defense before the public, hoping that many may be admonished by it, to practice greater obedience to the organic laws, and thereby, in a manner compatible with the requisitions of Providence, lessen or reduce the present standard of human mortality. 
We hold that the profession have been shamefully guilty of a dereliction of duty to the public, in having, to this timet suffered it to continue ignorant of the great and paramount truths with which, it will be seen, this subject is pregnant. If parents had, long since, been made familiar with it, two 
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great and important results would now be exerting a salutary influence on society; namely, in view of progeny, every one thus instructed would take more care, than is now thought to be essential, of his physiological condition ; and secondly: every one would meet the loss of children, by the ordinary causes of death, with that propriety and submission which become an intelligent understanding of its necessity. Such events would produce conviction that the organic laws cannot be infracted with impunity—such suffering parents would be penetrated with the conviction that their bereavement was just to them, and merciful to their progeny. Such information could rarely fail to produce a more vigilant obedience for the future. 
How stands the case now, in the public mind ? All act as though all children should live, all desire that they should live, without any reference to consequences, and when they die, the event is referred to a mysterious dispensation of Providence— not a word is said to them by doctor or preacher to enlighten them upon the subject of their own unsoundness, or daily violation, in almost all they do, of the organic laws. They are not taught to look for the cause of their bereavement in the history of their own lives. If the bereaved be piously disposd, he inquires of himself, have I not kept the commandments ? have I not been charitable ? have I not been just? Then why should such a dispensation fall upon me ? We answer, for the reason that you have not obeyed the organic laws. For all your obedience you will have your reward in kind, and for all your disobedience you will suffer a corresponding consequence in kind —the antecedent and the sequent are always related to each other in kind—if you sow tares you must not expect to reap wheat. Moral rectitude is not rewarded by an immunity from disease. # 
It may be considered as an undebatable, and therefore a self-evident proposition, that every animal or living thing was placed here to enjoy existence; and if children leave their parents before they have enjoyed, to any conscious extent, existence, the cause cannot, legitimately be found in the arrangements of Providence. And if parents shall suspect us of a disposition to insinuate, that if their histories were properly investigated, the cause of juvenile mortality might be found ; 


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We will only say, that we would feel greatly enlightened by having the histories of all such. What a flood of light the profession might, in a few years, shed upon this subject, by making a record of the organic history of all parents, whose children die under five years of age. It would, we suspect, be found that a few had married cousins ; many had married incompatible constitutions ; many had married diseased ones; many dissipated in exciting amusements; many were in a constant excitement about their pecuniary liabilities; others, about their political prospects; some were gloomy for the want of business ; others for having failed in business ; and many were miserable because of discord. 
Our whole purpose for introducing this subject, is, to make parents, and all who expect to become parents, think of the 
organic laws, to which they must render obedience, or suffer in themselves, in their children, or in both. We desire that it shall furnish a motive to individual and social improvement. If any have applied our remarks to themselves, the fault is not ours; we have followed the plan of Providence—we have aimed at the good of the race, and not at that of individuals. 
With these introductory considerations, we proceed to an exposition of the truth of our proposition. 
There is no principle in the dynamics of the natural administration of this world more obvious, more visibly displayed, or more defensible, than that the organic laws were so arranged, as to provide for the preservation of species, at the expense of individuals. The principle, furthermore, is illustrated by all nations, civilly, politically, and religiously. All communities cut off criminal individuals for the good of the many— the community; all nations lose thousands of their citizens in war, for the preservation of their political independence and privileges ; and all religious associations expel irreligious individuals, for the purpose of maintaining the purity of the church. The least attention to the principle will show, that it is eminently philanthropic; and a little more attention to it, will we think, show that philanthropy is a more exalted virtue than either justice or charity. If we shall now show, that the good of the race—the species—is promoted by an extensive juvenile mortality, then we will have gained our point. In doing 


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this, we admit that we throw all the responsibility upon the parents —we take from them the consoling unction, that the fault was not theirs; although they may have loved their children, tenderly nursed them, and employed the most distinguished medical skill for them. Behind all this lies concealed their disobedience; and their children were taken out of the species, and as certainly for the good of the species, as that criminals are taken out of society, for the good of it. 
Suppose any given number of children should take the small-pox, and all exist under equal circumstances, and onethird of them should die; would not the conclusion be, that with reference to this disease, that the two-thirds who recovered, possessed a more conservative, a more effective vital force than those who died ? If this conclusion be admitted, then it follows, that some children have a greater constitutional tenacity of life than others, and that diseases are the proper tests of this vital force. 
Children are the acts of parents, and their early death proves, cceteris paribus, that they were incompetent to stand disease, the test of vital force; or capacity to maintain existence, threescore and ten years, and consequently the cause is justly referable to the parents. 
The fact is well known, that great longevity is peculiar to some families, and it exists in defiance of every variety of morbid invasion. We may speculate as we please as to the cause, but we will have to conclude, virtually, that it depends upon a strength of vital force which is capable of expelling from the system all causes of morbid action, until worn-out or exhausted by age. We are acquainted with a gentleman who had a severe attack of Asiatic cholera, in the seventy-ninth year of his age —he was self-willed—obeyed neither his physician nor any one else—he would have to eat and drink whatever his appetite desired; consequently he ate heartily of pickled cucumbers, and drank freely of buttermilk—no one expected him to live, and yet he is still living in the eighty-third year of his age, and apparently as able to sustain another attack of cholera as he was before. Now, we may inquire: What enabled him to live so long in the midst of epidemics that have carried off thousands of younger men, from immediately around him ? Shall we not attribute his present existence, under all 


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the circumstances by which he has been surrounded, to the superior integrity of his vital force ? 
The principle that aims at the perpetuity or preservation of the species, is strongly exemplified in various conditions of human society. In hospitals and prisons, where very many are crowded together—too many for the health of all—so many that all will perish without a reduction of their number, a cause of disease is generated, which fells all but the few whose vital force can resist it; and thus at the expense of many, a few are spared to preserve the race. Did not these few possess a stronger vital force—more power to resist disease than the others ? 
In old and dense communities, where vicious habits, outrages upon the organic laws, have become so extensive as to render enfeebled a large proportion of the population, a poisonous epidemic makes an assault, carrying off all whose vital force cannot resist it. Can any one be so stupid as not to perceive in this, not only that the survivors possessed a stronger- - a more resisting vital force, but also an immense advantage to the cause of human existence, as a species ? Those who escaped, possessed the requisite vital force to become the progenitors of a vigorous posterity. 
It will, we think, be perceived from what we have said, that disease is the test of vital force; and consequently the younger a person dies, the greater the defect in this essential of existence. "When, therefore, we contemplate epidemics—disease in general, with a proper philosophical spirit—it becomes apparent, that it is not only the great avenger for sins against the organic laws, but is indispensable to the aggregate of human life; and that without it, the species would become extinct, through the degeneracy of vital organization. 
Horticulturists select the seed of their various crops from the most developed and vigorous plants; and yet some of the seeds will have a feeble vital force, indicated by the feebleness of the plants they produce, which he extirpates from the soil. Does not death perform the same important function in the garden of human life ? He destroys its plants in their youth— he does not allow them to produce seed, and in so doing, he preserves the species in that condition which is adequate to a perpetual existence. We have frequently heard it said, that 


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epidemics were, no doubt, wise and profitable dispensations of Providence, but inscrutable to man. We admit the first, but deny that their purpose is inscrutable—indeed, we think that we have made their purpose so plain, that the most ordinary intellect can understand it; and in understanding it, the presumption is, that it will admonish all to become more acquainted with, and to practice a greater obedience to, the organic laws. 
If disease was intended to test the vital force, and to cut down the feeble in their youth, some may be disposed to suspect that it is useless, if not improper, to attempt to save those who may be thus assailed. "We should come to no such conclusion. In very many instances the vital force is nearly equal to the disease, and with a little judicious aid, would overcome it; and then by proper culture, the former may be so strengthened, as to contend with epidemic and other causes of disease, even to old age. And in cases where the vital force is sufficient to overcome the disease, it must be perceived, that a little injudicious meddling may reverse the relation, and then death must supervene. 
A few illustrations will render this principle obvious. Suppose a case in which the vital force is inadequate to the removal of the disease, it is clear that by rendering a little judicious aid to the former, in removing impediments and equalizing its forces, it may obtain a sufficient ascendency. 
Suppose again the disease to have resulted from epidemic poison, and that the vital force is adequate to its removal; but as the friends do not know this, a physician is sent for. Upon his arrival, he finds a high degree of febrile excitement, and mistaking it for the disease, and a very general mistake this is, he bleeds the patient. Does he not, by this act, reduce the vital force ? Suppose again that he gives a purgative; will it not also reduce the vital force ? And lastly, suppose he gives mercurial alteratives ; does he not add to the labor of the vital force, by introducing another poison ? In view of these mistakes, and they are the prevailing practice of the age, is it strange that the patient should die ? would it not be strange if he did not ? And yet in first class constitutions, the vital force is frequently able to contend with both the disease and the doctor. 


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In review of the prevailing practice, we feel justly called upon to attribute a large percentum of the existing juvenile mortality, to the medical profession. When the febrile symptoms, in any given case, run so high as to induce those who maintain that fever is disease, to bleed and purge; they would induce us to believe that there was present, vital force enough to save the patient, consequently we are inclined to hold that branch of the profession responsible for every instance of mortality, that supervenes such a practice. 
This question we shall discuss in the next Book—it has incidentally come up here, in our purpose of showing to what extent the existing juvenile mortality, is indispensable and useful in the consummation of the great purpose of Providence—the preservation of the species. 
In the preceding Chapters of this book, we have labored to enlighten our readers upon the subject of their duties to themselves, with reference to children, and of their duties to their children in view of life, health, longevity, usefulness and happiness ; and in conclusion, we conceive it to be our duty to make an exposition of the necessity, utility and philanthropy of that mortality which results from their neglect of those duties. 
If, in the discharge of this duty, we have inspired in some, a desire to become more extensively informed with reference to the laws by which God governs his physical Providence, we advise them to read, and to study the " Constitution of Man " by George Combe, Esq 


APPENDIX TO BOOK I. 
(PAGE 73.) 
The subject of this appendix, Mrs. Catharine Schooley, the wonderfully Adipo-Lymphatic Lady, was unknown to the public at the time our first book passed through the press; and as her case is one of much interest, we conclude to introduce it in this manner, rather than not all. The following wood-cut presents a good likeness of 
MBS. CATHARINE SCHOOLEY. 
The condition of this lady belongs legitimately to the doctrine of the temperaments, and as her case has suggested some thoughts which did not occur to us when treating of that subject, and as she is an admirable illustration of them, we hope to render clear some distinctions which physiologists have not hitherto noticed, so far as we have observed. 
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193 
Anatomists and physiologists have expended much labor in an endeavor to ascertain the average amount of fat or adipous matter which is common to the human race; but when we reflect that the largest accumulation of it was in a German individual who weighed eight hundred pounds, and the smallest, which, perhaps, amounted to a total absence of it, was the well known Calvin Edson, who weighed only fifty-eight pounds, and whose stature was that of a man—being some five feet ten inches high, and of good general health. Between these extremes there is a difference of seven hundred and forty-two pounds. Therefore, as we were about to remark, that where such extremes exist, it cannot be an easy task to determine the average. Nevertheless, it has been agreed to consider onetwentieth part of each human being, upon an average, to be fat or adeps. According to this rule, a man weighing one hundred and sixty pounds would have eight pounds of fat. 
In this active and excitable country, cases of leanness or atrophy are much more numerous than those of even moderate hypertrophy; but in Holland, and in some parts of Africa, it is probable that, in a majority of individuals, the tendency is to hypertrophy; and yet the instances of such astonishing fatness, or hypertrophy, as Mrs. Schooley exhibits, have been remarkably few among all nations and in all ages. 
In 1834, a gentleman from Kentucky, by the name of Prichard, exhibited himself in the Cincinnati Museum on account of his fat—he weighed 550 pounds. We regret that we do not know his height and other proportions, because, upon these depend much of the interest of the case. Some twenty-five years since, a man exhibited himself in Philadelphia under the designation of " the Canadian Giant," who weighed 618 pounds, and had an altitude of six feet four inches. Dupeytren has published the case of a beggar-woman, who was five feet one inch high, and five feet two inches in circumference, but he has not given her weight. But the most distinguished case known to physiological history is that of Daniel Lambert, of England, who weighed 739 pounds. His altitude we do not remember, but it was over six feet. 
Before proceeding to an elucidation of this subject, we will introduce the facts as to the person of Mrs. Schooley, and a brief outline of her history: 
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APPENDIX TO BOOK I. 
Mrs. Schooley was born March 28th, 1816, in "Warren coun- 
ty, New Jersey. Her father, Anthony Lurch, when in the prime of his life, weighed about 250 pounds, and her paternal grandfather weighed more than three hundred, and his wife more than two hundred. She had seventeen children—twelve boys and five girls—and at her death, which happened in the 78th year of her age, she had, to the best of Mrs. Schooley's information, about two hundred grandchildren, and one hun- 
dred great grandchildren. 
Mrs. Schooley herself has a brother and sister, who respec- 
tively weigh about two hundred. It appears, then, from the history of her family, that she has inherited a liability to an adipous hypertrophy of constitution; and, so far as she knows anything of herself, she has been, with more or less regularity and rapidity, gaining fat and increasing in size ever since her 
infancy. 
When she married, which was in 1835, she weighed 160 
pounds, and in 1836 she had a son, who lived to be more than four years old, (this was the only child she ever had). In 1839, Mr. Schooley and she moved from New Jersey and settled in Pickaway county, Ohio, at which time she weighed 280 pounds. She has had up to the present moment, as a general condition, excellent health, and weighed, in 1845, five hundred and fiftythree pounds, and she thinks that she has gained one hundred pounds since; but good judges of weight, from appearances, estimate her weight at six hundred and thirty-five or forty 
pounds. 
The following measurements will convey a pretty accurate 
idea of her magnitude: 
Height of person, 5 feet 2 inches. Circumference of the head, .... 1 foot 11 " " " neck, .... 1 " % « " M chest, . . . . 5 feet 5 u " " abdomen, . . . 7 " 0 " " " arm near the chest, 3 " 2 u «' " arm 4 inches above elbow, 1 foot 10 " Measure over head from meatus to meatus 1 " 2 ** Measure over head from nasal suture to occipital protuberance, .... 1 " 3 M 


APPENDIX TO BOOK [. 
195 
Her hair is of a light chesnut color, and very sparsely set upon the head ; the complexion of her skin is about that of a middle-aged sanguine man—rather opaque and reddish on the face and hands, but fair where not exposed. 
Her eyes are unusually full and prominent, and of a bluish gray color, but the eye-lids do not approximate as they usually do in the lymphatic constitution, but they do, nevertheless, give to the face an expression of heaviness. Her features, as a whole, are much of the sanguine order, large, fully defined, and withal, good-looking. It should be remarked, however, that her forehead is more vertical, and the crown of the head is more elevated and expanded than is common to the sanguine constitution. All of the superior anterior part of her head is peculiarly lymphatic in its appearance. Her nose is straighter and of a more graceful form, and the lips are thinner than is common to the lymphatic constitution. 
In her chamber she is active—sits down, gets up, and turns about with more quickness and promptness than is common to many ladies of much less portable dimensions; but a few movements, however, exhaust her. The walking of thirty yards would prove a very fatiguing task to her. 
From the time of her accouchement to 1847, she was disposed to sleep the most of her time—she would fall to sleep when eating, with food in her mouth ; the presence of no ordinary excitement could restrain this propensity. During this soporiferous condition, she was much troubled with a feeling of weight or heaviness in the basilar region of the anterior lobes of the brain, with aching and tumefaction of the eyes. For the purpose of relief, she was advised by a medical friend to smoke tobacco—she did so, and was relieved, and continues so—she is now as wakeful as any one, but cannot dispense with the remedy. 
Her intellect is active and judgment good, superior to that of most of her sex—it even approaches masculinity. She converses well, but soon becomes fatigued. She manifests, furthermore, a large share of that social delicacy for which her sex is distinguished. The conviction that she is both useless and helpless, and daily becoming more so, if possible, is a source of exquisite grief to her. She cannot refrain from shedding tears when her helplessness is alluded to, but in 


196 
APPENDIX TO BOOK I. 
general she is social and apparently happy. Nothing but a sense of duty, with reference to a possible necessity, occasioned by the conviction that her condition requires the whole of her husband's time, sustains her in becoming an object of public curiosity. 
Finally, she is not to be regarded as merely a large animal, but a lady of excellent judgment, fine social sympathies, and a faultless propriety of deportment. 
When we contemplate the low stature of Mrs. Schooley in connection with her weight, she becomes at once an object of more anatomical and physiological interest than any other one known to history. The Canadian Giant was six feet four inches high, and therefore, if he had been as fat as she, he would have weighed 143 pounds more, while in reality he weighed 17 pounds less. Considering the respective altitudes of Mrs. Schooley and Daniel Lambert, their weight respectively, is about equal. 
So far as we have well authenticated information, Daniel Lambert must still be regarded as the largest man who has lived, and as the measurements of Mrs. Schooley are greater than those of the beggar woman named by Dupuytren, she must be regarded as the largest woman known to have existed. 
To the scientific inquirer, the most interesting relations of this class of persons, are yet to be considered. 
What is the difference between the Adipous and Lymphatic constitutions ? Lymph is not fat, and yet physiologists confound the two —they have drawn no distinction between them. Most of them would regard Mrs. Schooley as they did Daniel Lambert, as of the Lymphatic constitution. Those who are merely fat or obese, have small heads—that is, they are not larger than those of lean persons ; but those of the Lymphatic constitution have large heads. This is not all; Lymph is never partial in a normal state of the system —there is never a hypertrophy of \* in one part of the system, and an absence of it in another. It pervades equally all parts of the system—the brain as well as the body. Lymphatic individuals never become so heavy as the fat or adipous. Fat persons, furthermore, retain the features of their former and more dense condition, and of the dense varieties from which they had departed, except in the circumstance of their adipous hypertrophy. But the features of 


APPENDIX TO BOOK I. 
197 
the purely Lymphatic, are peculiar and unmistakable—the eyelids are partially closed, the nose is pugged, the lips are thick, and the head is large and round. 
Mrs. Schooley's head indicates the presence of Lymph, but not to the extent of her magnitude; and although her head is above the average of female heads, yet it is not larger than some among the dense varieties. We decide that she is an obese specimen of the Sanguine-Encephalo-Lymphatic constitution. The coronal aspect of her head, and certain peculiarities of her mouth and eyes, indicate the presence of Lymph. Her complexion and nose in particular, and to some extent her mouth, eyes and posterior portion of her head indicate the presence of the sanguine, as may be observed by a comparison of her portrait with the cut of Gen. Washington. 
The fullness or breadth of her head at the level of the parietal ridges, and the prominence of her inferior jaw, but more particularly the former, show that she participates, to some extent, in the Encephalic temperament, as exhibited by the cut of the Eev. Dr. Reinstadt. 
It appears that Mrs. Schooley's constitution is composed of three; the sanguine and lymphatic, however, preponderate over the third or encephalic. With the Bilious she seems to have not the least affinity—she is as much unlike it as she is of any distinct race of the species. The bilious constitution is peculiar for its denseness or compactness, while her leading peculiarities are just the reverse. A comparison of her portrait with that of Akiosto, exhibits a bold contrast. 
Having considered the constitutional relations of this remarkable lady to the species, we return to the question, What is the difference between an obese and a lymphatic constitution ? If we are to be directed to our conclusion from the known chemical composition of Lymph, and of Adeps, then there is no similitude between them, and this, in reality, is our conviction. Fat consists of hydrogen and carbon, and lymph of water (about 96 per cent.), a small quantity of the salts, common to animal life (about two per cent.), and variable proportions of fibrin and albumen. 
The Esquimaux Indians have been regarded by physiologists as Lymphatic. How is it possible for a lymphatic people to live in such a climate I The crania I have, show them to be 


198 
APPENDIX TO BOOK I. 
bilious, while the necessity of their climate and the nature of their food would render them fat. 
If we mistake not, the winter and spring conditions of hibernating animals, illustrate the fat and the lymphatic conditions incidental to human life. They never repair to their hibernacles until they become very fat, and while there, they drink water, but take no food—their fat maintained or provided for them the necessary animal heat during the winter. "When they leave their hibernacles in the spring, they appear to be as fat as when they went in; but this could not possibly be the case; and that it is not the case, we may infer from the fact that they soon become very lean after leaving their hibernacles in the spring. Their condition then was that of lymph; a compound of water, fibrin, albumen and salts, which is entirely incapable of sustaining animal heat. 
There is another circumstance connected with this subject which is not without interest. Lymphatic people live mostly upon fluids, or non-carbonaceous food—the adipous upon the carbonaceous, and so do the tuberculous, but they do not select the gross varieties —having a more fastidious appetite. From the preceding considerations it seems probable that the cellular tissue may be filled to repletion with lymph, in one individual, in another with adeps, and in a third with a combination of both. 
I do not feel willing to admit the existence of an adipous temperament, because the presence of adeps is never universal —it is not in the brain, and because we have become satisfied that it depends upon either an abstract or a relative deficiency of the pulmonary function, consequent upon a small medulla oblongata and a large cerebellum. The disposition, then, to obesity results from a local Encephalic arrangement, while lymph depends upon, as yet, some unknown, but general peculiarity of organization. There is another circumstance which sustains this conclusion; we have never found any difficulty in tracing this constitution in its combinations with the other temperaments —but this we cannot do with the adipous. 


APPENDIX TO BOOK II. 
(PAGE 118.) 
The following cases were overlooked by the compositor, and as we consider them to bear with great strength upon the question at issue, we have concluded to give our readers the benefit of them, though out of place, more especially as they have never been published. Professor Newton, one of the authors, is responsible for their accuracy: 
Mrs. M., formerly of G., Ohio, about seven and a-half months advanced in pregnancy, was picking some fruit from an apple tree, when, in moving a branch, a snake fell, and, as she supposed was falling upon her, and she, in her fright, drew her hands to her face, placing two fingers of each hand into the orbits of her corresponding eyes. In due time she was delivered, and the child was without eyes, but in the orbits were firmly attached the extremities of two fingers of each hand of the respective sides. 
Mrs. S., on the day before she was confined, labored very hard at the wash-tub; she was not accustomed to such labor, nor was there any necessity for it at the time, but because of some domestic vexation she did it, and did it in a sitting posture, with the washboard resting against her stomach, and her arms resting on the edge. The process of washing had chafed and even removed the cuticle from her wrists and fingers, so that they were sore and somewhat inflamed at the time of her delivery. 
The child, when born, exhibited an extensive bruise across the epigastrium; the skin upon the wrists and fingers was abraded and the muscles of both arms, corresponding with the bruises made by the wash-tub upon the mother's, were divided to the bone, and the clefts were full of blood, which, after being washed, was found coagulated in the deeper portions of them. The child was born dead. 
199 




BOOK III. 
THE NATURAL HISTORY, PATHOLOGY AND TREATMENT OF THE VARIOUS FORMS OF DISEASE INCIDENTAL TO INFANCY AND CHILDHOOD. 




INTRODUCTION. 
PATHOLOGICAL CONSIDERATIONS. 
Before entering upon the consideration of the special manifestations *bf disease, a few general remarks, with reference to the whole subject, appear to be called for. 
We have thus far spoken familiarly of disease and diseased action, and our readers, no doubt, conceived that they thoroughly understood us, and we think it very probable that they did, so far as the nature of the subject demanded; that is, they have understood us after the manner of unprofessional society. But, as we approach the Practice of Medicine, it becomes indispensable that we should be definitely understood as to the ideas we attach to certain words, which constitute the initial of medical study. A misapprehension of our meaning of these words will lead to a misunderstanding of all of our subsequent reasoning. A few illustrations will render this matter transparent. 
At this time, the prevailing opinion in the profession is, that fever and inflammation are diseases, and upon this opinion is founded a certain medical practice; now, suppose this idea to be founded in error, then it follows that the practice founded upon it must be equally erroneous, and consequently mischievous. At this point we will make two or three citations to prove our statement to be correct. 
Watson's Practice, page 94, informs us, that inflammation is " a special form of disease to which all parts of the body are liable—a disease that meets us at every turn." 
Professor Paine's Institutes, page 464, says, that " inflammation and fever are the two orders of disease which make up the great amount of human maladies and form the general outlets of life." 
Professor Gregory says, that " fever is the most important, 
203 


204 
PATHOLOGICAL CONSIDERATIONS. 
because the most universal and the most fatal of all the morbid affections of which the human body is susceptible." 
These quotations are made from standard and highly esteemed authorities in the allopathic branch of the profession; but, without any expression of opinion on this subject, the allopathic practice authorizes the inference as to what its fundamental doctrine must be. If fever be not disease, then there is no warranty for bleeding, purging, and poisons. 
People generally believe that if the old school physicians neither bleed or give mercury, they are on a par with the new school—but here they are mistaken; the difference between the two is not confined to a difference between their therapeutical agents, but in the principles that guide to the use of them. Life can be destroyed without the use of the lancet or mercury—and so fever can be brought down without them. 
The proper question is this: which is the physician, the one who regards fever as a disease, and therefore uses all the means he can command, as bleeding, purging, poisons, and starvation, to reduce and break it down, or the one who regards fever as a proper physiological act of the system to remove disease, and therefore does all he can to sustain and equalize it ? It is true that bleeding and purging will equalize it, but in doing this they equalize the patient with the dust from whence he came. But the idea of sustaining fever and inflammation does not belong to their practice. 
Because we sustain fever and inflammation as the two most important physiological friends the animal economy can acknowledge, and sustain our principles by a consistent materia medica—one without poisons*—we have been denounced as 
* As there has been much caviling as to "what constitutes a poison, we will present our definition of the word, as we use it. Every substance is a poison, in the abstract, absolutely and necessarily, whose inorganic elements cannot be digested, assimilated, or appropriated, by the function of nutrition, to any normal purposes in the animal economy. 
Strychnine and hydrocyanic acid are not, in the abstract, poisons, but relatively they are, in common with all other substances which are not, in the abstract, poisons. 
Under this definition, mercury, arsenic, antimony, bismuth, etc., are, and in defiance of all caviling or sophistry must be, poisons ; and, so long as the smallest conceivable particle of any such absolute poison is in the system, the vital force will labor to cast it out, because it is, per se, a foreign body—a source 


PATHOLOGICAL CONSIDERATIONS. 
205 
innovators, charlatans, and quacks. We will reverse this charge and clench it, before we have done. 
Most of the modern allopathic writers on inflammation and fever refer us, for the purpose of obtaining a more thorough understanding of these subjects, to Professor John Hunter's work on inflammation. Well, what does Professor Hunter say? 
In vol. iii, page 285, he tells us that " inflammation, in itself, is not to be considered a disease, but as a salutary operation consequent either to some violence or some disease." It " is an action produced for the restoration of the most simple injury in sound parts, which goes beyond the power of union by the first intention." 
He continues, on page 293, " Pure inflammation is rather an effort of nature than a disease." 
On page 286, he again remarks, " From whatever cause it (inflammation) arises, it is an effort intended to bring about a reinstatement of the parts to nearly their natural functions." 
Upon this doctrine we stand —a doctrine that is recommended by the most distinguished allopaths of the day; and yet, strange to tell, it is especially and peculiarly the one which they have all abandoned. Who are now the innovators, the charlatans, and the quacks ? The allopaths recommend this doctrine, and yet, practically, denounce it—we believe it and practically conform to it—which, then, is the most consistent ? 
Now,- suppose we try the Hunterian doctrine of inflammation by a few illustrations. 
A mechanic has a splinter forced under his finger nail, and so broken that he cannot extract it. Is not the first observable result in the part inflammation, and then follows suppuration, granulation, and cicatrization ? Is not the whole of this process normal, under the circumstances ? Could the part originally have been in a normal condition if these phenomena had not succeeded to the accident ? Was not the inflammation 
of irritation and cannot possibly be converted into anything that is not unfriendly to the animal tissues. 
In the Western Journal of Medicine, vol. 2, page 636, Professor Drake says that " mercury has been found in the bones, blood, brain, and nerves," and yet it cannot form a part of either of them, nor can any other substance that is embraced by our definition—they are all emphatically poisons. 


206 
PATHOLOGICAL CONSIDERATIONS. 
absolutely essential to the expulsion of the splinter ? Now, suppose the patient to have been bled to such an extent as to have prevented the inflammation, would the splinter have been expelled % 
As a further exemplification of this subject, we extract the following illustration from " Simon's General Pathology :" 
"A man has a sudden and severe pain in some part of the surface of his body, accompanied by a rush of blood to the painful spot, and by a disposition to the pouring out of serum there. This, obviously, is not a condition of health. But, if you knew that a quantity of boiling water had just been dashed on the part, you would be disposed to transfer the term unhealthy from the effect to the cause—from the man to the kettle. In fact, the man would have been unhealthy if this redness and vesication had not occurred." Then, as they did occur, they were right actions, under the circumstances, and cannot, therefore, under any definition of disease, be called diseased actions. 
Doctrines as sound as this have been proclaimed by several of our living allopathic professors, but they appear only as luminous rays that occasionally flitted across their minds— they were not maintained with consistency, nor followed by practice. In proof of this, we will select a few illustrations : Professor Paine, in his Institutes, page 465, teaches that " inflammation takes its rise in purely physiological conditions and holds its progress and decline under the same great natural laws of the constitution." The professor could not have expressed himself in language more compatible with truth, but he certainly did not understand the import of it, or he would never have written the following: on page 464, he says, " Inflammation and fever are the two orders of disease which make up the great amount of human maladies and form the grand outlets of life." 
In inconsistency Professor Watson has more than equaled the preceding. He says, Practice, page 94, that "It is by inflammation that wounds are closed and fractures repaired— that parts adhere together when their adhesion is essential to the preservation of the individual, and that foreign and hurtful matters are conveyed safely out of the body." This doctrine is correct, but that he should administer calomel to break 


PATHOLOGICAL CONSIDERATIONS. 
207 
down inflammation, and, when down, to expect it to carry such a "hurtful matter "out of the system, is much more than we can conceive to be possible with a rational man. But we will hear him again: on the same page, he teaches that " inflammation is a special form of disease, to which all parts of the body are liable—a disease that meets us at every turn." Upon which of these principles did he found his practice ? npon the latter, and in aiming his blows at fever and inflammation he destroyed many of his patients, no doubt. 
It is not our purpose to discuss, at length, this question— we only wish to make our pathological position known, that the fundamental principle of our practice may be understood. We will not, therefore, pursue it further than to present two cases to illustrate the two systems of practice which are founded, respectively, upon its two horns. 
In 1837, the writer had the inferior extremity of the right fibula fractured—his general health at the time was, perhaps, never better—it was treated by a Philadelphia graduate, who subsequently devoted a year or two to the surgical wards of the Parisian hospitals. In the course of the treatment he was duly bled, purged, nauseated, calomelized, and starved, and what is equally worthy of note, he approved of it. In four months he left his room by the aid of a crutch, but very much reduced in flesh. In 1841, he had both bones of the left leg fractured ; but, let it be remembered, in the meantime he had changed his opinion of inflammation, and of course his views of practice. In the treatment of this fracture, he was neither bled, purged, nauseated, nor starved ; but upon the supervention of fever, he took, in two days, twenty grains of quinine; this was all the treatment he had, except plenty of palatable and nutritious food. In thirty days, by the aid of a crutch, he left his room, weighing some ten or twelve pounds more than when the accident happened. 
These two cases, in our judgment, perfectly illustrate the two systems of practice. In the first case, the efforts that were made to break down, and to keep down, the inflammation and fever, kept the patient down. In the second instance these manifestations were received as friends, who had come, expressly, for the purpose of mending a broken limb, and, therefore, instead of trying to bleed, purge, and starve them 


208 
PATHOLOGICAL CONSIDERATIONS. 
out of existence, they were fed on quinine. In the treatment of this second case, it will be perceived, furthermore, that he had a thorough faith in this doctrine, notwithstanding the force of education to the contrary. It may be interesting to add, that he had with him a fellow graduate who manifested much concern for his condition —he frequently implored him to abandon his course—that he was risking not only his leg, but his life; but he gave no ear to him, because he saw that he could not see well—that he was still wearing the old foggylooking spectacles that were given to him by the university. 
Although we have perhaps sufficiently illustrated our position, we have not specifically defined our understanding of the words, disease, fever, inflammation, physiology, and pathology. 
Disease we understand to be that condition of a part which disqualifies it for the performance of its function. 
Fever is a manifestation of an effort of the system to remove disease — a physiological action under the circumstances—a general or constitutional indication of disease. 
Inflammation is an evidence of local disease—an action produced for the restoration of a diseased part —an effort of the vital force to remove disease. 
Physiology is the science of life in all its modes of being, but is now usually restricted to life in a state of health. 
Pathology is the science of life in a state of disease—it is physiology under abnormal circumstances. 
We may be asked, what is gained by these views, definitions, and explanations ? We answer, everything that can be gained by having the truth, instead of a fiction or a falsehood. There is a wide difference between considering ourselves as called upon to treat fever as a disease, instead of a physiological action, or an effort of the system to remove disease—as much difference as there is between bleeding and purging on the one hand and the administration of antispasmodics and tonics on the other. There is, we conceive, a wide difference between supporting the vital force under the inflammation of a broken leg, by nutritious diet and tonics, and such bleeding, purging, and starving as will break down the inflammation and defeat a restoration of the part. There is a wide difference between setting up, by the use of means, a new pathological action, that is always hazardous and frequently 


PATHOLOGICAL CONSIDERATIONS. 
209 
fatal, and that of aiding and regulating a pre-existing one. Finally, we think that there exists a wide and an irreconcilable difference between assisting nature—the vis medicatrix natures, to effect a desired physiological change, and that of crippling all of her efforts and energies. 
If our definitions be correct, and they are supported by such authority, as the most distinguished allopaths recommend to our study, then the difference between the eclectic and allopathic practice is as great as that between noonday and midnight. 
It will be conceded by all, that without vital force there is no manifest life—death only exists. And it will readily be admitted, that without blood there is no life, and that death can be easily produced by bleeding, and that to the extent of any abstraction of this fluid is the vital force reduced. It is equally well known, that purgatives and poisons will diminish and even destroy the vital force ; and, finally, we think, that it would be difficult to prove that an animal can have too much vital force. 
Now, is it not absolutely true that a very large majority of physicians do pretend to cure disease by bleeding, purging, and the administration of poisons ? Do they not sometimes, yea, frequently, bleed and purge to reduce, or else to equalize vital action, and then, in a short time, give stimulants and tonics to sustain the vital force? Do they not bleed in cholera and then presently inject salted water into the veins to supply the place of the blood they had just abstracted ? But we will be more special. 
Dr. Armstrong, speaking of scarlatina maligna, says, "the vehemence of the attack and the intensity of the excitement rapidly exhaust the vital energies." And what does he recommend to support them, and to prevent their destruction ? " Emetics followed by brisk purgation." Is not this equivalent to bleeding a man to keep him from fainting ? A disease must be very violent when it can exhaust vital energy with more rapidity than " brisk purgation." A patient must certainly have a vigorous vital force to sustain himself under both. Professing to be the friend of the " vital energies," he gives aid to the disease; but this is not the only glaring inconsistency of his practice. When he visited the patient, he found 14 


210 
PATHOLOGICAL CONSIDERATIONS. 
the " vital energies " struggling to force the poison upon the surface, or, in other words, to remove the cutaneous obstructions, and he immediately countermands the effort and orders "brisk purgation," to force the "vital energies" to retreat to the bowels and to leave the disease in possession of its stronghold. Great must be the " vital energies," when they can successfully resist a malignant disease, reinforced, as it usually is,, by bleeding, purging, and poisons. 
Next to the lancet, mercury is most prized in the treatment of inflammatory affections, and perhaps on account of that quality which Professor Harrison assigns to it, "a most powerful depressor of the energies of life." According to our definition, it is a poison, and Hooper's Dictionary teaches, that "all our most valuable medicines are active poisons." 
Now, inasmuch as all epidemics are produced by a poison of some kind, and as the " vital energies are frequently incapable of expelling it," would common sense suggest the propriety of introducing into the system another poison, on the plea that two poisons are more easily expelled than one, more especially as one of them is unalterably a poison, and "a depresser of the energies of life?" 
This specimen of practice, by Dr. Armstrong, is a pretty fair illustration of allopathic practice in general—it was once our own—and as one illustration is enough to expose its hideous deformity, we will drop it, and proceed to the consideration of more agreeable subjects. 
Having disposed of such physiological and pathological matter as became suggested to us, with reference to our leading object, it yet remains for us to indicate and illustrate that fundamental law or principle that will guide our practice. We say fundamental law or principle, because, maintaining as we do, that disease is but one—a unit, there can be but one fundamental change, which is to, or from, health; and, as the leading object of this work is to teach how we may, with the most facility and certainty, effect the first—a change to health, it becomes the paramount duty of students to discover, as far as possible, the processes which living organized systems establish for their own preservation, under the various contingencies incidental to existence. So far as they shall accomplish this, they will find that they have nothing to do but to 


PATHOLOGICAL CONSIDERATIONS. 
211 
aid, and every dose of medicine they shall administer, during their ignorance of the intentions, or the character of the efforts the system is making, will be done empirically. 
It will not, we presume, be disputed, that the vital force is a unit, if not in fact, at least in its action, as much so as steam —neither of them can accomplish anything, without appropriate apparatuses to act upon; and we are so constituted as to believe that all living organizations have been so arranged and endowed as to act, under existing circumstances, not intelligently, but in harmony or in accordance with the laws of intelligence—that the various organs that constitute the system cannot and will not act, except as they are compelled by the vital force, and that when they do act, it is with the wisdom of that intelligence which designed them, and assigned to each its peculiar mode and range of action. A denial of this conclusion is a virtual denial that science does or can exist; it is equivalent to admitting that a living organism, in a state of disease, may become as perfectly a mass of confusion—a chaos—as a mere mechanical aggregate. 
"We do not know that any one ever doubted that living organizations act in harmony with the laws of a predetermined wisdom; but it will be seen, before we have done, that physicians have practiced, and now do, with either a shameless ignorance of, or a careless indifference to, the laws or economy of the living system. The man who has not an intelligent, a fixed, and an abiding faith that , every action that takes place in a living system, is, under the circumstances, wisely directed— because directed by the provisions of that wisdom which is science—which admits of no errors—no accidents in the measureless bounds of the universe, is unfit for the profession. 
The physician who is thus constituted, and thus qualified, never bleeds and purges to support the " vital energies, 1 ' but removes impediments —the causes of abnormal actions—and aids the vital force to maintain such movements as shall be in harmony with the living norma. 
In a state of health, the vital force is adequate to the maintenance of an equilibrium of action in all parts of the system, but under the influence of a local injury, this is not the case— it is indispensable that a major action shall be sustained in the injured part. In the case of a fractured bone, constipation 


212 
PATHOLOGICAL CONSIDERATIONS. 
immediately supervenes, or else a diarrhea, which is invariably an unfavorable symptom —and these remarks are equally true of small-pox. All agree that constipation in this malady amounts almost to a pathognomonic symptom ; and when diarrhea happens to appear in its stead, it is regarded by all writers as unfavorable. 
Now, the fact that constipation attends all inflammations of the animal system, cannot be regarded as an accidental circumstanc —it should teach us something in reference to the agency of the vital force, under the existence of such forms of disease as we have alluded to. During the inflammatory stage of small-pox, purgatives are positively prohibited ; now, we would be pleased to know why they are not prohibited in fractured bones and gun-shot wounds ? If no valuable reason can be given for this difference of practice, then it is empirical. 
Let it be remembered, then, that in fractures and other wounds, something more is required of the vital force than barely to maintain repairs; and to afford an additional force to the injured part, an inequilibrium of force must be effected in the system ; and, as it cannot be taken from the animal, under the circumstances, it is taken from the vegetative, and constipation results, and continues until the work of recovery has fairly become established. 
If, in such a case, a cathartic be administered before the thorough establishment of inflammation, the recovery of the part is retarded—and how often has it been retarded by a rigid antiphlogistic treatment ? 
In the case of the small-pox, the unmistakable purpose of the system is to become relieved through the cutaneous surface—to it the vital energies are directed, and the obvious effect of a purgative is to counteract the vital force, and to expend as much of it upon the mucous membrane of the alimentary canal, as might be sufficient to force the disease or its cause upon the surface. 
Observation, during many years, has satisfied us that cathartics are used too much by every branch of the profession. Our object is a sanative course of treatment in all the manifestations of disease, and we are sure that an injudicious use of cathartics is as far removed from such a practice, as the use of the lancet is. In fevers and inflammations, 


PATHOLOGICAL CONSIDERATIONS. 
213 
cathartics become indicated when the fecal contents of the alimentary tube become a source of irritation. Health cannot be restored, in any form of disease, until secretion becomes re-established, and when it is, we have always observed the alvine excretion to return with promptitude, and to continue with more health, than ever follows the use of cathartics. 
In diseased conditions of the tissues and organs of animal life, they are not properly indicated, not even when the brain and lungs are invaded, because more legitimate means of equalizing the circulation can be employed. Except for the purpose of dislodging sources or causes of irritation, and this irritation must become manifest, we have no more use for cathartics—purgatives, than we have for the lancet. When the intestinal contents are producing no irritation, is it not better to let them alone, than to introduce into the bowels a certain cause of irritation ? 
In the most confluent forms of small-pox there is no danger so long as an equilibrium exists in the irritation and circulation of the system, and if this equilibrium cannot be maintained without purgatives, then there is but little probability that it will be with them, because they cannot be administered without producing more or less of inequilibrium. In most cases of constipation, to the extent of mischievous irritation, the want of action is most generally confined to the large intestines, and more particularly the rectum; consequently, it can be relieved by enemas, and nothing further is needed. When disease invades the system of vegetative life, cathartics become indispensable, but not to the extent, even then, of Dr. Armstrong's idea of sustaining the "vital energies, by "brisk purgation." 
In dangerous forms of disease, our allopathic friends resort to what they call " heroic remedies," which consist of bleeding, purging, blistering, and mercurialization. Now, it will be admitted, that it is impossible to draw blood without reducing the vital force; purging will do the same, and as to mercury, Professor Harrison says, that it is "a most powerful depresser of the energies of life." 
Cholera wastes life as rapidly as bleeding and purging, and it is as great a "depresser of the vital energies of life," as mercury. In view of these facts, it is exceedingly singular 


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that an attempt to cure it by bleeding and the administration of a pound of mercury, more or less,* bhould ever have been seriously entertained by a well-informed physician. 
We have also our " heroic remedies," but they only reduce spasm or constriction, equalize the circulation, promote secretion, and thus remove disease by depuration; and they do all this without imposing a tax upon the " energies of life," and without the establishment of another form of disease, as a mere sequel, that may prove as fatal as the one it supplanted. 
Although, in the case of inflammatory fevers, the arterial action is very greatly augmented, yet we are not to conclude that there has been an increase of vital power, or of the energies of life, because disease is not creative—it can neither produce nor augment life—it can only occasion a suspension of its manifestation in some functions, and an accumulation of it in others. When that quantity of vital power, which, in health, maintained the functions of secretion, excretion, and nutrition, is again returned to these functions, fever ceases to exist. The increase of vital manifestation, in fevers, is not universal, nor even general, for while there is an exaltation of vitality, in some parts, there is a deficiency in others, as is most clearly evinced by a loss of appetite, the wasting of the body from an absence of nutrition, by the weakness of the muscles, in many instances, and by a sense of prostration. When we can equalize this vitality, we restore health; but if we abstract vitality, by bleeding and purging, we just so far incapacitate the system to repair the lesion that disease has inflicted ; for this end, then, it is absolutely essential that we should carefully husband the vitality and its resources. 
We have shown that neither fever nor inflammation is disease, but are accumulations of vital force for the removal of it—that disease is an incapacity, in a part, or parts, to perform their functions ; and we now add, that this incapacity depends upon chemical, mechanical or vital impediments or obstructions, and when it is of the third character, it is a result of defective or suspended depuration. 
Now, suppose the skin to have failed to perform its function, 
* We cannot prove that more than eleven ounces were administered to the same patient in a case of cholera. 


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and that the failure has resulted from suspended secretion, and therefore replete with obstructions from arrested or suspended depuration ; how is it possible for bleeding or purging to remove the obstruction ? By reducing the vitality, they reduce the energy of the effort that is made for its removal, but the obstruction still exists, and the power to remove it is diminished. Is it not obvious that every effort that is made to remove the disease, by such means, only tends to confirm it ? 
Suppose the lungs to fail in depurating the venous blood, and tubercle shall result, will bleeding and purging remove it ? Suppose, again, the kidneys to fail to eliminate, to a sufficient extent, the urea, and rheumatism shall result, will bleeding and purging remove this urea, and thereby remove the rheumatism ? Has not experience proved that they cannot % 
If, then, disease consists in obstructions, and that they result from suspended depuration, is not the indication of cure a re-establishment of the depuration ? Do not the hot-springs of Arkansas, cure rheumatism by establishing secretion and depuration ? 
It will now be understood that our " heroic remedies " consist of those articles, and of that mode of practice, which are the best calculated to equalize the circulation, promote secretion, and consequent depuration. Is it not equally perceptible that we may do all this without the least intention of reducing the absolute quantity of the vital force ? Nay, more, that the less we waste of it, the greater is our success ? Is it not, furthermore, obvious that we may, by producing hyper-secretion, injudiciously weaken or exhaust the patient? And is it not equally clear that our antiphlogistic treatment consists in removing the disease, and not the vital powers of the patient, or both of them indiscriminately ? 
The preceding views have been advanced with reference to those forms of disease in which the allopathic branch of the profession would bleed and purge ; but there is another form, in which they would not resort to the same practice, and yet, it would be equally rational; it is that, in which there is less equality between the amount of the obstruction and the power of the vital force—a case of congestion in which there is not existing sufficient power to effect a reaction. In these two forms of disease there is no similitude in the treatment bv the 


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allopathic physicians, and yet the two forms are essentially the same—differing only in degree—the vital power in the one, or the obstruction in the other, predominates. In the former, there is more demand for antispasmodics, and the latter, for revulsives. When the circulation shall become equalized, secretion will follow —depuration will take place —the blood and tissues will become purified—the obstructions, and, of course, the disease, will be removed. 
While, as eclectics, we reserve to ourselves the right to use any and every article, now known, or that may become known, when we shall become convinced that it is the best we can do for the patient—that we entertain no prejudice against any one—that so long as a proper use can be made of any one, we advocate it. But, as observation has taught us that the indigestible medicines act unkindly upon the system, and frequently do irreparable mischief; and, as the same great teacher has most thoroughly convinced us that we have a digestible materia medica that is adequate to achieve all that is desirable, in a higher degree, too, than the indigestible, we hold it to be humane, wise and philanthropic to discard from our practice all indigestible medicines—that is, all poisonous elements—indeed, we hold this course to be, on the score of justice, absolutely imperious. 
But, after all, more depends upon correct principles, in practice, than upon the agents used. Nothing but mischief can follow the application of a false principle. Those who contend that lever is a disease, would do about as much present mischief with purely digestible medicines, as they now do, the difference being only in the sequelae. Those who practice, consistently, upon false principles, do more mischief than those who have no principles, because the latter may sometimes be right, while the former never are ; it becomes, then, a matter of tiie first importance, that we should be certain that our principles constitute the expressions of truth; when this is the case, so long as we are consistent, we can never be wrong, though we may be ignorant. 
There exists throughout the length and breadth of the medical profession, an opinion—for such it merely is—which we think to be an error, and, as such, is attended with much mischief —we allude to the opinion that some forms of disease 


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are hereditary. If the truth of this opinion was ever questioned, or doubted, we have not learned it; and yet, if there be in the profession an error more clearly exposable than it, it has escaped our notice. 
In the first and second Books of this treatise, we have used the word hereditary in its common acceptation, because, as yet, we had afforded us no proper opportunity to expose the error of it; but now, as we are about to commence the consideration of the special forms of disease, it becomes proper that we should make known our opinions upon all leading subjects—and this one is of that character. 
As the hereditary character of phthisis pulmonalis is not doubted, we. shall make a principal use of it in the illustration of our views. 
In table, page 20, we have, by measurement, and we may add, the observation of twenty years, shown, that consumption is associated with a certain relative development of the medulla oblongata and the cerebellum. When we consider the functional relation which these parts bear to the lungs, we must conclude, that if the coincidence we have pointed out between the disease of the former and a certain development of the latter be uniform, that they hold the relation, primarily, to each other of cause and effect. 
We have found that those who are liable to phthisis have generally a large medulla oblongata and a small cerebellum, relatively, and the exceptions to this law come under the reverse of these organic conditions, through the instrumentality of very different exciting causes. Because of these peculiar organic conditions, as to development, it does not follow that there existed either active, passive, or latent elements of disease, nor even the most remote possibility of a predisposition to it. 
Peculiarities of both size and form are transmissible from parents to their children, and each form, under causes of excitement, must and will represent its identity in its mode of action, which, of course will be modified by influencing circumstances. In other words, no two different forms can manifest the same mode of action under the same cause of excitement and the same attending circumstances. Every one form 


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of disease, therefore, is as vulnerable to the charge of being hereditary as phthisis. 
In one peculiar form of organization, there exists a liability to rheumatism, to gout, to cancer, and perhaps to some other forms of disease; in another, there will be found a liability to passive congestion of the brain, phthisis pulmonalis, and other kindred forms of disease, depending upon different degrees of development, different, or even the same, causes of excitement and attending influences. 
A large proportion of society are so nearly balanced as to have no preponderating liability to any particular form of disease, and yet may be liable, under the force of exciting causes, to any one. 
The truth of the doctrine we have here taught, can be, we think, amply sustained by a reference to well known facts. 
Take a case of what is called a "hereditary predisposition to phthisis,"—tell the patient that this is his condition, and what becomes his conclusion ? Nothing less, inevitably, than premature death—he considers himself fated — doomed irrevocably to such an end. With such a conclusion preying upon his mind, how is it possible that he should recover from any form of disease that has become constitutional ? 
Perhaps his physician may send him to the island of Cuba, in order that he may possibly recover under the peculiarities of such a climate. But what is the principle that actuates him in sending him to the south % If any one has discovered the principle, we have not seen it. He is sent there, so far as we have learned, empirically; he is sent there under the hope that he may be as fortunate as some who had preceded him. But if his disease be hereditary, how should any one expect him to recover by a change of climate, of diet, or of anything else ? 
In Boston, a given measure of atmospheric air contains more oxygen than the same measure does in Cuba, and yet the Boston patient breathes as though he was struggling for more oxygen, and he really is. If then, he obtains, in Cuba, less of what he wants than in Boston, why send him there ? 
A simple illustration will explain why he should go south: A horse is breaking down under the weight of his load, 


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although he receives regularly a full measure of food. Now, can he not stand the travel better with one-eighth less food, if one-half of the load be taken off him ? Every reader, we think, will answer in the affirmative. 
The lungs perform two functions—by inspiration they receive oxygen, which is indispensable to the production of animal heat (to say nothing of other purposes); but in Cuba he requires less animal heat, and therefore for this purpose he requires less oxygen. The other pulmonic function is that of expiration—an elimination of carbon from the system. Now, while in Boston, the lungs had no aid in the performance of this function—they had to perform the whole duty—that is, they had to carry the whole load; but in Cuba, the high calorific temperature so excites the skin and liver that they take from the lungs half their load. In view of this explanation, we can understand how it is that a young man, before any disease occurs in his lungs, by going to the south, although organized for consumption in the north, will far more probably die of some bilious form of disease than with any pulmonic one. 
It seems, then, that the patient had not inherited a predisposition to phthisis pulmonalis, but that he had inherited a peculiar organization, which was not compatible with a continuance of life under certain circumstances. It is possible, however, that, by such training as would develop his cerebellum, he could so have changed his organization as to have adapted it to its native situation. 
It is possible that his organic condition may have been just the reverse of what has been previously supposed—his medulla oblongata may have been feeble, and the cerebellum large, and consequently, he may have been obese; but the nutritive process, in this relation, may have become arrested, and hence the lungs have to eliminate as much more carbon, than usual, as the system had been in the habit of converting into adeps, which, proving more than they can do, they finally generate tubercles in themselves, or cause them to be deposited in other parts. We do not believe that consumption is often produced under these circumstances, but it does happen—that is, men have become obese, and subsequently have died of phthisis pulmonalis. But in this case, as in the other, proper 


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training in youth—such as will produce an equilibrium between the medulla oblongata and the cerebellum —will prevent the disease. 
No age, it seems, is exempt from this fatal form of disease, and the reason why it is so must now be obvious. Some children are born so feeble, in one or the other of the abovenamed organs, as to render it impossible for them to live to maturity—some have such an endowment of them, in connection with circumstances, as will sustain them even to old age; but as the cerebellum begins to decline at the meridian of life, it finally becomes too feeble to sustain the lungs against disease ; hence the cause of consumption at a very advanced age. 
It is well known, that many men have lived to old age whose parents had died of consumption, and we have no doubt that they would have died of the same disease if they had lived under the same influences. It becomes, then, our duty to investigate the influences by which such persons were saved, so that we may do for some, by design, what accident has done for others. 
We do not doubt the accuracy of our premises—we believe them to be easily and satisfactorily demonstrated, and if so, there can be no doubt as to the proper prophylaxis —exercise of the muscular system, particularly of the superior extremities and chest. This will force a development of the muscles— increase and strengthen the circulatory and the respiratory systems, and, as a matter of course, those portions of the encephalon which preside over them. 
By this course, those organic forms which have been transmitted from parent to child for numberless generations, are broken up —an improved modification has been effected, and the further transmission of a phthisical liability is arrested. 
We shall now make a few extracts from " Simon's General Pathology," for the purpose of showing how little is known upon this subject, and how impossible it is to reach a sound conclusion by reasoning from a false position. He is treating of the hereditary character of the tubercular diathesis, and especially about the tuberculous nature of a rabbit's liver that was sent to him. 
1. " On inquiry of a candid poulterer, I found that these 


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'tubercular' livers are common — very common; that they will be found often in almost every tame rabbit cut open, and in litter after litter; and, strangely enough, that they do not appear incompatible with good health, or at least with sufficiently good for market purposes." 
2. " In continuation, I made various experiments to see if I could produce tubercle artificially, and various other examinations to see if I could find it in rabbits dying under other circumstances. The result may be told in a word: I have never seen tubercle in a rabbit." 
3. "One sort of experiment does apparently tend to develop tubercle. As we often stay the process of phthisis in the human subject by transferring our patient to a tropical climate, so, conversely, we can facilitate the development of the disease by importing the subject of our experiment from warmer to colder latitudes. It is said, that among the beasts of the Zoological Society's Gardens, tubercle is a frequent cause of death ; and especially those which come to our climate from one of a higher temperature. From my own knowledge, I will only venture to confirm this statement in regard of monkeys; as they have the dignity of standing next to man in form, so they have the inconvenience of this very human liability : when transferred from the hotter climates to England, and when surrounded by the artificial circumstances of a menagerie, they are apt to die with tubercles in their lungs, mesentery, and spleen." 
5. " Here, however, let me detain you on the subject of hereditary transmission of scrofula, and explain to you what I mean, when I speak of its being continued in this manner from generation to generation; I do not mean that, in the process of impregnation, actual tubercular matter passes from the system of the scrofulous father into the germ of the infant, to remain latent there, till circumstances call for its development ; nor that, during uterine life, the blood of the child is poisoned by its mother's blood, as occurs in small-pox or syphilis. What I mean is this: that the scrofulous diathesis—that the disposition to form tubercles is transmitted ; that the child inherits an imperfect pattern of development." 
6. " I must explain this more fully, for the inheritance of dispositions to disease does not belong to scrofula only; it 


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forms a very important problem in the pathogeny of cancer, with its allied disorders (for they are hereditary), of gout, and rheumatism, for they too are heirlooms in families; and it, consequently, constitutes one of the most important questions in the study of General Pathology." 
7. " Every one recognizes in the process of generation a certain amount of that influence by which a parent becomes the pattern of formation for his child. No man expects to become the father of an armadillo, or a flying-fish, or a stagbeetle. But more than this, it is expected, and, on the whole, very generally realized, that the child shall be more like its father than its god-father. So far the case is clear; but I wish you to observe the tendency further. Follow the child in its ulterior development, for that is the point, and mark how exactly, in various exterior and noticeable signs, he repeats the development of his father; how, in arriving at the age when his father got corpulent, he acquires the same figure; how, at the age when his father became gray, or bald, he, too, becomes gray, or bald, and with the same succession of parts — vertex first, or temples first, or forehead first, as the case may be; how his teeth decay, or drop, or protrude, just as his father's ; how his pulse is of the same character—even, as we have often noticed, to the degree of copying an intermittent rhythm; and how his habits of sleeping and waking follow the same direction." 
8. " Now, observe, for the distinction is one of great importance, that these things are not connate; the child is not born a copy of the father as he begat him ; but he is born, having his father's past development as a type for his own future development, so that he shall be developed as his father was developed, and shall hereafter become like him. In addition to that general law of human development, by virtue of which he is destined to be a mammal rather than a bird; and a man rather than an ox; and to reach puberty, manhood, old age, and death in a certain defined succession; he is further possessed by an inherited personal and particular law of development, which affixes a something peculiar and individual to his passage through each period of his existence." 
9. " If my meaning in all this has been intelligible to you, you will readily conceive that diseases affecting the development 


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of the body are peculiarly those which transmit themselves in the line of hereditary succession; that the disposition to a disease would be hereditary, where the disease consisted of a faulty type of development, affecting limb, or viscus, solid or fluid, in the body; and that no disease would be hereditary, except in so far as it might be developmental." 
10. "Accidental mutilations do not become hereditary; for many centuries the Jews and the Mahommedans have undergone circumcision of the prepuce; but the local deformity has never transmitted itself; the new-born Jew or Mussulman offers probably as much foreskin to the knife, as the immediate successors of Abraham or Mahommed." 
11. "And, if you transfer these arguments to the several varieties of disease, you will know, on the one hand, in what diseases to anticipate hereditary transmission; and on the other hand, what peculiar character of disease, to-wit, its developmental character, may be inferred from the fact of its hereditary succession. Of a disease like scorbutus or ague, dependent on the presence or absence of certain exterior accidental conditions, you would anticipate that it could not be hereditary, any more than a wound or a dislocation. Of those accidental accompaniments of scrofula—the morbid processes which arise in defective nutrition, the ulcerations of the cornea or intestines, for instance, which depend on insufficient or inappropriate nourishment, and which, as I have said, are essentially co-extensive in their duration with the exterior causes which produce them—you would know that they have no natural tendency to perpetuate themselves in this way. Of another disease, on the contrary — one like plethora, relating essentially to the rate or degree of development in an element of the body, you might predict that it would tend to become hereditary. And whereas it is in the blood, more strikingly and more constantly than in any ingredient of the organism, that development is ever in progress; whereas, it is eminently in the blood, that we have at each moment an epitome of the whole development of the body, and find the earliest rudiments and the latest relics of every organized tissue, nascent or in decay ; so surely it would be in this fluid—the scene or the subject of so many developmental metamorphoses, that one would expect to find the material explanation of many 


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hereditary diseases. One would expect that an inherited disposition to form, at various periods of life, and in a number of different organs, certain special and characteristic materials, bearing definite relation to the normal products of the body, would indicate a peculiarity in the development of the blood, whereof those deposited materials would be the result and the expression." 
12. " Such is the state of the case in regard to scrofula; and therefore it is, that I have analyzed this question of hereditary tendencies to disease. Strict experiment would not, I think, justify me in telling you, as a certainty, that the scrofulous diathesis has its explanation in such grounds as we have gone over." 
13. " But, though we are short of absolute demonstration on the subject, (14) I may tell you this with confidence: there exist many facts rendering it highly probable that tubercle has its rise in disease of the blood; that this disease of the blood is one affecting its development; and that it is as adevelopmental disease of the blood that scrofula acquires its tendency to hereditary succession—its tendency to perpetuation as part of a family likeness. I shall presently give you other evidence in support of the same view." 
15. " Meanwhile, to return for a moment to the narrower ground from which we started, remember, that what is meant in calling scrofula a hereditary disease is—not that the tubercular material is to pass from parent to child—not that the child is to be born with tubercle already in its body—but that the disposition to form blood in a manner which shall give tubercle as a collateral phenomenon, exists as a clause in the child's charter of life, and forms a part of its type of development, as truly as any exterior resemblance which he may bear to the configurative growth of his parents." 
16. " I may illustrate to you the importance of these considerations, in quoting the result of some statistics collected at the Consumption Hospital, by the officers of that institution, and published by them in their last year's Report. They find that, among their female phthisical patients, thirty-six per centum report their parents to have been consumptive. If you consider this statement simply, you will be struck with its importance, and with the magnitude of its consequences; and, 


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in order to do full justice to it, you must further remember, that, in the remaining sixty-four per centum, there may have been another considerable proportion whose parents had not indeed suffered from tubercular phthisis, but may have suffered from tubercular deposit predominantly in other organs than the lung — in the lymphatic system, perhaps, or elsewhere ; and that there may have been a second considerable proportion, in whose family the parents may, perhaps, have escaped tubercular disease in their own persons, but may yet have transmitted the predisposition from their own immediate predecessors to those latter inheritors of the disease : for it is notorious, in many matters of family likeness, that some very characteristic feature, healthy or morbid, may develop itself only in alternate generations, or may at least remain latent during a single generation, unless many circumstances conspire powerfully to favor its evolution." 
We have made the preceding long extract, to give our readers the best and most labored argument we have ever seen in support of the hereditary pretensions which has been claimed, from time immemorial, for certain forms of disease, and will now proceed to notice it in detail in the order of the numbers we have attached to it: 
1. The poultry and rabbits, of which he speaks, had been fed to great repletion without exercise, and as, in such cases, there is but little waste and little necessity for repair, the food they took being more than enough for these purposes, the surplus was stored away in the form of adeps, but in this process too much duty had been imposed upon both the lungs and liver, and as a consequence tuberculation would fall upon one or the other, or upon some other part. A similar result is common to our hogs and cattle which are treated in the same manner. The general health of the animal is good, and whatever of disease that may be discovered to exist, is local, and confined to some glandular structure —but this is not always the case—in a few instances the muscles are full of tubercles. 
2. Why should he expect to find tubercle in rabbits under other circumstances ? It may be reasonably supposed, that rabbits, in a state of liberty, would live in accordance with their organic laws. 
3. We think it much more than probable, that monkeys 15 


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imported into England, and set at liberty, would, for several generations, if not perpetually, escape from tubercle; but that they, or any other animal, should acquire tuberculous forms of disease, after years of confinement in a close cage, with even tolerable feeding, is what we should certainly expect. It is certainly very improbable that they acquired the disease by hereditary entail, and if they can, under certain circumstances, spontaneously, acquire the disease, then it may, in a similar manner, obtain in human society. 
We have shown in the beginning of this paper, and incidentally in several other places, how tubercle originates under certain circumstances, with certain organic conditions. A modification of the same principles accounts for it in these monkeys and other animals similarly circumstanced —as the poultry and tame rabbits. (See answer 1.) 
In all cases of phthisis pulmonalis, in our northern latitudes, the lungs are incapable of depurating the venous blood—tubercle or obesity is the result; and should the latter result become arrested or distributed, tubercle will or may still result. In the case of the monkeys and other confined animals, a surplus of carbon is accumulated in consequence of insufficient exercise—their lungs, though adequate to all the ends of normal existence, become, under the confinement, as in the case of feeble development, incapable of adequate venous depuration, and the consequence must be the same. 
4. If he had possessed the most remote idea of the cause of tubercle, he would never have written this paragraph. The poultry and rabbits were not rendered tuberculous by " deficiencies in air, in exercise, (and) in diet." 
5. We perfectly agree with him in this statement, with one qualification, he should have added, under circumstances; and we also admit his final conclusion, but we claim the same in every instance where there is any kind of imperfection or weakness of constitution. But, in the beginning of this paragraph, he promised to explain what he meant by " hereditary transmission " and concludes by a simple admission or statement of the fact, which is not an explanation. " The child inherits an imperfect pattern of development." When was there one born that did not ? 
6. We hope he will, for as yet he has certainly failed. Wc 


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admit that all these forms of disease do appear in families in succession, and we admit that a liability to them, under circumstances, is inherited —just as a liability to bilious fever or any other form of disease is inherited by those who have had it, under the circumstances of their exposure to the proper exciting causes. 
7. And, he might have added, he has, like his father, a thick lip, a pug nose, or red hair. We admit the whole of this paragraph—every word of it. Under the peculiarities of the child's organization, all is normal—in nowise blended with disease, and, so far as we know, entirely beyond the reach of any modification—no change of place will change the color of his hair or the thickness of his lips; hence we can see no similitude between these organic conditions and a hereditary transmission of a tubercular disposition. 
8. We admit the whole of this paragraph, except so far as it involves the kind of disease of which he may die. The father may have died of phthisis pulmonalis, but the son may have avoided the necessary exciting circumstances, or his pursuits in life may have proved a complete protection againsi; it, or he may have gone to the south when young, where he could not have phthisis, but would, under the circumstances of organization, most probably have some form of disease peculiar to the digestive system. By the laws of procreation, the child could not be anything else than human, and by the same laws he was forced to follow the type of his parents, no matter what his pursuits may be, or into what country he may travel. He may enfeeble or strengthen his system, but the elements of it will still be the same. Neither disease, nor a predisposition to it, was incorparated into the organic laws; on the contrary, a strict obedience to these laws constitute a certain prophylaxis. Hence it is seen, that the moment we leave those organic forms which are essential to humanity, the necessary similitude between parent and child ceases. 
9. We do not admit that there are any organic predispositions to disease, but we do admit that a faulty type of organization or development must occasion a liability to certain forms of disease, under appropriate exciting circumstances. Our 


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last comment furnishes a reply to the closing portion of this paragraph—nothing can be hereditary except that which is essential to the organism of the animal; but all the organic forms may be faulty, and then, as a natural consequence, liable to deranged or morbid actions. 
The existence of any disease indicates the existence, also, of a " faulty type of development;"—in what other way can we explain the fact that some men live to old age without having been sick, while other individuals cannot escape from the most common forms of disease incidental to the climate in which they live. All forms of disease are developmental, except those which exhaust the susceptibility of the system by one or more invasions. In other forms of disease, one seizure increases a liability to a second, a second to a third, until it finally becomes incurable, except by a change of residence. This is as much the case with ague as it is with phthisis. 
10. "We admit the whole of this paragraph, and for the reason that such circumstances were not provided for in the laws of procreation in mammals; and it is upon the very same ground that we deny that any cause of disease, exciting, predisposing or otherwise, ever becomes a part of the organization. * 
A disposition to disease, such as is contended for, is just as much a lesion as an incised wound or an amputated arm. The whole arrangement of the organic laws contemplates an exemption from both, and not a disposition to them. A disposition to disease, is not a disposition to health—then, so far as it extends, it is a disease —there cannot be established a point of indifference between health and disease, and if, therefore, the disposition be to the latter, can it be regarded as anything less than a lesion ?—and let it be remembered that lesions cannot be transmitted. 
11. There are in Charleston and New Orleans, as many persons consumptively constituted as there are in Boston, in proportion to the population of these cities, respectively ; how does it happen, then, that there are no cases of consumption among the native population of the south % Simply for the reason that a change of temperature and other minor circumstances, have transferred the major action from the lungs to 


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the digestive system, which is manifested by diarrhea, dysentery, ague and fever, bilious fever, etc. Defective nutrition is not only the cause of the accompaniments of scrofula, but of scrofula itself. He has labored through the preceding pages to show that the hereditary transmission of a disposition to tubercle is a part of that great law which determines that the child's platform or model of life shall be that of its sire; and as that operation of the law is peculiarly incomprehensible, he resorts to the blood for the purpose of finding a solution for the whole subject. 
Now, if we admit that we find the " earliest rudiments" and the " latest relics of every organized tissue," it becomes essential to his argument for him to show that the hereditary matter in question is so organized that it can furnish to the blood a rudiment, or a relic—the transmissibility treated of, must inhere in something, and that something must be a tissue, or it cannot be under the influence of the blood. All the organs of the body and all its tissues, hold suitable relations to the blood, and it is true that the blood contains rudiments and relics of all the organs and tissues of the body—but does it contain rudiments and relics of the peculiar transmissibility for which he contends ? He may find in it an " epitome " of the nose, eyes, and possibly of the whole body—but can he find the epitome of this hereditary transmissibility of disease 2 This is the question. 
The blood is an elaborated fluid, and therefore it must represent the materials from which it was elaborated and the apparatus that elaborated it; and, we think, it is about as possible for him to discover in the blood, the imperfections of the apparatus that elaborated it, as it would be to discover in a mug of beer the imperfections of the beer-shop. 
12. We admit that he has labored assiduously in the analysis of this question, and so did the mountain in labor —it brought forth a mouse, and he nothing. And we grant, furthermore, that he is correct in his " certainty," that the scrofulous diathesis has its explanation in the grounds he has passed over—that is, in the human system ; but we deny that he has discovered it. 
13. In the forepart of this article, he appeared quite certain 


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PATHOLOGICAL CONSIDERATION'S. 
that he would conclusively develop this mysterious subject, but now he admits that he has not found a demonstration for it. 
14. When he first cast his eyes into the blood, and found the rudiments and relics of all the tissues, and even an epitome of the whole being, he appeared quite sanguine that he would accomplish his object, but now his confidence and lengthened argument are reduced to a high probability that " tubercle has its rise in disease of the blood," and in this wise it becomes to constitute a part of the " family likeness." He assures us, that in favor of such a probability there are many facts. We would like to have one fact to show why it should be in the blood, rather than in the nervous, serous, mucous, fibrous, or osseous tissues ; but, unfortunately, he has omitted to give us one. 
15. We now understand him—the blood is the great agent through which all family resemblance and hereditary transmission of certain forms of disease is perpetuated. It is a very pretty hypothesis, but there exists one serious objection to it, which is this: it is not consistent—and, therefore, it is not true. Any number of boys may be taken to Charleston, S. C, and while each one will retain his family likeness, the whole of them will lose their parental liability to a certain form of disease—and yet there may be no change in their respective organizations. Now, in this case, the blood must undergo a very peculiar change to maintain all the elements of the child's charter of life, except one—the disease and mode of death. The man who can conceive of the possibility of such a change, has, we admit, a very different capacity from ours. 
16. We admit it to be very probable, that thirty-six per centum of consumptive patients were of consumptive parentage ; but, if we believed the disease to invariably originate in such parentage, we should begin to doubt the truth of our hypothesis if we should fail to trace seventy-two per centum to such an origin ; twenty-eight per centum would then be left to be accounted for in the manner in which he has attempted to account for sixty-four. We regard this table as decidedly hostile to his conclusion. But if all of them had 


PATHOLOGICAL CONSIDERATIONS. 
231 
been of consumptive parents, he would have been sustained only in the result, but not in the cause. (See Answer 3.) 
If it be true, as we contend, that a certain relation of development between the medulla oblongata and the cerebellum constitutes a liability to this form of disease, under certain influences, as those of a cold climate—and if we shall examine all of them and find the cerebellum to be about the same in all, then the remote cause of the disease, in all, is discovered, and in a manner more satisfactorily than by the unexplainable cause contended for. 
By our doctrine, we can comprehend how it is that the same organization can result in two very different forms of disease in two equally different latitudes. But the existing hypothesis explains nothing. If produced by that organic law, which determines the features, complexion, etc., then, it is incurable and unalterable by any medicine or change of circumstances; or else, it must be shown that features can be changed by medication or change of place. It is now well known that neither of these positions is defensible. 
We have no occasion to prove that organic forms are transmissible—it is admitted ; and, with reference to those who may become afflicted with phthisis, in the north, it is well known that they have in common a similar outline of person, and we only extend the idea a little further, and contend that this morbid condition finds its origin in certain minor or subordinate forms and their relations, under certain circumstances. It follows, then, that by changing the forms and relations, or by changing the circumstances, a security is obtained against the malady. This, as a fact, no one will question at this time. 
If this form of disease be hereditary, science can offer neither a remedy nor a prophylaxis, nor any solid foundation for an indulgence of hope, the great sustainer of life—the patient's doom is well established in this respect, as with reference to the shape of his mouth or nose. But, under our views, science dictates a prophylaxis —a certain exercise or change of place or both, and, consequently, a rational foundation for a useful hope. 
But the most remarkable circumstance connected with this 


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subject is, that the doctrine should be as old as the profes sion, and still in good character, without a single claim to respectability. 
We shall continue the use of the word hereditary, as hitherto, because it is convenient; but we shall understand by it the transmission of certain organic forms and relations (and when used with reference to disease), which may result in certain forms of disease under certain circumstances. 


SYMPTOMATOLOGY. 
Since the dawn of Medical Science, the symptoms or characters which indicate particular forms and varieties of disease, have been a leading object with every medical investigator. We have but to reflect upon the multiplicity of the parts, the multiplicity of the degrees of disease or derangement to which each part is liable, and the multiplicity of complications to which all the parts and degrees of disease are subject, to be convinced that such a science as that of Symptomatology can never exist. 
Each organ has, however, its own pathognomonic expression, which, like the pathognomy of the face, may be perceived and even comprehended by a practiced observer; but the knowledge thus acquired cannot be communicated to others. Such manifestations of disease as appear upon the surface, may be distinguished and described, because they can be seen; but we can have no such advantage with the pathognomonic indications of internal disease. 
In our treatment of disease, we shall treat of such symptoms as are generally found to obtain, and in this place treat of the manner of arriving at a knowledge of the symptoms, and of some other incidental matters. 
In every portion of our country there appears to be an abundance of faith in the benefits to be derived from the medication of children, particularly of infants, at the hands of old women and illiterate impostors, with a disposition to repose but little confidence in the skill of the regularly-educated physician. 
Instead of denouncing this state of the public mind, we should rather endeavor to ascertain the cause, that we may qualify ourselves for its removal. Old and illiterate physicians and women do, most generally, possess a rich fund of 
233 


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SYMPTOMATOLOGY. 
knowledge which they have acquired by observation, and which, because they have not methodized it, they cannot impart to others in an available manner. On the other hand, reading or learned physicians are not usually so practiced in observation. The former have but few tools, but they are rich in the use of them; while the latter are rich in tools— they possess the accumulations of centuries—but have not acquired the use of them. It follows, then, that patient and accurate observation are just as indispensable to a physician, as extensive and accurate study—without the two combined, no one can hope to become an able practitioner. 
It is unfortunate that medical students, too generally, in the course of their studies, come to the conclusion that, as disease in infants is governed by the leading principles of the profession, a special attention to it is comparatively a waste of time. They do not even extend to the professors of this chair that respect which they consider to be due to those of the other departments of their professional education. They seem to be influenced by the principle, that as children are little things, the man who devotes himself to the investigation of their diseases, must possess a mind as much below that of a man, as a child is in age and stature. We are not sure but that a feeling of this kind has more or less pervaded the profession, because that attention which the subject is now receiving cannot boast of a very ancient origin. In this very fact, we should no doubt seek the cause of that general distrust of physicians, in infantile disease, which pervades almost every ramification of society. But students of the present day should remember that the horticulturist who does not understand the cultivation of his young and tender plants will have no fruit. If children are not sound, there can be no adults. It is clear, then, that this neglect or indifference, on the part of students, has been followed by an incapacity on the part of practitioners that has resulted fatally to thousands of children, who, otherwise, might have lived and proved as useful as other thousands have been, who were more fortunate. 
Students ought to remember that it is much more difficult to come at a knowledge of infantile disease than at that of adults. The latter can very generally communicate their 


SYMPTOMATOLOGY. 
235 
feelings and the locations of them, but from the former no euch information can be had, consequently their disease requires a closer observation and a clearer discrimination to secure success than is essential to that of adults. The fact that infants cannot communicate their condition, and the fact that they are feeble, are not the greatest obstacles which physicians have to encounter in the management of their disease ; but in the more complicated, extensive, and varying range of their sympathies. 
In the infant, it rarely happens that any one organ suffers alone, a morbus that is essentially local will so spread its influence throughout the system that it will be found, by the most astute and discriminating, very difficult to detect its primary position. In the adult, the work of development is completed, and therefore it continues much the same from day to day and year to year; but with children there is a restless mutability — their bodies, like those of adults, suffer waste, which must be repaired, and, attending this repair, development has to be effected—new functions are constantly being demanded, and new organs are to be developed to perform them. This is not all. These newly developed organs have absolutely to learn how to perform their respective functions. The organs that exist at any given moment may do their duty, but we cannot infer from this circumstance that those which are yet to come into service will do the same. In this multitude of developments, sympathies, and mutations, lie concealed hopes and fears, which time and proper attention can alone confirm or dispel. 
Students of medicine must readily perceive, from what has been said, that, in the midst of so many and varying circumstances, it cannot be an easy matter to obtain a diagnosis of infantile disease, and in this difficulty they ought to discover the magnitude of the advantage to be obtained from a teacher who has had a lifetime practice in the various forms of disease which are incidental to children; and they ought, furthermore, to infer, that this is the first proper step for them to take, in order to acquire a deserved ascendency over the old women of society. 
Now, it is possible for a student to be thoroughly educated in all that pertains to the various manifestations of disease 


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which he may be called to treat, and yet, when introduced to the suffering infant, he may feel as little at ease, as it he were in the society of mutes, or those speaking a different language from his own. To relieve all those who may become thus embarrassed, is our present object; but before we proceed, we must remark, that those who are not instinctively fond of children (for, as strange as it may seem, little children can as certainly discover their friends, as masons can their brethren), will find it very difficult to reduce to practice any lesson that we can give upon the subject; while those who possess a contrary disposition will soon learn to make their way, even without our aid. 
We premise, then, by stating that there is as certainly a pathognomy of disease, as of health or of mental emotion ; and dull must be the observer who could mistake the language or pantomime of anger for that of kindness or benevolence. The foreigner, whose language we do not understand, and mutes, who must be dumb, can make known all their wants by signs, and these signs constitute the natural language of the faculties that dictate them. 
Now, if it be true that the various organs that unite to make up our bodies, throw off, spontaneously, when in abnormal condition, signs which are expressive of their specific mode of physiological being, then we can understand why an old woman should excel a merely learned or a young and inexperienced physician in the diagnosis of infantile disease. 
The importance, however, of pathological pathognomy is not confined to children. The physician who is guided in his practice by the statements of his patients will never succeed in his profession—with all the learning of the schools, he will still be inferior to an experienced old woman. 
Beside the ignorance and stupidity which we frequently find among adults, even with reference to their own physiological condition, it often happens that they are not in a state to make any communication whatever. In such cases, therefore, the physician can do nothing, unless he can seize upon the indications of his duty as they are being pathognomonically manifested. 
As an illustration, we were, many years since, called to consult with a well-read physician upon a case of protracted 


SYMPTOMATOLOGY. 
237 
fever—the patient being unable to speak and almost without consciousness. Upon arriving at the house, we met the doctor at the gate, and asked him how his patient was. "In the course of last night," he answered, " he was seized with pulmonary hemorrhage, and is now, I fear, past recovery." We proceeded to the door of the patient's chamber and discovered him lying on the side of the bed, and the blood running passively from one side of his mouth. 
Now, it so happens that nature never intended this physician for the practice of medicine, nor any other one who is so stupid as to refer to the lungs a passive flow of blood from the mouth. Before we approached the patient, in the above case, we were sure that some portion of the bucal cavity was the source of the hemorrhage, and so informed the doctor, and the examination that followed discovered it issuing from a hollow tooth. The attention that we immediately gave to the tooth opened the eyes of the wife to the error of the doctor's diagnosis, and she discharged him. It does appear to us that no one who is not too lazy to think, could commit such a mistake. 
The preceding remarks will certainly impress students with the importance of giving a very close attention to every look, movement, sound, and indeed to every variety of manifestation that escapes from a patient, and if possible to investigate the relation that each one holds to the existing disease. 
It is a prevailing opinion, that inasmuch as children cannot communicate their feelings to us by vocal signs, the physician cannot come to a knowledge of their disease, and it is a matter of regret that this opinion is but too well founded, in very many instances ; but still it must be deemed as fortunate that such is not necessarily the case. 
All persons, without distinction as to age or sex, may be regarded as children when sick, and all can testify how unpleasant it is to have about the chamber one who is blunt, abrupt, or in the least unkind. If such manifestations are unpleasant to adults, what must be their impression upon young children, who seem to be conscious of their dependent and helpless condition. It follows, then, that the physician who is ambitious to be useful, and desires, at the same time, to live by his profession, must first learn to be particularly agreeable 


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in the sick chamber. His manners, whatever they may be in the drawing-room, should have all the simplicity of those of a child in the abode of disease. Every tone of his voice should indicate kindness and sympathy; and no matter as to what may be the responsibility of his situation, or the danger of his patient, he should never betray, by his manners or the pathognomy of his face, the presence of fearful apprehensions. He should, also, as carefully avoid levity. Cheerfulness should always play upon his face, and to the friends of the sick, nothing but candor should escape from his tongue. In fine, he should be, in the sick chamber, an example of patience, forbearance, kindness, cheerfulness, vigilance, promptness, and decision. While he causes no one to feel restrained or embarrassed, all should feel that they exist under martial law— that his will, and nothing but his will, can be executed. Any yielding to the suggestions of the unprofessional, however few or many they may be—however light or heavy the responsibility, is as unbecoming in a physician, as in a general. ' He should consider it as imperious to decide upon his duty and do it, without any reflections as to consequences. A comparatively trifling want of decision may lose a battle—and it may lose a patient. 
Upon being called to a sick child, the first object of the physician should be to ascertain, under the guidance of what we have taught, under various heads, concerning viability, whether the child is constituted to live. With this view, he will ascertain the vital condition of the parents, the disease with which they have been afflicted, and of which their relations have died. But, in the meantime, he should be seated sufficiently near to the child to observe its manifestations, and to afford it a chance to observe his, for the reason that he will be unable to make any satisfactory examinations of it, before it shall have discovered that he is a friend. During the pauses of conversation with the mother, he should turn his attention, incidentally as it were, to the child—present it some toy as a token of kind feeling, talk to it and play with it. But all this should be done without a suspicion being excited that it is the special object of his visit. 
He should ascertain of the mother whether she has lost any children, and if so, of what forms of disease and at what ages 


SYMPTOMATOLOGY. 
239 
they died. He should particularly obtain the history of his patient, as to general health, dentition, weaning, food, etc. When he shall discover that the child has become acquainted with him—betrays no alarm or excitement when he puts his hand upon it or takes it up, he may safely proceed to make his personal investigations of it; otherwise he need scarcely expect to obtain a normal exhibition of its circulation and respiration. 
If the child should be asleep upon his arrival, he should avail himself of the occasion to notice the character of its sleep, the condition of its eyes, as to whether they are closed or partially open, the frequency of its respiration, the temperature of its skin, of its head, and the beat of the pulse. If, while making these observations, he should discover it about to wake, its mother or nurse should be at hand to take his place, and he should so dispose of himself as not to be seen by it upon waking, for the reason that a strange face at such a moment, might be productive of unpleasant consequences. 
Without having thoroughly gained the confidence of the child, it is useless to expect to find any portion of its pathological expression, such as it would have been, but for his presence; and for those who are not naturally fond of children, it will be about as difficult as for one to make " sweet sounds," whose musical capacity is feeble. But, under the most favorable circumstances, he should examine the pulse two or three times during his visit, because this function suffers important changes, in infants, from slight and even inappreciable causes. 


P A E T I. 
MANIFESTATIONS OF DISEASE IN THE ANIMAL OR CEREBROSPINAL SYSTEM. 
INTRODUCTION. 
A reference to the table of measurements of the medulla oblongata and cerebellum (page 20), leaves no possible room to doubt that those forms of disease which have hitherto been denominated cerebro-spinal, should really be called oblongatocerebello-spinal, and that the cerebrum has no direct participation in them. Furthermore, they admit of a division into three sub-parts or groups: 1. Into those which result from an equal development of the medulla oblongata and cerebellum— as gout and rheumatism. 2. Those that result from a full endowment of the cerebellum and a feeble one of the medulla oblongata—as obesity, anasarca (perhaps dropsies in general) and probably apoplexy, epilepsy, etc.; and, 3. Those which result from a full endowment of the medulla oblongata with a reversed condition of the cerebellum, as tuberculosis and its kindred manifestations. These conclusions, we contend, are authorized by cranial measurements and observation upon disease and its results. 
We regret exceedingly that we are unable to make such a classification of the clearly recognized forms of disease. In the reports of such forms, we have barely found enough, incidentally thrown out in their history, with what we have observed, to feel assured of the practical advantages that would result from such a classification, correctly made; it would be Equivalent, so far as etiology and prophylaxis are involved, to all that has been done. 
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INTRODUCTION. 
241 
As we have remarked, we are unable to adopt such a classification, and yet, in the following treatise we may be able, without much risk of error, to designate the primary or organic cause of many of the classes or family forms of disease, but we shall not do it with a view of present advantage to therapeutics, so much as for the purpose of exciting or inviting observation to the subject. And when we shall speak of patients as being of the first, second, or third class, we shall have reference to the table above referred to, on page 20, Book I. 
16 


CLASS I. 
MANIFESTATIONS OP DISEASE IN THE CEREBRAL APPARATUS. 
INTKODUCTI ON. 
The exalted position which the cerebral apparatus has ever held in the estimation of physiologists, either because of their conception of its superior importance, or because of the exceeding difficulty that attends its investigations, pathologists have, we think, most generally, commenced their nosological classifications with its manifestations of disease. 
Professor Meigs tells us, that " the source of all vital power is in the nervous mass—whether the cord, or its bulbs, the great sympathetic or the plexuses, or the nervous tractus, wherever situated." 
We have been in the practice of admitting the truth of this doctrine when viewed with reference to man's social relations and the great purposes of his existence; but when we have meditated upon the subject of animal life—animal power, we have hitherto maintained that the lungs constituted the great indispensable. The indispensability of oxygen to life—the immediate certainty of death without it—the indispensability of oxygen to all the nutritive processes—its agency in death, and the necessity of it to the production of great animal power, had brought us to the conclusion that the lungs, the apparatus that provides the oxygen, constituted more thoroughly their importance —a sine qua non to vital existence— than any other organ in the system. 
In support of this conclusion, we had observed that attempts to restore suspended animation, most generally, consisted of efforts to re-establish respiration — that animal motion appeared to hold the same relation to the diaphragm, that steam machinery does to the piston. We had also observed, that in 
242 


MANIFESTATIONS OF DISEASE, ETO. 
243 
the lowest departments of animal existence, we often met with a high degree of vitality with a mere trace of cerebral apparatus. Add to the preceding facts the circumstance that human greatness is never found unassociated with a highly endowed respiratory apparatus, aijd the conclusion that most plausibly presents itself is, that oxygen, if not life, is so inseparably connected with it, as to give the lungs more importance in the phenomena of life, than the brain and its associated parts. We could not avoid the conclusion, cceteris paribus, that as the quantity of steam was the measure of power in any given machine, so the quantity of oxygen was the measure of the power of any given animal organization. 
In harmony with this conclusion, we had seen powerless heads as large as those of Washington, Napoleon, and Scott, and that we had met with great men, comparatively, with small or moderately-sized heads; but in no instance had we found efficiency of character associated with a feebly-endowed pulmonary system. 
These views were entertained by us until we discovered the dependence that exists between the medulla oblongata and cerebellum, acting in co-operation, and the pulmonary system. In this, we discovered that all the vital influence of the respiratory function was imparted by the previously-named organs; their development became to us the measure of the respiratory function. 
But, notwithstanding this conclusion, there is ample room left for debate, as to which of the three great functions, the respiratoiy, the circulatory, and cerebral, is the most indispensable to present existence. Without properly-elaborated blood, there is no cerebral action ; and without respiration such blood cannot be produced, and when produced it is of no vital purpose without the cerebral function. The three systems constitute a circle, and each is indispensable to life—to present or momentary existence. 
Separate and apart from these considerations, there yet remains one which decides that we should commence the consideration of disease with those manifestations of it which appear in the cerebral apparatus ; and that is : it presides over and regulates all the apparatuses of animal life and greatly influences those of the vegetative. 


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MANIFESTATIONS OF DISEASE, ETC. 
Dr. West says, "beside the general interest and importance of these affections (cerebral), at whatever age they may occur, their extreme frequency in early life gives them an additional claim on our notice." 
He continues: "It appears from the fifth report of the register-general, that 7,603 out of 45,000 persons who died in the metropolis during the year 1842, were destroyed by the various forms of disease of the nervous system. But 4,847 of these deaths took place during the first five years of existence ; or, in other words, sixty-four per cent, of the fatal disorders of the nervous system occurred within that period." 
Now, it may be inquired, what are the causes of this mortality from the cerebral forms of disease ? We answer, none has been assigned, except such as are equally applicable to all the other apparatuses of the system. Their true causes remain vailed in impenetrable darkness. It is now time, however, that this vail was thrown aside. 
We have shown, page 20, that the power of the respiratory and circulatory functions depends upon the medulla oblongata and the cerebellum. Now, suppose these apparatuses to be too feeble to sustain all the functions of the body ; sixty-four per cent., Dr. West informs us, died of nervous disease under five years of age; now, if we subtract from this sum those who would have died but for the physicians, the natural mortality would probably be reduced to thirty-five per cent.; and this mortality may be assigned to an inherent want of viability (the consequence of violated law), which is invariably indicated by a feeble chest or very small cerebellum, more especially if the cerebral hemispheres are large; or it may equally depend upon a large cerebellum and a small medulla oblongata, attended by more or less of obesity, up to the invasion. 
If physicians shall find that we have truly indicated the source of vital power—viability—they will find no difficulty in detecting, in most cases, the causes of infantile disease and mortality, more especially if they will extend their observations to the parents, individually and relatively. 


FORMS OF CEREBRAL DISEASE. 
245 
ORDER I. 
INFLAMMATORY FORMS OF CEREBRAL DISEASE. 
Genus I. — Encephalitis. 
Simple Inflammation of the Brain. 
We use this term to designate an inflammation of the parts contained within the cranium; we shall not stop to inquire whether it is confined to the meninges or to the substance of the brain, because it may or may not involve the whole, and, further, a distinction can subserve no practical therapeutical purpose. Post mortem examinations generally reveal more obvious signs of inflammation on the surface and in the ventricles than in the substance of the organ; but this does not prove that the substance of the organ was not invaded, because it is possible and even probable that important, but inappreciable, changes may have been effected by the inflammation. 
With infants and young children, this malady is thought to be very generally confined to the base of the brain ; we should, a priori, expect this to be the case, because it can scarcely be supposed that any organ could be much disposed to morbid action before it became so organized as to perform the function for which it was intended, and this is not the case with the cerebral hemispheres in infancy; but the first moment of extrauterine existence calls into requisition the basilar portion of the brain. In a majority of instances, it is stated, that the ventricles also participate in this inflammation. 
The symptoms, however they may vary in different cases, are strongly marked ; and the disease is, perhaps, more likely to attack children in full and apparently good health than in the feeble and emaciated. In many cases, it commences, apparently (for the previous phenomena may not have been observed), with the most violent convulsions ; in other cases, after a few hours or a day of restlessness, they supervene; in others, the first admonition consists of nausea and vomiting, and they may continue for a day or two, or they may speedily cease, or they may mark the whole course of the disease. All ingesta received into the stomach, no matter how bland, is thrown up. Usually there is much constipation. The 


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INFLAMMATORY FORMS 
convulsions are, in some cases, continued almost without intermission to the close of life. In some cases febrile excitement is present at the beginning, or, if it is not, it soon makes its appearance and continues without remission to dissolution, which is rarely procrastinated beyond a week. 
As an illustration of this violent malady, we have deemed it proper to extract from Dr. Abercombie's treatise on cerebral disease the history of one case. 
"A child, aged 2 years, 21st May, 1826, was suddenly seized in the morning with severe and long-continued convulsions. They left her in a dull and torpid state, in which she did not seem to recognize the persons about her. She had lain in this state for several hours, when the convulsion returned, and during the following night it recurred a third time, and was very severe and of long continuance. I saw her on the morning of the 23d, and while I was sitting by her, she was again attacked with severe and long-continued convulsion, which affected every part of the body, the face and eyes in particular being frightfully distorted. The countenance was pale and expressive of exhaustion; the pulse frequent; her bowels had been'freely opened by medicine previously prescribed by Dr. Beiby, and the motions were dark and unhealthy. Further purging was employed, with topical bleeding, cold applications to the head, and blistering. After this attack, she continued free from convulsion until the afternoon of the 23d; in the interval she had remained in a partially comatose state, with frequent starting; pulse frequent, but pupil rather dilated; she took some food. In the after noon of the 23d, the convulsion returned with great severity; on the 24th, there was a constant succession of paroxysms during the whole day, with sinking of the vital powers ; and she died in the evening. 
" On removing the dura mater, the surface of the brain appeared in many places covered by a deposition of adventitious membrane between the arachnoid and pia mater. It was chiefly found above the openings between the convolutions, and in some places appeared to dip a little way between them. The arachnoid membrane, when detached, appeared to be healthy, but the pia mater was throughout in the highest state of vascularity, especially between the convolutions; and when 


OF CEREBRAL DISEASE. 
247 
the brain was cut vertically, the spaces between the convolutions were most strikingly marked by a bright line of vivid redness, produced by the inflamed membrane. There was no effusion in the ventricle, and no other morbid appearance." 
Causes.—This form of disease is not of very frequent occurrence in infancy, and hence its causes, at this period of life, are not well understood. It has been known to occur in children from exposure to the sun in hot weather, and, also, during apparent convalescence from scarlatina, but most frequently no cause can be assigned. "We think it very probable that its occurrence is measurably confined to the rheumatic constitution—a high endowment of the vital forces. After the second year, it is seldom manifested until after puberty. Dr. Wood says, that "it is singular that the tendency to tuberculous meningitis is exactly the reverse, being greatest between two and fifteen." It would not have seemed strange to him if he had known that the first is associated with a full endownent of the vital forces, and that the latter is always associated with, and primarily caused by, a feeble condition of them. 
Diagnosis.—This form of cerebral disease is more liable to be mistaken for tuberculous meningitis, but as the former occurs with high vital forces, and the latter with feeble and scrofulous, there is no necessity for such an error. The former is, furthermore, in its early stages, attended with more acute symptoms, as heat, thirst, delirium, etc. The initiatory stage of both of them may be confounded with several febrile affections, as small-pox, enteritis, etc. 
Prognosis.—This is always to be regarded as a dangerous affection. 
Indications.—These most evidently consist in causing a determination of the blood outward and downward—in diminishing the action of the arterial capillaries, and increasing that of the venous radicals of the brain and its meninges, and ultimately to secure a normal equilibrium of action. 
Treatment.—When we reflect that fever and inflammation are but obstructed general and local vital actions—accumulations of vital force to remove obstructions to secretion and absorption, there can remain no doubt as to the proper plan of treatment. 


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We recommend, therefore, that the scalp be thoroughly cleansed of all dirt and dandruff by vinegar washes and a comb, that it may become properly impressible to external agents and the vital actions of the system. To promote the venous and reduce the arterial actions, the patient should be subjected to, and continued in, a warm bath, until symptoms of syncope are induced, and then put to bed; much care should now be taken to keep the head cool by cloths saturated with a mixture of vinegar and water, or by constant sponging—the latter is preferable, because it admits of and promotes constant evaporation—a more cooling process than an unventilated application of cold substances. It is a very general practice to surround the head with ice; but to this we have the same objection that many thinking and discreet physicians have to blistering the scalp in this affliction. As a source of irritation, it is not inferior, perhaps, to water so hot as barely to avoid vesication, and in this, as in all other forms of disease, all causes of irritation that are not revulsive should be avoided. 
As soon after the warm bath as practicable, the bowels should be stimulated by enemas, and the inferior extremities kept warm with as much care as must be bestowed in keeping the head cool. 
As a further means of inviting circulation and irritation from the brain, the abdomen, lower portion of the spine, and inferior extremities should be kept covered with emollient substances, as a bread-and-milk or corn-meal poultice, sprinkled with mustard or cayenne, to a sufficient extent to produce redness without vesication. 
Purgatives, in this form of disease, can act in co-operation with the rubefacients, in promoting a determination of vital action from the brain, and for this purpose, and no other, are they admissible, in violent cases, where the native forces of the system are such as not to seriously contra-indicate their weakening influence; consequently, the hydrogogue cathartics should be avoided. For this purpose, we would suggest the use of the compound powder of Jalap and Senna, or Podophyllin, or Podophyllin and Leptandrin combined, either of which is to be used in small doses to avoid active catharsis; 


OF CEREBRAL DISEASE. 
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in many instances stimulating and laxative enemas may be given. 
In the meantime, or as soon as the inflammatory action reappears upon the surface, after the employment of the warm bath, all parts of the surface, hot acted upon by rubefacients, should be kept moist, or in an evaporating condition, by sponging them with an alkaline solution of such a temperature as to be agreeable—not omitting a frequent resort to warm pediluviums; nauseating antispasmodics should likewise be so administered as to aid the other means to keep down excessive action and promote an equilibrium of the circulation in the system. 
When the most urgent symptoms have abated, a more permanently depurative practice should be adopted—such as the use of tonic and stimulating alteratives, as Xanthoxylin, Myricin, Hydrastin, and, in some cases, Quinine combined with one or more of the above articles. 
Xanthoxylin, 
Hydrastin, 
S. Quinine, aa gr.j., 
Sacch. Alb., q. s. to make a powder, 
when the articles are triturated together; and which may be divided into from two to six or eight doses, according to the age of the child, and given three or four times a day. In some cases the Cornine may be substituted for the Quinine with advantage. 
This is the plan of treatment which we have found more generally successful, in this so commonly fatal disease, than any other which we have investigated. 
We would remark here, that the application of blisters to the head, a practice so universally recommended, and as universally fatal, cannot be too highly deprecated. During a practice of many years, we have never known a child to recover in whom the scalp had been shaved and a blister applied, and such is likewise the result of the observation of many of our oldest eclectic practitioners. 


250 
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Genus II.— Acute Hydrocephalus— 
Complicated Inflammation of the Brain. 
We have stated that Encephalitis is not a frequent form of cerebral disease in infants ; but Acute Hydrocephalus is, and it never occurs except in phthisical or tuberculous constitutions. It is stated, by pathologists, that in a large majority of cases, the inflammation is so predominant at the base of the brain, as to be regarded by some as pathognomonic of a scrofulous condition of the organ. But this peculiarity is said to be a very frequent condition of Encephalitis. This, a priori, we would expect, because it is not reasonable to suppose that much disease would invade the hemispheres before they are sufficiently developed to perform, to an appreciable extent, their functions. The base of the brain, and that only, is called into requisition to much extent during infancy and childhood. 
To the usual evidences of cerebral inflammation, may be added, in this form, opacity and thickening of the membranes, serous effusions into the ventricles, varying in quantity from very little to six ounces, and softening of the cerebral substance. In this form, furthermore, there are deposits of small and apparently compressed or flattened points of the size of millet seed, which appear friable under pressure, and closely resemble the gray granulations occasionally seen in the lungs or pleura of phthisical people—they are of a grayish or yellowish color, and semi-transparent and resistant. In proof that this is tubercular matter, Dr. West presents briefly the following results of observation: 
" First: That they are always associated with tubercle elsewhere. 
" Second: That their abundance is not proportioned to the amount of inflammatory mischief. 
" Third: That they are sometimes met with in cases where no head symptoms were observed during life, and unconnected with any sign of inflammation discovered after death ; and, 
" Fourth: That their chemical composition and their microscopic structure are identical with tubercle in other organs of the body." 
If we were to divide this disease into two stages, we should 


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251 
have all the indications, during the first, of inflammation of the brain or some of the parts; and during the second, all those which are characteristic of serous effusions and cerebral softening. Divide it as we may, and much confusion will still exist; if we adopt the above division, we shall often find both sets of symptoms to be attendant upon both causes. While effusion is taking place in one part inflammation is extending in another, and thus much confusion may result. 
Some divide it into three stages: that of increased sensibility — diminished sensibility — and the third is that of palsy and convulsions. It has also been divided into four stages: that of turgescence, inflammation, effusion, and palsy. But the same difficulty attends the whole of them. These efforts at elucidation prove, however, the difficulty that attends the subject. 
We shall assume that it is divisible into three stages, and among the first indications of its existence is the application, by the child, of its hand to its head, followed by such a cry as indicates severe pain—the motion of the hand to the head leads us to infer the location of the pain. Following or attending this symptom, we may probably observe restlessness, an indisposition or inability to sit up. Its sleep is unquiet and often broken by starts and screams, and attended frequently by a grinding of the teeth. When awake, it shuns the light and evinces an indisposition to be disturbed and an impatience to noise. The scalp is hot and the pupils are contracted. The appetite is whimsical or totally lost, the breath is offensive, bowels are constipated, the stools are green, or tar-like and black, the urine is highly-colored and generally scanty, the tongue is white, vomiting very commonly attends this stage, but the most pathognomonic symptom is said to consist in the change of the stomach from a tumid and tender condition to one of flatness or apparent emptiness, and that, too, without alvine excretions. The pulse is also regarded as another remarkable symptom, being exceedingly frequent and sharp. These symptoms leave no doubt that the inflammatory action is going on in the brain, but the period of their duration is uncertain —they may continue one, two, or several days, but rarely longer than a week, before they become replaced by those that distinguish the second stage. 


252 
INFLAMMATORY FORMS 
As the second stage approaches, the pulse is said by some to become less frequent, until finally its beats are slow and irregular, but others assert, that with its irregularity it increases in frequency. No great importance, we apprehend, when taken alone, is to be attached to it. The face now becomes expressive of extreme anxiety and suffering—there is an increased aversion to any kind of annoyance —it seems only desirous to be let alone, its eyes are generally closed to keep out the smallest ray of light, its condition is drowsy, if old enough to speak, it will complain of its head, all questions are answered rationally and briefly, its disposition is very irritable, but when quiet and undisturbed, it moans in a low tone, which is, very frequently, interrupted by a sharp, suffering cry; sometimes, instead of the moan and plaintive cry, there will be screams, which are so toned as to indicate the intensity of the pain. As night approaches, the symptoms usually become more violent, and the patient becomes noisy, vociferous, and delirious, but this is not always the case; sometimes the only obvious change is an increased restlessness. Vomiting, which was a troublesome and a painful symptom during the first stage, is apt to cease upon the introduction of this—the bowels have, if anything, become more obstinate in their constipation, and the evacuations continue equally unnatural, but all flatus has disappeared. 
Before the conclusion of this stage, the pulse becomes less frequent, and with it an increase of insensibility with heaviness and stupor, the light ceases to be troublesome, vision becomes imperfect, and squinting commences, it lies with its eyes half-closed, convulsions frequently occur, paralysis supervenes, the excrements are passed unconsciously, it picks its lips, or bores its fingers into its nostrils. This stage is rendered remarkable by remissions which occasionally characterize it —but these are sometimes gradual, at other times sudden and always deceitful; the indications of convalescence are sometimes sufficient to inspire hope, and yet, in a day or so, a relapse supervenes and a deeper coma dispels all expectation of recovery. This stage may continue a week or two. 
The next and last stage differs but little from the preceding, except that the pulse becomes again very frequent — as frequent as two hundred strokes per minute. One part of the 


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body will be hot and dry, while a cold sweat pervades another, convulsive twitchings take possession of one side and paralysis of the other, one cheek is flushed and the other is pale—feebleness rapidly marks the pulse, and death supervenes quietly or in the midst of convulsions. This third stage is very indefinite in its duration—lasting in some instances only a few hours, and at other times a week or ten days. The greatest duration of the disease, from the time the symptoms become well defined, is set down at about twenty-one days—terminating in some cases in four or five. 
In view of the symptoms and peculiarities of the three stages, as above described, it becomes proper that we should caution our readers against indulging a hope or expectation that they will ever witness the three stages to appear and progress exactly as we have described them, or that they will find, in every instance, the symptoms to be exactly in the place we have assigned them. 
Many of the symptoms which we have assigned to the second stage may occur in the first, and the reverse. A difference as to their date and the order of their occurrence must be expected—certain symptoms, though never altogether absent, may occur early in one case and late in another. Convulsions, per example, which are scarcely ever absent, may not appear at the same date in any two cases, nor be attended with the same phenomena. In one patient, they may convulse only one side; in another, the whole body. In one instance, they may be succeeded by a stiff and contracted state of the extremities, and in another by paralysis. But, however greatly the symptoms may be modified, in different cases, no error can be made as to the disease they collectively indicate—no mistake can be indulged as to the dangerous nature of their source. 
Causes. —'For the opinions of many on this subject, we refer to other and more voluminous works, and in this place record our own notions about it. 
We do not doubt but that it very often depends upon a tubercular diathesis, and is therefore hereditary ; but what is the condition of such a diathesis ? To refer this form of disease to such a diathesis, is leaving the cause as much in the dark as it was before. 


INFLAMMATORY FORMS 
254 
Such is the condition of the vital forces in all these children, as to place them in the third class, which entitles us to the opinion that this form of disease depends upon an imperfect pulmonic depuration. The skin aids in this depuration, more particularly when in a state of eruption, and it is known that a suspended cutaneous eruption will produce this form of hydrocephalus; and so may the arrest of any other secretion that gives aid to the lungs—as the deposition of adeps. 
Diagnosis.—As this form of disease, as we have before remarked, rarely if ever attacks the strong and healthy, so those who have previously appeared healthy may only have been obese. Hence it is that children of a scrofulous diathesis will gradually lose the rose and flush of health without any assignable cause, and when they have become sufficiently reduced by the disturbance occasioned to the nutritive process by the tubercular development, then Acute Hydrocephalus takes possession of the case. 
While, therefore, the physician is watching this wasting condition of his patient, he should be sufficiently vigilant as to anticipate the possible result, and this certainly is not a very difficult task when we have a knowledge of the parental diathesis or organization. 
Perhaps the patient has been tolerably well, until very recently, when it had an attack of febrile symptoms, attended with constipation, headache, and possibly vomiting; now, it would not be entirely unlikely that the case might be mistaken for one of remitting fever, and the only existing circumstance that should excite suspicion in the premises is the parental diathesis, which can always be known. If the patient be under five years of age, the physician may still more 6trongly suspect that it is not remittent fever, and if it be under three years of age, he may feel quite sure that it is not. 
As the human temperaments have, hitherto, been a sealed book, but little observation has generally been had upon the subject of human constitutions in general. As the seal is now broken, as we confidently believe, we entertain a sanguine expectation that observation will be commenced, and when a habit of the kind is formed, it becomes one not only of agreeable interest but of useful instruction. It has become as natural for us to observe the constitutional peculiarities of 


OF CEREBRAL DISEASE. 
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every one we meet, as it is to breathe, and certainly it consumes neither time nor money. 
If the physician will impress upon his understanding the peculiar symptoms that attend a remittent fever, he need not be long in doubt as to the character of the case before him, even without a knowledge of the circumstances we have named. Some cases of gastric disorder considerably resemble the incipient stage of Acute Hydrocephalus, but then, there are such differences as should prevent any mistake. 
To distinguish this form of cerebral disease from simple Encephalitis, we refer to the diagnosis of the latter. 
Prognosis.—Upon this topic we have but little to say, further than that it is, according to authority, very generally unfavorable ; for under every known treatment, and under every other known condition, it generally proves fatal sooner or later; the number of exceptions only serve to enable us to say that it is not absolutely incurable. 
"We are so well satisfied that this form of disease originates in a non-viable condition of the system, as to give it as our unqualified opinion that it is never curable, and that those who have been supposed to have recovered from it never had it. It is possible, however, that a few of the stronger of this class may recover from the less actively inflammatory stages of the affection, but it can only amount to a very short procrastination of death. 
Treatment.—As this affection so generally proves fatal under any treatment, we can do nothing more than to suggest a course similar to that recommended for Encephalitis, and would take occasion here to remark, that notwithstanding the general application of blisters in such cases, they have proved as unsuccessful as in Encephalitis. 
The following course has been adopted by several practitioners and occasionally with advantage. 
Alkaline bath to the surface, with considerable friction in drying; bowels kept soluble; diaphoresis maintained by means of spirit vapor-bath; compound tincture of Virginia Snake Root, and warm effusions of Spearmint, Crawley Root, etc.; local applications to the head of cooling lotion, tepid or cool, as indicated by the effects, and in some instances warm 


256 
NON-INFLAMMATORY FORMS 
fomentations of Hops, or Stramonium leaves applied to the whole head. Diuretics are also beneficial, as, 
V*. Tinct. Digitalis, 3j, Spirit. Nitr. Dulc, 3j ; mix. 
Of this five drops may be given to a child one year old, in an infusion of Parsley root, and repeated three or four times a day. All sources of irritation must be avoided; if teething, the gums must be cut; and a change of the nurse's milk will be frequently of service. 
ORDER II. 
NON-INFLAMMATORY FORMS OF CEREBRAL DISEASE. 
Genus I.—Cerebral Congestion. 
Congestion of the brain is produced by two distinct sets of causes, and consequently produce two distinct forms of disease. One variety may be produced by any cause that can increase the flow of blood to the brain, and when thus produced it is called active congestion. 
The other variety of cerebral congestion may be produced by any cause that can prevent or retard the reflux of the blood, and when produced in this way, it is called passive. As these two forms are very unlike, it becomes requisite to treat of them separately. 
Species I. — Acute Cerebral Congestion. 
The period of dentition being one of much vascular irritation, is not unfrequently attended, even from slight causes, with such cerebral congestion as to produce apoplectic symptoms and even convulsions. Such symptoms precede, or are introduced by, the eruptive fevers. Acute congestion of the brain is sometimes very rapidly produced—manifesting from the start such symptoms as indicate an immediate demand for medical attention. In other instances, it may seem to have commenced as suddenly, and yet, though unobserved at the time, but afterward remembered, that the alarming portion of the attack was preceded, for several days, with manifestations 


OF CEREBRAL DISEASE. 
257 
of uneasiness — some derangement of the bowels, either too loose, or, more probably, too constipated, and possibly with some febrile disturbance. 
At other times, these symptoms will gradually increase until they attract attention—the child has become more restless, troublesome, and fretful, and endeavors to evade the light, places its hand to its head, and if old enough to speak, it will complain of its head, which upon examination will be found to have increased in its temperature. That vomiting which was characteristic of more sudden assaults, now supervenes ; the pulse, though in young children rarely ever trustworthy, is usually quick, the attending fever is variable in degree and attended with considerable irregularity in its exacerbations. The child's sleep is not natural or healthy, its facial muscles twitch, it starts upon waking, and if the anterior fontanelle be unclosed, strong pulsations of the brain may be observed. 
Such paroxysms as this may be frequently seen with children during the period of dentition, and after continuing several days may even pass away without any medical attention. 
Notwithstanding that such paroxysms sometimes pass off without inflicting more serious mischief, yet we are not to make such calculations, because just such symptoms as those above detailed, very frequently indicate a formidable mischief, one that may have been accumulating for months, and which is to end, possibly, and even probably, in acute hydrocephalus. And, although all of the hitherto enumerated symptoms may subside—pass entirely off, and thereby inspire the most sanguine hopes, yet we should look out for the supervention of another and a very different set, to introduce what may be designated the second stage. 
As the disease emerges from the first stage, as the heat of the head may diminish, and the flush become slight and less constant, we may observe stealing over the patient an indifference to all objects of sense, with an increased weight and anxiety of the countenance and an increasing tendency to torpor. The bowels are still more or less constipated, and the vomiting is still in attendance,' but probably less frequent than in the first stage. Sometimes the second stage is introduced by an attack of convulsions, and if not, the state of torpor 
17 


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NON-INFLAMMATORY FORMS 
may gradually pass into one of convulsion, and after each repetition of the latter the torpor becomes more deeply founded, until finally coma supplants the convulsive tendency and closes the scene. This finale may supervene the first fit in forty-eight hours, or the disease may be procrastinated for several weeks, and even then recover. It is thought that in cases of such procrastination, the cranial sutures and fontanelles are not completed, and that the congestion is relieved by an effusion of serum into the ventricles, the yielding condition of the cerebral parietis admitting of easy adaptation to the corresponding increase of the mass. If we admit this solution to be the fact, we have an exchange of an acute form of disease for a chronic one—the congestion has produced hydrocephalus, an affection which is not always, but most generally, fatal. 
When the exanthemata are introduced by cerebral symptoms, the danger for a time must be considered as very great, but under such circumstances we know that if we can remove the congestion we will save the patient by the aid of the eruption that will soon follow. The attending vomiting may be a symptom of cerebral disturbance, or it may be consequent upon the ingesta of some indigestible substance. This is a matter which must not be overlooked by the attending physician, because an emetic in the first instance is as strongly contra-indicated, as it would be indicated in the second. 
As cerebral congestion results from such a variety of causes, it is obviously impossible to prescribe a definite course of treatment ; consequently, the physician is required to summon to his aid all the vigilance, discrimination, and judgment he can, inasmuch as a course of treatment that would be wisely adapted to one case, might prove destructive in another. Thus, if the convulsions have succeeded to mechanical violence, inflammation is much to be apprehended, and therefore an energetic treatment is demanded; but, on the contrary, if they have succeeded to long-continued gastric or intestinal irritations, or should occur during the dental process, the danger is to be apprehended from doing too much rather than not enough. 
Causes.—The causes in this form of disease may be the same as those of simple encephalitis, acting under a modifi- 


OF CEREBRAL DISEASE. 
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cation of circumstances. It is probably confined to those who possess a strongly-endowed vital system. Beside falls and blows, it may be produced or excited into action by almost any source of irritation that may be directed to the brain, as suppressed discharges, solar or artificial heat, and the various irritations common to the dental period. 
Diagnosis.—The physician who will observe the difference of cerebral conformation between the heads of those who are, respectively, suffering under the active and passive forms of congestion, will never afterward confound them. In active congestion, the face will give evidence of vital existence by its flushed condition, suffused eyes, and generally turgid appearance. For further diagnosis, see the next or second species. 
Prognosis.—If we were to draw our conclusions from the practice we have observed, we should conclude very unfavorably as to the prognosis in this form of disease, and yet there is nothing inherently indicative of danger in it. The vital force is, in general, adequate to the removal of the congestion, at least with a little professional aid, and when it proves fatal, it should be charged to the profession, as not having discovered the proper treatment, or in adopting an erroneous one— such as we consider bleeding and mercury to be. 
Treatment.—The indications for treatment are to overcome the spasmodic condition of the vascular system, which will produce an equalization of the circulation, and thus relieve the congested state of the brain by diverting the circulation from this organ; also, to remove all local irritations, whether gastric, intestinal, or dental. 
To fulfill the first indication, we commence with a free and repeated use of the warm bath, in connection with nauseants: as, 
r Syrup of Squills, 
Syrup of Senega, aa gss, 
Tinct. of Lobelia, 3ij. Mix. 
Of this, sufficient should be administered to produce nausea, say from ten to twenty drops to a child one or two years old, and which may be repeated sufficiently often to keep up the nausea and accompanying diaphoresis. We prefer this combination, inasmuch as it tends to prevent the recession of the exanthema so common to this affection, and which 


NON-INFLAMMATORY FORMS 
260 
recession is much to be dreaded and must always be carefully watched. 
Br. Podophyllin, gr. j, Lupulin, grs. v, Sacch. Alb., Bj. Mix. 
Triturate thoroughly, and divide into twelve powders; of these, one powder should be administered three times a day, or sufficiently often to allay the irritation; the laxative effect of this preparation will, in many cases, take place in from twenty-four to thirty-six hours; if it should prove too active in its operation, the intervals between the doses should be lengthened. 
If the gums are swollen, they must be cut; and the practitioner should always attend to this matter in children during the period of teething. 
The whole surface of the body must be bathed often with a weak alkaline wash, and in drying use considerable friction. In some instances, ligatures to the extremities will be found beneficial, and care should be taken that they be not applied too tightly, or removed too suddenly. 
Cold, or moderately cold applications must be applied to the head; but in their employment, we should carefully guard against producing a chill, either by having them too cold or by allowing them to remain too long. In connection with these, the extremities must be kept warm by warm foot-baths, stimulating liniments, or mustard. 
In many instances, the compound tincture of Virginia Snakeroot may be used with benefit, for the purpose of allaying that irritability of the system which favors this form of congestion, as follows: 
fy. Comp. Tinct. Virg. Snakeroot, gtt. x, Aqua distil, f. 3j. Mix. 
Of this, a fluid drachm may be given every three or four hours to a child five years old. 
Or the tincture of Aconite, or tincture of Belladonna, may be administered for a similar purpose; thus, 
$. Tinct. Aconitum, (or Belladonna), gtt. viii, 
Aqua Distil, f. giij. Mix. 
A fluid drachm of either of these may be given every three or four hours. If dilatation of the pupils should be produced by 


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261 
the use of these agents, the doses must be lessened and the intervals between the doses lengthened, or they must be omitted altogether. 
If convulsions are present, place the child in a warm bath, and administer antispasmodics, as the tincture of Lobelia and Capsicum. 
In all cerebral diseases, both during the attack and the convalescent stage, the room of the patient should be kept darkened and perfectly quiet, and everything calculated to vex or irritate the patient must be avoided. All diet of an irritating character should be strictly forbidden. . 
The severer symptoms having abated, the same tonic and stimulating course may be pursued as recommended in treating of encephalitis; as follows, 
Xanthoxylin, 
Hydrastin, 
S. Quinine, aa gr. j, 
Sacch. Alb., q. s. 
to make a powder when the articles are well triturated together ; and which may be divided into from two to six or eight doses, according to the age of the child, and given three or four times daily. 
In the treatment of this disease, success mainly depends upon the judgment of the practitioner in the timely administration of remedial measures. 
Species II.— Passive Cerebral Congestion. 
Although no age is exempt from this form of congestion, yet it occurs much more frequently immediately after birth, and certainly no one can be puzzled to understand why this should be the case. In many still-born children, the swollen scalp and livid face indicate the extreme congestion of the cerebral vessels, that produced the fatal result by sanguineous effusion upon the surface of the brain. When, in a living infant, there is great lividity of the face, and the actions of the heart are feeble and of lengthened intervals, there would be reason to fear that cerebral congestion was present. Just in such cases as this, death sometimes takes place without a single respiratory movement being made. 
When this congestion of the brain has continued for some 


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length of time, a sanguineous exhalation is effected upon the surface of the meninges, which, by coagulating, creates pressure on the brain, producing symptoms characteristic of apoplexy. But the effusion takes place most generally into the arachnoid cavity ; sometimes a very large quantity of blood is discharged there, and if death should speedily succeed, the blood will be found unchanged, but otherwise the serum and crassamentum become separated, and the latter, after a further time, loses its coloring matter and passes to the formation of a false membrane which is in close apposition with the parietal arachnoid. When the effusion has been inconsiderable, the serum becomes absorbed, and the only indication remaining to show that the disease has existed, is the false membrane lining a portion of the arachnoid. In the event the serum is not absorbed, it may become encysted, or it may continue in the arachnoid cavity, and if the quantity be great, the cranium may enlarge as in chronic hydrocephalus. 
The symptoms indicative of an effusion of blood upon the surface of the brain, are generally obscure. Paralysis may or may not be present, nor will the occurrence of convulsions, and their frequent repetition, or their alternation with spasmodic contractions of the extremities, be a sufficient indication disconnected from other circumstances and the general history of the child. If great feebleness in the manifestation of the vital forces has from birth characterized the child, the affirmative, under the symptoms above given, may be strongly suspected. Post mortem examinations prove these effusions to happen much more frequently with exceedingly feeble children than otherwise. 
Upon this subject, with adults, there is, even in the profession, a wide-spread error. It is in this: that a great fullness, of what is called health, with a large chest, small head, and short neck is associated with apoplexy, and that a constitution of a contrary character is, absolutely, exempt from it. Than this, no greater error could exist in the profession. We admit that active congestion is associated with the first; but apoplexy, from passive congestion, occurs with a class of men who are constitutionally and organically the opposite. We can give an illustration of this, attended by such circumstances as will forever impress it upon the mind of the reader. 


OF CEREBRAL DISEASE. 
263 
Sometime about the close of Januar}', 1840, .in Holly- Springs, Miss., A. H. Powell, Esq., called upon the writer for his phrenological opinion of himself. The said Powell possessed the sanguine encephalo-bilious constitution, with a very considerable preponderance of the encephalic element; accordingly, his head was large, neck long and slender, and chest small. The opinion given of him, by the writer, was written, and one of its items consisted of an injunction to avoid intemperance, particularly in the use of ardent spirits, or the consequence would probably be, at the close of some debauch, apoplexy. 
This opinion he exhibited to his medical friends, who assured him that such an organization was never known to have apoplexy—that the phrenologist might understand his subject, but that he could not be a well-informed physiologist. 
In a little more than two months, we received the following letter from Hon. J. W. Chalmers, which reveals the remaining history of this matter. 
"Holly Springs, Mississippi, 
Monday morning, April 6, 1840. 
"Prof. Powell: — Dear Sir —We had, on Saturday night, a most fearful confirmation of your foresight and discrimination in the phrenological opinion given by you upon the examination of the head of our distinguished professional brother, Alfred II. Powell, of Holly Springs. You will remember that you told him, on the examination of his head, and gave the same to him, in writing, that he was liable to apoplexy, particularly when recovering from an intemperate indulgence in ardent spirits. A. II. Powell was taken with a fit of apoplexy on Saturday night last at 10 o'clock, and expired about 7 o'clock next morning. The proximate cause was a hearty supper of coffee, meat, and pickled oysters, and as his attendant physician thinks, a predisposition caused by a drinking spell of some four days indulged at Hernando, the week before, but from which he had, to all appearance, recovered three or four days before the attack. 
" Your remarks upon his conformation and predispositions are the subjects of general remark in Holly Springs at this time, and Dr. T., who has settled with us, joins me in asking from you a more explicit statement of the developments and 


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mode of reasoning by which you arrived at a conclusion which has so suddenly and fearfully been confirmed. 
"I remain, etc., Jos. W. Chalmers." 
When a gentleman of Dr. T.'s professional attainments shall desire such information as called for in the preceding letter, it may be reasonably supposed that the mass of the profession has something to learn upon the general subject of apoplexy. If our opinion of his danger had been sustained by his professional friends, it is possible that he would have been still living. 
It is to us a matter of no little gratification that Dr. West sustains our convictions upon this subject.* We do not only maintain that passive congestion may take place in the adult brain, and produce apoplexy, but we can select those who are liable to it, when walking the streets of the city: and those who shall investigate the subject of the first part of this work, will soon find themselves competent to the same. 
Dr. West has illustrated his lecture on this subject with several cases, all of which took place in very feeble subjects. He would very greatly have increased the value of his illustrations by the addition of their temperaments or those of their parents. How much longer will this subject be neglected as it has been ? 
Cerebral congestion of this kind is very rarely attended with an extravasation of blood into the substance of the brain. 
The symptoms of this malady, in infants, are so obscure to those who are unacquainted with the temperaments and their combinations, and even those who are, can only have a wellgrounded suspicion of it, that but little indeed has, consequently, been discovered concerning its therapeutics. 
* The letter of Judge Chalmers shows that we taught, as early as 1840, the doctrine of passive congestion or apoplexy of the brain—that this disease could occur in persons of large heads, long small necks, and small chests, as ¦well as in those of a contrary organization. As early as 1840, we had never seen anything like such a doctrine announced, and if such a one had, at that time existed, we believe that a physician as well read as Dr. T. would have known it; and yet, we were so conversant with the subject, at that time, as to be able to select from any crowd those who were peculiarly liable to it, as we have shown by the letter of Judge Chalmers. If it can be shown that any one taught this doctrine, and described the class of persons liable to it, under specified circumstances, at a period even as early as 1840, then we shall abandon all claim to the right of discovery or priority. 


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Causes. — The difficulty with which respiration becomes established, in certain kinds of children, and the changes to be effected in the circulation, may, to some extent, enable us to understand how this apparatus should frequently become injected with blood to any degree, varying from the normal to the truly apoplectic condition. Among these difficulties, it may be remarked, that any cause which can impede the passage of the blood either into the right side of the heart, or from the right to the left side through the lungs, will produce it. Thus far the cause is mechanical, and of the same character must be considered those instances of cerebral congestion which result from pressure upon the jugular veins by a hypertrophoid thymus gland and enlarged tuberculated bronchial glands. But it sometimes occurs in feeble children without any assignable cause, and also in adults, having more or less the encephalic constitution, from slight causes, and sometimes, as in children, without any assignable cause. 
Although the shape of the head does not indicate, necessarily, the existence of any particular form of disease, yet it does indicate a liability to a certain range of morbid action, and therefore it always justifies a negative inference. When the cerebellum is very small and the hemispheres are, relatively, very large, we may feel sure that the acting form of disease is not active congestion of the brain, lungs, or any other part; and then, by a reference to the existing symptoms, the particular form may be arrived at. 
We may set down the remote cause of congestion to be, most generally, an inherent non-viable organic condition, and that any of the usual sources of irritation may bring it into action. 
Diagnosis.—In this form of disease, the neck, chest, and, of course, the cerebellum, are all small, while, relatively, the cerebrum is large and expanded at the level of the parietal ridge; and, instead of a flushed face, as in the previous species, it is livid, and all the symptoms indicate exceeding debility. 
Prognosis.—Always unfavorable. 
Treatment.—The indications to be fulfilled in passive congestion, are 1st. To divert the blood from the brain, which may be effected by purgatives, stimulants, and counter-irritation 


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to the spine and inferior extremities; 2d. To overcome the debility produced by the impression made upon the nervous system by the congested condition of the brain, as well as to increase the action of the heart, and which may be attempted by the administration of Quinine, Myricin, Xanthoxylin, and Hydrastin, in combination, as mentioned in the previous cerebral affections. 
Genus II. —Chkonio Hydrocephalus— 
Dropsy of the Brain. 
We have seen several crania of hydrocephalic subjects, and in every instance we have found the external surface marked with inflammatory indications. We have one of a Creek Indian boy, six years of age, which measures twenty four inches in circumference, and seventeen over the top of the head from one meatus to the other. The frontal suture is not only closed, but obliterated ; the other sutures are all complete— one squamous suture is entirely obliterated, and every portion of the surface indicates that the pericranium was in an inflamed condition. 
We have also the skull of a very intemperate Chickasaw Indian—it is remarkably thin, and so rounded at every angle, and so elevated in the hemispheres, that the original or Indian form of it is lost. Every suture is obliterated, except a portion of the right squamus; and every part of the surface bears the impress of pericranial inflammation. In such cases, there can be no doubt that serous accumulations existed in the brain, and such crania beautifully illustrate the physiological powers of the system to adapt the cranium to the changing condition of its contents. 
In those cases of hydrocephalus, in which the cranial bones continue separated, we suppose the absence of pericranial inflammation—with this inflammation the activity of the ossific process is truly remarkable. But, as to the Indian just mentioned, we have not been able to decide whether the result of his intemperance was cerebral hypertrophy or hydrocephalus— he was killed in the midst of his dissipated habits. The cranium is very thin. 
We are disposed to regard this case as one of hypertrophy of the brain, a frequent disease among those tribes who have 


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long had access to ardent spirits, and in all the crania of the kind we have seen, inflammation of the periosteum was an attendant. 
With a cabinet of five hundred crania, with some historical information of almost every specimen, it will be confessed that we have advantages which are rarely possessed by others, perhaps by no other individual in any country, we will be excused from digressing a little to drop such information as may, even remotely, elucidate our subject. 
The cerebral dropsy, as it increases, produces various modifications in the form of the cranium—it is perhaps never symmetrical. The basis cranii continues to preserve its normal length and breadth, at least without much variation or departure. The posterior lobes are developed upward and backward, the anterior, forward and upward, so as to rise perpendicularly above, or even projecting over, the face; the middle lobes increase outward and upward, while, in some instances, the hemispheres seem to spread laterally, giving the head a projecting aspect in every direction except upward—hence the top of the head appears broad and flat. 
In other instances, the hemispheres are carried upward, giving to the whole hemispherical portion of the head a beautifully-turned and normal aspect. But, in consequence of the child carrying its head more in one direction than in any other, or in resting more in one position than in any other, it is never equably balanced—one portion of one hemisphere appears more developed than the corresponding portion of the other. 
While the head is being thus developed with much more than normal rapidity, the facial bones are enlarged, usually, with even less than is common to health; hence, the contrast between the size of the face and head becomes so truly remarkable, as never to fail to excite the sympathy of the spectator. 
This variety of dropsy sometimes commences before the conclusion of intra-uterine life, and has so far progressed in some instances that the destruction of the fetus became essential to the preservation of the mother in parturition. Under the circumstance of a less accumulation of serum, the fetus is delivered unhurt; in other instances, this accumulation does 


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not commence until after birth, and then it may be procrastinated for a few weeks or even a few months. 
During the days of Dr. Gall, for the purpose of refuting his doctrines, it was gravely maintained that instances of hydrocephalus had been discovered in which the entire brain had been dissolved, and yet, the mental functions had been normally manifested to the close of life. 
Dr. Spurzheim, however, demonstrated the fallacy of this objection, by showing that in such cases as exhibited such an appearance, the brain was absolutely existing in all its integrity, but expanded into a membrane, of the extent of the internal parietis of the cranium. In the beginning of the disease, the fluid is contained in the cerebral ventricles, but they are, by the progress of the disease, lost in that general cavity which is formed by the extension of the brain into a sheet or membrane. 
In such a display of the disease, it becomes obvious that all the superficial fissures and all the convolutions must become lost in the process of cerebral expansion. 
We have thus conveyed an idea of the cerebral condition in a large majority of cases; in the exceptions the brain has not been unfolded, but is situated in the bottom of the cranial cavity, while the fluid is above it and in contact with the dura mater. It is not known that any essential difference exists in the disease, as manifested in these two dispositions of the brain. The first variety is known as internal hydrocephalus, and the second, as external hydrocephalus. Although the lateral ventricles present the greatest changes and are the most constant receptacles of the fluid, yet none of them are exempt from the invasion. The transparency and polish of their lining membrane become lost while their thickness and toughness are increased, showing that they have been inflamed. 
The symptoms of cerebral disturbance, in the advanced state of the disease, differ very greatly in different cases. Sometimes there is but little disturbance further than uneasiness and restlessness, with an occasional increase of temperature of the head ; in others, convulsions occur very often, and from very slight causes. In some instances, the patient lives to mature age and upward, with a respectable strength and soundness of the mental faculties ; but, in other cases, blind- 


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nes8, deafness, paralysis, fatuity, and idiocy may all supervene and continue for a period longer or shorter before death. 
It seems reasonable to suppose that these results are produced by pressure upon the brain, and if so, then there must exist a pathological difference between the two forms of disease. In that class of cases which is exempt from these terrible symptoms, the cranial sutures must be open, or else the constitutional power of maintaining a constant adaptation between the cranium and its contents, has become lost. In those cases of serous or dropsical accumulations in the brain from intemperance in the use of ardent spirits, the normal relation between the cranium and its contents is thoroughly maintained, and in these cases there existed an extraordinary activity in the process of ossific absorption and deposition— apparently an inflammatory condition of the pericranium. The same facts we have noticed to attend the cranium in cases of hypertrophy of the brain, and also in two cases of chronic hydrocephalus, in which all the bones were united and all the faculties were normally manifested. 
In another hydrocephalic cranium, with which idiocy or fatuity was connected, the volume of the head was contracted in the direction of each of the sutures, and upon it the marks existed, also, of a preternatural activity of the pericranium. If we should venture a conclusion from what we have observed, it would be this : that where the sutures are unclosed, and where the patient is restless and troubled frequently with an increase of temperature of the scalp, the mental faculties will maintain more or less their normal condition. 
Some instances have been observed in which the disease ceased to progress or become suspended, but the dropsy continued; that is, the fluid is not absorbed, the health becomes reasonably good, and the faculties continue fit for all the ends of society and business. In cases of hypertrophy of the brain, we know that the abnormal growth becomes absorbed, and that the internal table of the skull leaves the external and maintains its adaptation to the decreasing volume within. Now, why should this process never take place in hydrocephalus ? 
While it is unfortunately true, that almost every case of this disease proves fatal, yet it is equally true that all do not die 


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of the disease. All such patients possess a feeble constitution, and are, consequently, unable to contend with other forms of diseases when assailed; the consequence is, that many die of a disease which has no connection with the cerebral affection. 
Upon the treatment of this form, much has been taught, but very little has been effected. In the spring of 1835, Mr. P., a member of the New Orleans bar, invited us to see his little son, some six or seven years of age, afflicted with chronic hydrocephalus. We did not measure his head, but suppose it to have been about two feet in circumference, and rather flat or spread out on the top. In the succeeding January, we met the father again and inquired after the condition of his son, when he informed us that during the preceding fall he had an attack of yellow fever, which had had the effect to entirely arrest the disease—that he appeared to be in good health, and to have a prospect of doing well. 
In 1845, we met with a black child about a year old, which had chronic hydrocephalus, and as much health and strength as could be considered compatible with the existence of the disease. We desired of the owner, a gentleman of extensive information, the privilege of trying upon the child an experiment, which, as he had no expectation of its recovery, he readily granted. 
Under the hint we derived from the case of the boy in New Orleans, we prescribed the Sul. Quinine, in such portions and with such frequency as to maintain a pretty high arterial action. We continued this course some two or three weeks, or until we were admonished to cease by the fretfulness, feverishness, and loss of appetite of the child. Up to the time of our leaving the State, a period of four or five months, there had been no dropsical increase of the head—its mother and mistress regarded the disease as arrested. We have learned nothing of the case since; but, if it be true that the disease was arrested, it would not be safe to conclude that the arrest was effected by Quinine, yet the result suggests the propriety of a further trial, and we have had no opportunity since of making one. 
Causes. —This disease appears to be one of infancy, almost entirely, and one that appears under a considerable variety of 


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circumstances; it is sometimes congenital; sometimes from poverty or meagerness of the food or nourishment; sometimes from a sanguineous congestion of the brain; at other times, from some error in the cerebral circulation. 
" In the majority of cases, however," says Dr. "West, " the disease is not a mere passive dropsy, but is the consequence of a slow kind of inflammation of the arachnoid, especially of that lining the ventricles, which may have existed during fetal life, or not have attacked the child until after its birth." 
Dr. Wood says, that it is possible that the same condition of the blood that induces other dropsies may induce this. Suppose we admit it, and what do we gain % What caused that condition of the blood? We are disposed to attribute it, in most cases, to a direct want of organic vital force. This view has been sustained by our observation, but it has not been very extensive. 
Diagnosis.—A highly encephalic constitution has been mistaken for hydrocephalus, and normal depressions of the cranium have been mistaken for mechanical depressions — no diagnostic description can help such observers. It is said that it may possibly be confounded with hypertrophy of the brain, to which we refer for further information. 
Prognosis.—When hydrocephalus results from organic defect in the vital forces, its prognosis is decidedly unfavorable, and this condition can always be determined by the developments of the head, particularly the base. If the malady has followed scarlatina or some other febrile affection, more hope may be indulged—but still, the fact of its presence indicates a constitutional infirmity, which forbids, strong expectations of recovery. 
Treatment. —The indications of treatment in this affection, are, 1st. To arouse the action of the absorbent system, by a judicious administration of hydragogues, diuretics, and sudorifics; 2d. To give tone to the nervous system, by Quinine, or Quinine and Prussiate of Iron, with bathing of the surface followed by stimulating liniments ; and, 3d. To remove the morbid conditions of the various tissues which give rise to the effusion of serum, and for which we have found the following preparation to be decidedly the best: 


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Compound Syrup of Stillingia, f. 3 iv, Iodide of Potassa, 3ss; mix. 
Of this, twenty drops, three or four times a day, in a tablespoonful of water, may be given to a child five years old, or in proportion to age. 
The diet should be nutritious and not stimulating, and all sources of mental irritation, or gastric derangement, carefully guarded against. 
Compression of the head has been recommended in this form of hydrocephalus, but, from our own experience, we cannot 6ay anything in its favor. 
Genus III. —Cerebral Hypertrophy— 
Enlargement of the Brain. 
This disease we have not witnessed among children, but among our Indian crania we have a number of remarkable illustrations of its existence and recovery, through which we hope to explain some things with reference to its character. 
In treating of this disease, we shall extract from Dr. Watson's Practice all that is pertinent to our purpose. In speaking of the first case he saw of this affection in a female, he says: 
"She had been in the hospital scarcely a week, when she had a violent fit of epilepsy ; and when she was somewhat recovered, she told us, for the first time, that she was subject to such attacks. The convulsions recurred on the same day, and she became insensible, and remained during the whole of the next day, and until the evening of the day after, when she died. During this period of insensibility, she had many convulsive fits; the pupils were dilated, the pulse one hundred, small and feeble. 
"When the surface of the brain was exposed, by the removal of the skull-cap, and of the dura mater, it was observed that the convolutions were remarkably flattened, so that the little furrows between them were nearly effaced ; and the surface of the arachnoid membrane was perfectly dry. These are not very unusual, though they are unnatural, appearances. The ventricles were even smaller than natural, and contained scarcely any moisture. The skull-cap was afterward examined, 


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and the bone was found to be uncommonly thick, dense, and heavy; and its inner surface, without being rough, was very irregular." 
We must here pause to notice one fact contained in the preceding extract; the skull was found to be "uncommonly thick." It may be stated as a law, to which there are no exceptions, that no part of the cranium will ever become thick so long as it is under the influence of pressure. In the temples, the brain presses against the bone on the inside, and by the temporal muscle on the outside, and the cranium, at this part, is always thin, when compared with parts that are differently circumstanced. The supra-orbitical plates are thin ; they are pressed upon by the anterior lobes on one side, and by the globe of the eye and its muscles on the other. The base of the occipital is in the same condition. 
With regard to other portions of the cranium, twenty years of observation, under the most favorable circumstances, enable us to assert, without the most remote fear of successful contradiction, that so long as even normal pressure, such as is furnished by a healthy activity of the brain, at the indicated point, the skull will continue thin, and that just as soon as that part of the brain shall, to any extent, cease to act, it will become atrophied or smaller — just as will an unexercised muscle — and that to the Bame extent will the skull increase in thickness; and we further assert, that this law continues the same under abnormal as well as normal circumstances. The remembrance of this law will serve us important purposes in all of our examinations of cerebral conditions. 
According to this law, there was no pressure upon the internal surface of the skull alluded to in the above extract, at the time of the bony deposit. The cranial hypertrophy may only have commenced when she became insensible, as the brain may then have ceased to act. 
To illustrate and confirm the truth of this opinion, we will give the history of one which bears directly upon the point before us: 
A Choctaw Indian, in Yicksburg, Miss., some years since, in a drinking scrape, was struck upon the side of the head and felled to the ground. Eight days afterward, he was found 
18 


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in the woods, a mile or two from the city, in a comatose and expiring condition. "We have his skull; it was extensively fractured—extending from the base of the left sphenoidalwing obliquely upward and backward, crossing the parietal ridge, and terminating within an inch of the sagittal suture. The edges of the fracture, at about its middle, are separated about the sixteenth of an inch, at which part the original thickness of the skull is clearly discoverable, and the bony matter deposited upon the inner surface, after the infliction of the injury, is nearly equivalent to the original skull. 
In this case, coma succeeded to the injury, and a suspension of the cerebral action was the immediate result, and to this succeeded cerebral absorption, which was attended with cranial hypertrophy. However we may explain the phenomena, the fact is, that the thickness and weight of the skull were nearly doubled in eight days. When absorption of the brain commences, no matter from what cause, a plenum is soon produced, and the internal table of the cranium adapts itself to the decreasing volume of the brain. 
Now, in the case of the woman before us, there was, no doubt, pressure on the brain, and that it occasioned the insensibility, the absorption of the brain or some of its fluids, and the thickening of the skull; and this pressure may have been produced by congestion, a circumstance which the doctor overlooked. 
But where is the proof that this was a case of hypertrophy of the brain i He has not made a statement in proof of it, and the symptoms do not demand the admission of it, and hence we would as soon believe that he was mistaken as to take his word for it. 
He proceeds: " Laennec, also, in Corriesart's Journal, states, that upon opening the bodies of persons whom he had thought affected with hydrocephalus, he had been surprised at finding a very small quantity of fluid in the ventricles, while the convolutions on the surface of the brain were strongly flattened ; proving that the cerebral mass had undergone strong compression, which could only have arisen from its preternatural volume and undue nutrition." 
We shall find good reason for not being surprised at this, without the admission of hypertrophy, before we conclude. 


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" Beside the characters we have mentioned, the hypertrophied and compressed brain is firmer and tougher than natural ; it contains but little blood; and sections of it seem to be unusually dry and pale. 
" In several of the cases of hypertrophy recorded by authors, the patients had suffered epileptic fits, or rather paroxysms of convulsion; and in some the convulsions terminated in paralysis. Andral states, that the intellectual faculties have been observed, in some instances, to become dull and obtuse. Many of the patients were subject to severe headaches. All these symptoms are common to various cerebral complaints. The diagnosis of this rare disorder can be no better than conjectural, and its treatment we have still to seek." 
"Andral remarks, what is very true, that hypertrophy of the brain, i. e., an undue and disproportionate development of that organ, may, and does, happen without giving rise to any morbid phenomena at all. But, in such cases, the brain-case is equally enlarged in capacity ; so that no pressure upon the cerebral mass results from its own preternatural growth. It is only when the brain increases faster than the bony sphere which contains it, that the hypertrophy becomes a disease. In my patient, there was, also, in one sense, a hypertrophy of the skull; the bone was considerably thicker, and more compact and heavy, than is usual; but the capacity of the cavity had not undergone a proportional augmentation ; nay, it might, for anything I know, be diminished in consequence of the increased thickness of the bone; the case may have been one of concentric hypertrophy of the bone, without any fault of the brain itself; but what makes this the less probable is, that in other cases, the skull has been found of the ordinary thickness and density, but too small for its contents." 
We may possibly fail to shed any light upon the special character of the disease under consideration, but we feel confident that we can illuminate some of the darkest spots connected with cerebral physiology, and therefore remove some of the heaviest clouds that beshadow cerebral pathology. The preceding paragraph is replete with error and doubt—we do not make this remark with a fault-finding spirit, because no one can be expected to know more than his advantages would or could dictate—and, upon the physiology of the skull 


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and its relation to the brain, we have found the truth only in our eabinet of crania, which was obtained from various races, tribes, and clans, and in divulging its developments we only liquidate, in some measure, the many obligations we are under to the profession. 
What proof has Andral that hypertrophy exists where there are no morbid phenomena ? By what rule does he judge of it ? Is it not true that there is a physiological harmony in every system in a state of health ? Does not a lesion of this harmony, however insignificant, constitute a pathological state ? Was it not in the laws of this harmony that Cuvier was enabled to determine the species of an animal by a fragment of its skeleton I He admits a perfect harmony between the skull and the brain, and yet, because the brain is large, it is a case of hypertrophy ! 
We have shown that the lymphatic and encephalic temperaments have large heads, and we have shown that the progeny of sanguine bilious-lymphatic parents have also large heads ; but these facts belong to whole classes, and therefore they are normal, however disproportionate they may appear to Andral or other persons. We venture to assert, that we have examined more heads than Andral ever did, and yet we have seen no such cases of cerebral hypertrophy. 
Dr. Watson does not seem to be certain that a hypertrophy of the skull, by diminishing its cavity, might not have produced the suffering and the fatality in the case of the woman which he reports —that the brain may not have been at fault. If the profession at large have as much to learn upon this subject as Dr. Watson — and so far as we have learned, they have —they are certainly unfit to judge of cerebral disease. 
We shall now state a circumstance, and assert it to be unqualifiedly a fact, viz: The skull is subordinate to the brain— it holds the same relation to the brain that the bark of a tree does to its ligneous matter. If the brain wants room, the skull provides it and becomes thinner—if the brain becomes smaller, the cavity of the cranium becomes smaller and the skull thicker. This law holds good both in health and disease. 
The doctor states, that it is only when the brain increases with more rapidity than the cranial cavity that mischief 


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ensues. "We deny the whole of this proposition, and repeat, that when the brain wants room the physiological forces produce it. He speaks on the subject as though the skull was an unyielding and lifeless box, and not under the control of the vital forces. 
We would first correct the language of Andral, and then explain the difficulty of Watson. When the head is disproportionately developed, without congestion or inflammation, it is normal; and when attended by either of these phenomena, it is abnormal or diseased. With reference to Dr. Watson's difficulty, we say, that the diseased phenomena which attend the last variety of hypertrophy, are occasioned by the turgescence and inflammation consequent upon the disease and the cranial absorption and replacement. Whenever coincident inflammatory action is set up between the cerebral meninges and the pericardium, a deposition of cerebral or other matter is effected on one side, and bony absorption and replacement take place on the other; consequently, as one process increases the magnitude of the contained part, the containing part maintains a precise adaptation to it. Thus, in chronic hydrocephalus, the cavity of the cranium enlarges in proportion to the fluid accumulation. 
And, further, there is no proof that undue pressure is ever made upon the brain in this form of disease; and the only conclusive proof of it would be the discovery of a hypertrophied skull, upon post mortem examination, and this, we believe, has not been done; because, just as soon as pressure should be made by the skull, upon the principle of the bandage, an absorption of the brain or fluid would commence, and with this would commence a hypertrophy of the skull. 
We have the hemispherical portion of the cranium of a man who died in a lunatic asylum, and who, for some time previous to his death, had been in a state of almost complete fatuity. A brain in a condition so inactive, would necessarily decrease very much in a comparatively short time; and, if our doctrine be true, that the external table of the skull, in an atrophy of the brain, remains stationary, and the internal one maintains a close adaptation to the brain, it would follow that this skull should be unusually thick ; and so it is—generally equal to three-eighths of an inch in thickness and very heavy. 


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We have two crania which show very conclusively that the subjects had had hypertrophy of the hemispheres of the brain and recovered from it. One was a female Hitchetee Indian, of whose history we know nothing, except that she died of the small-pox ; the other was a Chickasaw Indian. Upon obtaining his skull, we became exceedingly anxious to obtain so much of his history as might explain the hypertrophied condition of the whole superior portion of it. We obtained the assistance of a white man who had lived several years in the neighborhood of this subject to assist us. Those Indians who knew him, represented him as " moping about," unfit for any pursuit, and living at the expense of his relatives and friends—and that this diseased condition continued some three years when he recovered, and in six or seven years more he died of cholera. All parts of the cranium indicated the normal thickness, except at the superior portions of the hemispheres, where the space between the tables were equal to three-eighths of an inch. The external surface, over this hypertrophied portion, bore evident marks of pericranial inflammation. The following cut represents a transverse section of it, just anterior of the coronal suture: . 
To account for this peculiarity of the cranium, we must conclude, that as he recovered, the hypertrophied portion of the brain was absorbed, and as the absorbing process went on, the internal table of the skull left the external and adapted itself to the decreasing volume within. The female skull is marked in precisely a similar manner. That the brain had been hypertrophoid, the external figure of the skull left no doubt. It is said, by writers, to be difficult to form a diagnosis 


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between this disease and chronic hydrocephalus, but this we think to be a mistake, at least, in many instances. 
In the latter disease, as the head enlarges, all the parts of the cranium change their distances from the fixed points—such as the meatus auditorius externus ; the parietal ridges become more elevated; but this is not the case in hypertrophy of the brain—the enlargement is located, usually, between the two parietal ridges, and rises in a manner which no phrenologist would mistake for a normal development. 
Normal atrophy of the brain, or such as is produced by a neglect or inactivity of the atrophied part, presents no sign external to the cranium, but the internal table leaves the external precisely as it does in cases of recovered hypertrophy. 
Atrophy of the brain, more or less general, is quite common among plantation negroes, resulting from an absence of mental excitement, and, of course, of cerebral activity. Having but few cares or responsibilities, there is nothing connected with their condition to rouse and maintain cerebral activity. All ethnologists, we believe, assign to the negro a thick skull; but this is an error ; free negroes, as a class, have as thin crania as free whites of the same grade of mental activity. 
In civil society, because of a division of labor, partial atrophy, or atrophy of some portion of the brain, exists more or less in every individual, but, in savage life, where the pursuits of one individual are common to the tribe, the skull presents a uniform thickness. 
As to normal development of the brain, in adult life, or such as is produced by mental activity and toil, we have no indication, except the thickness of the cranium, or measurements of the head made at different periods. Some facts of this latter kind which exist are truly remarkable. 
We have dwelt upon the various conditions of the cranium, in several cerebral affections, at considerable length, because our investigations, in this wise, and our advantages have been very extensive, and because the full advantage of post mortem examinations of cerebral affections cannot be had without a correct idea of cerebro-cranial physiology; and, lastly, because no one can pathologically understand the disease under consideration, without the information we have detailed. 


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" It is of some importance for you to be aware that the brain, and its case, may be extravagantly developed without there being any disease, or any symptom of disease. M. Scantetlen gives an instance of this which he observed in a child five years old. Its head was as large as that of a wellgrown adult person." 
Such language as this, with reference to the head, is not only faulty, but calculated to propagate and perpetuate error in the popular mind. Let it be remembered then, that the cerebellum alone, and not the cerebrum, is developed in relation to the body. A large man may have the little cerebrum of an idiot, and a little man may have the large cerebrum of a Napoleon. In brief then, the cerebrum is always developed, not in harmony with the body, but in relation to the mental functions. 
" The skull was from a line and a half to two lines in thickness." 
A skull of this thickness, in a young person, has never as yet been known to contain a sound brain, or rather a brain that has always been sound. No amount of human testimony could affect our opinion on this subject. Human testimony must never be brought to bear against natural law. 
" The dura mater adhered firmly to the bone," [Does this show that there had never been disease ?] " and the cerebral mass exactly filled up the cranial cavity. The superior and posterior part of the brain was developed beyond measure, so that to reach the ventricles it was necessary to make an incision nearly three inches in depth. There was nothing unusual to be remarked in any of the cerebral functions of this child; it was just like other children of the same age in respect to intellect. It died of inflammation of the bowels." 
The thickness of the skull, in this case, is to us a demonstration that the hypertrophied brain was in progress of absorption at the time of its death, and probably had been for some time ; and the firm adhesion of the dura mater to the skull, shows that inflammation had existed. But, of all the evidences that can be had of the present or previous disease of the brain, the external surface of the skull invariably presents the most indubitable. No adequate idea of these indications can be conveyed by description, but when 


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once recognized, they will never be forgotten. And what appears singular to us, is, that no writer, so far as we have seen, has noticed these cranial evidences of disease. 
" The majority of cases of hypertrophy of the brain that have come under my notice, in London," says Dr. West, " have occurred in infants about six or eight months of age. Their history has usually been, that, without any definite illness, they had lost their appetite, and grown by degrees dull and apathetic, though restless and uneasy. Notwithstanding the general apathy, this restlessness is often very considerable, though it does not show itself in cries so much as in a state of general uneasiness, and in frequent startings from sleep. Short gleams of cheerfulness occur when the children are awake, but these are usually very transient. The head seems too heavy to be borne, and even when its size is not much greater than natural, it hangs backward, or to one side, as if the muscles were too weak to support it. If placed in its cot, a child thus affected bores with its occiput in its pillow, while its head is almost constantly in a state of profuse perspiration. Convulsions sometimes occur without any evident cause, but threatenings of their attack are much more frequent than their actual occurrence, the child awakening suddenly with a start and a peculiar cry, like that of spasmodic croup, the surface turning livid, and the respiration becoming difficult for a few moments, and the symptoms then subsiding of their own accord. Such attacks may issue in general convulsions, which may terminate fatally; but infants thus affected do not by any means invariably die of the cerebral disorder, but being weakly, they are often cut off by the first malady that attacks them. 
" If life be prolonged, it becomes more and more evident that the process of nutrition is imperfectly performed; the child loses flesh, and looks out of health, and an enlargement of the wrists and ankles shows the connection between this disease and rickets—a connection which becomes more evident in the second and third years of the child's life. When the child survives infancy, or when, as occasionally happens, the symptoms of hypertrophy of the brain do not come on until dentition has been in a great measure accomplished, convulsions are of very rare occurrence. Complaints of headache, 


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however, are frequent and severe; and, though drowsy in the daytime, the child generally rests ill at night, and often awakes crying and alarmed. Beside these symptoms, too, the child has occasional attacks of feverishness, with great increase of the headache, and giddiness, which last for a few hours or a day, and then subside of their own accord, while it grows by degrees more and more dull and listless, and its mental powers become obviously impaired. 
" You must not infer that hypertrophy of the brain has existed in every instance in which the organ may appear to be large, and its convolutions somewhat flattened, although the ventricles are free from fluid. The weight and apparent size of the brain are much influenced by the quantity of blood contained within it, and it may appear too large for the skull, simply because its vessels are over full. In true hypertrophy, on the contrary, the brain is generally pale and anaemic, unless death should chance to have taken place as the result of an attack of cerebral congestion. Neither, indeed, is the process one of mere increased growth of the organ, but the nutritive process is modified in character as well as increased in activity. The gray matter of the brain is but little involved in it, and, with the exception of its color, being somewhat paler than natural, it shows scarcely any alteration. The white matter, on the contrary, is both paler and firmer than in a state of health ; and Professor Rokitansky states, as the result of many microscopic examinations, that its augmented bulk is not produced either by the development of new nervous fibrils, or by the enlargement of those already existing, but by an increase in the intermediate granular matter. These changes, too, do not affect indifferently all parts of the brain, but are confined to the hemispheres, implicating neither the base of the organ nor the cerebellum.* 
" The history of the patient would afford some help toward determining whether the disease be hydrocephalus or hypertrophy, for the symptoms of the former generally come on earlier, and soon grow much more serious than those of hypertrophy of the brain, and the cerebral disturbance is throughout much more marked in cases of the former than in those of the 
* This remark is in harmony with an opinion we have given, and with the cut that illustrates it. 


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latter kind. The form and size of the head, too, present peculiarities by which you may often be enabled to distinguish between the two conditions. Both forms of disease are attended by enlargement of the head, and in both the ossification of the skull is very tardy,* but the head does not attain so large a size in hypertrophy of the brain as in chronic hydrocephalus, neither are the fontanelles and sutures so widely open." 
Our author, Dr. "West, now gives some descriptive views, upon which we shall offer a few comments, and therefore this call of the reader's attention. 
" The skull, likewise, presents some peculiarities in form, which are so remarkable as to have attracted the attention of several observers, though I must own that I do not thoroughly understand how they are produced. The head not merely shows no tendency to assume the rounded form characteristic of chronic hydrocephalus, but its enlargement is first apparent at the occiput, and the bulging of the hindhead continues throughout especially striking. The forehead may, in the course of time, become prominent and overhanging, but the eye remains deep sunk in the socket, for no change takes place in the direction of the orbiter plates, such as is produced by the pressure of fluid within the brain, and which gives to the eye that unnatural prominence, and that peculiar downward direction, which are so striking in cases of hydrocephalus. In hydrocephalus, the anterior fontanelle is tense and prominent, owing to the pressure of the fluid within, but when the brain is hypertrophied, there is no prominence, but an actual depression in this situation. I have more than once observed this condition, in a very remarkable degree, the depression not being limited to the anterior fontanelle, but being observable at all the sutures; and you may notice something of the kind in this cast." 
We have never seen this peculiar form of head in either the white or red race of the American population, but we have frequently seen it in the black. Persons having such a head, are said to be double-headed. As often as we have seen this 
* We have, in our cabinet, the most irrefutable evidence that cranial ossification is exceedingly active in chronic hydrocephalus. 


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form of head, we have never known it to be attended by any morbid symptom; and, although the occipital and frontal regions appear, in some cases, very much developed, yet the great depression across the head, involving the coronal suture, in such cases, has been so great, that we have considered the quantity as normal, but forced fore and aft, by the depression. We have not comprehended the physiological cause of this depression, but finding it unattended by any symptom of disease, we have concluded, that whatever the cause might be, it acted in harmony with cerebro-cranial sympathy. 
" When hypertrophy of the brain occurs in adults, the symptoms that arise are, in a great measure, due to the compression which the organ undergoes from its bony case being too small to contain it. These symptoms are, of course, obscure, while, even if the nature of the affection cannot be recognized, its cure must be hopeless." 
We very much dislike this mechanical mode of reasoning about vital processes. Every mill-boy knows, that if an unyielding saddle be placed on a horse's back, in a short time the back is moved away from the saddle. Every physician knows, that if an unyielding bandage be placed so tightly on a well finger as to make pressure, the finger is speedily absorbed, and that the process produces no pain, except at the time reaction is taking place. Suppose then, that the skull was to make pressure upon the brain, how long would it last ? Only one or two hours, and then would commence an atrophy of the brain and a hypertrophy of the skull. 
While we repudiate the idea of cranial pressure upon the brain, we admit that there is pressure in it. The cranium, during life, is always ready to accommodate the brain with space or room when it is demanded, either in health or disease. The brain, under mental action and industry, enlarges, much more sometimes than the thickness of the skull—why, in these cases, does the brain not suffer because of the unyielding character of the skull ? 
Dr. West, furthermore, thinks this disease would be hopeless in an adult; but in this, we think, he is mistaken, inasmuch as we have the crania of two adults who did, spontaneously, recover from it. 
Beside the various symptoms we have named, we may add, 


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profuse perspiration of the head, which is "effectually checked," says Dr. West, " by a thin linen cap which may be removed once or twice during the night." As we approve of the practice of Dr. West, in this disease, we cannot do better than to extract it: 
" The remedies, under the continued use of which 1 have seen the most good result, are the extract of bark, from which you might pass to the preparations of iron—such as Vinum Ferri, or that very elegant syrup of the Ferro-citrate of Quinine. I have not made much trial of the Iodide of Potassium, since, in all the cases that I have seen, some more decided tonic appeared necessary. I have, however, given the syrup of the Iodide of Iron sometimes with advantage, and, in cases where the tendency to rickets was well marked, I have observed a most decided improvement follow the use of Codliver Oil, in doses of a drachm twice a day, for a child three years old. I may just mention, that, notwithstanding its nauseous taste, this medicine is usually readily taken by children, some of whom even become fond of it. 
" With reference to diet, it will probably be desirable, if the child be not weaned, to obtain for it a healthy wet nurse, while after weaning, a diet of milk, with an egg once or twice daily, will often agree better than any other food. In cases of this kind, and, indeed, in all where the digestive powers are feeble, a preponderance of farinaceous food is not desirable, while the child may with safety be allowed a little veal-broth or beef-tea daily, or even a little meat if it have cut some of its molar teeth." 
Genus IV.—Hydkocephaloid Disease. 
Debility of the Brain. 
This disease was first described by Dr. Marshall Hall, and he named it as above expressed. It bears considerable similitude to that condition of the brain which follows excessive venesection, hemorrhage, or purging—such as extremely painful headache and other symptoms of encephalitis. He divides it into two stages ; the first, he calls that of irritability, and the second, that of torpor. He says: 
" In the former, there appears to be a feeble attempt at reaction ; in the latter, the powers appear to be more prostrate. 


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These two stages resemble, in many of their symptoms, the first and second stages of hydrocephalus, respectively. 
" In the first stage, the infant becomes irritable, restless, and feverish; the face flushed, the surface hot, and the pulse frequent ; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise; there are sighing or moaning during sleep, and screaming; the bowels are flatulent and loose, and the evacuations are mucous and disordered. 
"If, through an erroneous notion as to the nature of this affection, nourishment and cordials be not given, or if the diarrhea continue, either spontaneously or from the administration of medicine, the exhaustion which ensues is apt to lead to a very different train of symptoms. The countenance becomes pale, and the cheeks cool or cold; the eye-lids are half closed ; the eyes are unfixed, and unattracted by any object placed before them, the pupil unmoved on the approach of light; the breathing, from being quick, becomes irregular and affected by sighs; the voice becomes husky, and there is sometimes a husky, teazing cough; and eventually, if the strength of the little patient continues to decline, there is a crepitus or rattling in the breathing ; the evacuations are usually green ; the feet are apt to be cold." 
Any circumstance that can undermine and break down the vital forces of the system, may produce this affection, more especially if, previously, the encephalon has suffered from any variety of disease; a circumstance of this kind acts as a predisposing cause. Premature weaning, more especially if followed by such diet as may so derange the nutritive function as to produce marasmus, or some special disease for the removal of which exhausting remedies were pushed too far, may occasion those symptoms which constitute this disease. 
When such symptoms as we have described shall be present, it may be impossible to determine from them alone whether the complaint be acute hydrocephalus or the hydrocephaloid disease. In such an event, we should seek the family diathesis of the patient, and the history of its various forms of disease ; in this wise we may become able to determine whether we are called upon to treat a case of threatened encephalic exhaustion, or exaltation. Which ever way the 


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mistake might be made, it would be equally fatal to the patient. If the family of the patient be clear of a scrofulous diathesis, if cerebral forms of disease have not been common to the family, and more especially to the patient; if, furthermore, the patient has had bad health since being weaned, or has been weakened by venesection, hemorrhage, or diarrhea, then we may pretty safely conclude that the patient is suffering from hydrocephaloid disease. 
It is possible to mistake the consequences of an over treatment of cerebral congestion for a continuance of the disease, instead of exhaustion. In cases of congestion of the brain, if the patient be an infant, we would find the anterior fontanelles tense and full, instead of being depressed, as they certainly would be in case of exhaustion. Diarrhea and symptoms of cerebral disturbance are very apt to run together, hence it is proper to guard against mistaking such as are really consequent upon a diseased condition of the bowels, from such as might indicate cerebral congestion or the hydrocephaloid affection. As it would be proper to treat the diarrhea, a proper vigilance over the case will soon determine the character of the cerebral symptoms. 
In the treatment of infantile forms of disease we should always have before us the possibility of inducing the hydrocephaloid disease by heroic treatment, and by the history of the patient's condition before the arrival of the physician, the difficulty of diagnosis, from the symptoms in the abstract, may scarcely have to be encountered. 
Treatment.—The only useful treatment in this disease, is the administration of Iron and Quinine, generous and nourishing diet, and all means calculated to increase the quantity and quality of the blood, and to invigorate the nervous system. 


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ORDER III. 
NERVOUS FORMS OF CEREBRAL DISEASE. Genus I. —Epilepsy. 
This form of disease, when idiopathic, is, beyond all question, cerebral; but, when symptomatic, it may frequently result from spinal irritation. A paroxysm or convulsion may occur, having all the features of epilepsy, and not be epileptic, but when it shall frequently recur at irregular intervals, and for months or years, and without any evident cause, then the name epilepsy is given to it. It is a disease of all ages, but that which immediately precedes puberty, seems to be most liable to it. 
The paroxysms are marked by a loss of sensation and consciousness, with convulsive motions of the muscles. Most generally the fit attacks suddenly or without the least premonition ; at other times, it is preceded by pain in the epigastrium, or vertigo, or stupor; sometimes a sensation like a cold vapor is experienced, which, arising in some part of the body, travels toward the head, and upon reaching it the patient falls to the floor. 
The most usual duration of a fit, is from five to twenty-five minutes, but sometimes it is protracted for hours. In all cases, there is a sudden falling, loss of consciousness, distortion of the face and eyes ; complexion of the face, in the white race, red, purple, or violet; foaming at the mouth: convulsions of the limbs, grinding of the teeth, by which the tongue and cheeks are frequently badly injured; difficult respiration, and occasionally involuntary discharges of urine and faeces. 
When the fit has passed off, the patient has not the least recollection of having had it, but complains of headache, looks stupid and wearied. 
Causes and Diagnosis.—Dr. Marshall Hall is of the opinion that epileptic seizures are produced by a compression made upon the jugular veins by the platysma and other cervical muscles. He states, as evidence in support of this opinion, that the paroxysm consists in a fixed condition of the head and eyes, dilated pupil, and deep flush. We have shown, in the first part of this work, that idiopathic epilepsy, at least, is 


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always associated with a full development of the lateral portions of the cerebellum, particularly of the organ of muscular motion. 
It will be remembered, too, that we have shown that apoplexy, when resulting from active congestion of the brain, is connected with the same condition of the cerebellum; and Dr. Hall contends that there is no difference between epilepsy and apoplexy, in their milder forms—that the first degree of both of them consists in trachealismus — a spasmodic action exhibited in efforts upon the venous circulation of the face and brain. 
We have also shown that idiopathic rheumatism is associated with a high endowment of the organ of muscular motion and of the medulla oblongata; hence, when the blood becomes highly charged with urea, through a fault of the kidneys, rheumatism may result, and epilepsy is said sometimes to be produced in the same way; it would seem then, that between an epileptic and a rheumatic constitution, there is some affinity. 
As a loss of consciousness is the most important symptom in epilepsy, and as such a loss cannot be effected by any condition of the spinal cord, Dr. Todd concludes that epilepsy must be a disease of the cerebrum, and after a consideration of the function of various parts of the encephalon, he concludes that the gray substance is the primary and proper seat of epilepsy, because he considers it to be the seat of consciousness. If he include the whole surface of the cerebrum in the function of consciousness, to what portions of the brain will he refer the fifty other functions which the mind is known to manifest ? If this whole surface act as a single instrument, how does it happen that a loss of a portion of it does not impair its function ? It is our opinion that phrenology is now too well established to allow of such a pretension. 
We are of the opinion that phrenological inference and vivisections both authorize the conclusion that the source of consciousness is situated in the base of the brain, and possibly in the mesocephale; and Dr. Todd is of opinion that this portion of the brain may be secondarily affected. But if it be the seat of consciousness, then it must be primarily affected. But as to how it is affected, unless it be by congestive pressure, 19 


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we know not, and mere speculation on the subject can be of no avail. 
If epilepsy ever occurs in those who have a small thorax and neck, it must be similar to the passive variety of apoplexy, of which we have given an admirable illustration. If it ever do occur in such subjects, then Dr. Hall's views are still more confirmed, and the distinction we have pointed out between the two classes of subjects, must be attended with important practical results. 
Dr. Todd gives it as his opinion that epilepsy consists in an abnormal nutrition, which manifests itself in an unnatural development of force at particular times ; and Dr. Hall believes that epilepsy and apoplexy are the same during their first stage, and it is admitted that the latter is both active and passive. 
Now, we desire to know how it is possible to reconcile Dr. Todd's development of nervous force with both of these conditions. Though we have never seen a case of anaemic or passive epilepsy ; yet, we cannot doubt that it may occur, if the explanation of Dr. Hall is at all reliable. 
The known causes of epilepsy are various, and so are, no doubt, the unknown. In some families, it is hereditary, and in many instances the predisposition is such as to make it depend upon the exciting cause as to whether it shall break out in the form of rheumatic mania or epilepsy. The apparent health of the patient seems to have but little to do in the production of the malady—attacking almost indiscriminately the feeble and the strong. It is frequently occasioned by a fall or blow on the head; also by a fright or terror, and, lastly, by the presence of worms in the alimentary canal. 
Prognosis.—As to ultimate recovery, it is unfavorable without it is attended to at an early period—it does not much endanger life, but it does worse—leads to imbecility. Under such a prognosis, convulsions, in young children, should receive every possible attention, in order to prevent the formation of an epileptic habit in the system. A mischievous reliance is too frequently placed upon the changes which puberty brings about in the removal of this affection. 
Treatment. —It is always essential, in the treatment of this disease, to remove the cause if possible. During the paroxysm 


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but little can be done ; we think that we have sometimes shortened the fit and lessened the subsequent headache and lassitude by dashing cold water over the head, face, and neck. One thing is certain, we have not found it best to indulge the patient in a horizontal position or a sleep after a fit. 
It will be well, if practicable, to introduce a piece of soft wood between the teeth at the beginning of the fit to prevent injury to the tongue and the inside of the cheeks. If the fit has been occasioned by indigestible food, the remedy is obvious, and whatever may have been the cause, indigestible and trashy food will provoke an increased frequency of its recurrence. Any cause of mental irritation can increase its frequency, such as disappointments, children's quarrels, parent's scoldings, etc. 
Whatever the cause may have been, the treatment must be directed to two general objects, the first to break up and abridge the paroxysm, and the second, to prevent its recurrence. 
With reference to the first, it is not generally requisite to attempt anything, as the paroxysm usually passes off in a few minutes ; but when the paroxysm continues longer than usual, or becomes much more alarming or apoplectic, it will be judicious to attempt some relief by the application of cold water, in any convenient form, to the head, and hot water, frictions, and rubefacients to the extremities. 
Beside these external means, injections may be administered, consisting of the Tincture of Castor, or Asafoetida, with a decoction of Scutellaria. If the case be one of infancy, the warm bath may prove highly beneficial. Should the paroxysm be attended with apnoea, Camphor or ammoniacal liquids may be applied with some good effect to the nares ; and in the event of suspended respiration, it will be advisable to direct through the diaphragm an electro-magnetic current. 
When the paroxysm is over, in many instances, it is best to rouse the patient to a vertical position, to prevent sleep ; while in other instances, a contrary course may be the most advisabl —experience must decide this question in all cases. 
All our hope of effecting a cure must rest upon our skill and exertions during the intervals we obtain between the paroxysms, and upon our discriminations as to its nature or 


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true character; for it may be only sympathetic, depending upon disease in some other part; or it may depend upon certain organic relations in the encephalon ; and it may depend upon such a diseased condition as to render the recurrence of the paroxysms periodical. 
The second variety is the only one that is considered to be incurable; but even in this, we are not willing to admit the idea of incurability, because organic relations can be changed by proper exercise or training ; indeed, we are not willing to admit the incurability of any disease, in the abstract, because disease is not a constituent element of life—we only admit our ignorance when we fail to cure. 
Our first duty, without reference to the original character of the disease, is to investigate the present state of health, and if we find it vitiated, then we must regulate and repair it, and while engaged in the discharge of this duty, we may discover, in connection with the history of the case, enough of its nature or special character as to guide us in our subsequent practice. 
So far as we have observed, the second variety of this form of disease is associated with an imperfection of the respiratory function, as is indicated by small and contracted nostrils, and the same remark is applicable to apoplexy — exceptions may exist, but we have not seen them. If this view be correct, we cannot, so unqualifiedly as has been recommended, place the patient upon an exclusively vegetable diet. Farinaceous food must increase the difficulty, and so will all highly carbonaceous food—we suggest, therefore, that the diet should consist of succulent vegetables, vegetable and animal albumen, and the fibrinous portions of animals. 
Beside generally impaired health, there may be a troublesome source of irritation—during the first dentition — the revolutionary period of infancy, they are many, and at a later period of life, there may be others of equal magnitude, as family discord, and all such subjects as can disturb mental equanimity. So long as obvious causes of irritation exist, it is idle to attempt a cure. 
The remarks we have made might be considered to embrace all causes of irritation, but it may be proper to be more specific. In epileptic patients, without any reference to the cause, 


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there is generally present some variety of derangement in the digestive system —the appetite is precarious—sometimes voracious—sometimes fastidious —craving improper food. Under such variations of the appetite, we may naturally expect gastric acidity, difficult digestion, and imperfect nutrition. 
Sometimes helminthic irritations prove to be the whole cause of the disease; at other times, a diseased condition of the spleen, or suppressed menstruation, may be the only cause. When, therefore, we can reach the cause, we have only, in a great measure, to remove it to cure the patient. 
When the paroxysms recur periodically, the case should be considered as curable by a perseverance in the use of antispasmodics and antiperiodics; but even their use is contraindicated, until the constitution shall become elevated above a generally morbid or vitiated condition. In the use of the former class of remedies, such should be selected as are calculated to maintain a constant determination to the surface; perhaps Valerian, or Black Snake-root, administered in a syrup of Ginger, would fulfill the indications. To break up the recurrence of the paroxysms, a combination of Quinine, Leptandrin, and Hydrastin, will answer every general purpose, where they assume a periodic condition. In cases of anaemia the Prussiate of Iron will be found to be a very valuable adjunct. 
Dr. Lusanna reports (Braithwait's Retrospect, part xxv) very favorable results from the use of Atropine; and Dr. Bullar (in the same work, part xix) reports considerable success from the use of the Cotyledon Umbilicus. These and other articles may seem to have a specific effect in isolated cases, but as a rule of practice, we should rely upon such a plan of treatment as will best secure general health. 
In those cases which result from some peculiar organic condition of the encephalon, a rheumatic development of it, we would, in an especial manner, direct attention to the respiratory function ; and we are inclined to the opinion, that that practice which succeeds best in rheumatism will succeed best in this particular form of disease. We found this conclusion upon the similarity of organization. 
In addition to the foregoing, we give the following treatment of Professor J. King, who has had considerable and 


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successful experience in the disease. If the cause can be ascertained, as worms, uterine difficulties, etc., treat them accordingly ; but in those instances where the causes are obscure, he adopts the following plan: 
During the convulsive paroxysms, he gives to an adult a powder composed of Sulph. Morphine, one-third of a grain, and of Quinine, two-thirds of a grain; this dose is repeated every ten or twenty minutes, or as the patient may be made to swallow it — having it mixed in water. "When the paroxysm has subsided, the bowels are to be kept regular by the use of Leptandrin, and Fodophyllin, given in small doses, and the following pills employed during the intervals: 
Ext. Stramonium, gr. j, 
Valerianate, or Sul. Quinia, iv, 
Hydro-alcoholic ext. of Macrotys, grs. viii; mix, 
divide into eight pills, and give one three or four times a day. 
A stimulating liniment must be applied to the spine, as the following, which has been much used by ourselves, as well as Professor King: 
Oil of Stillingia, 3j, 
Oil of Cajeput, 3ss, Oil of Lobelia, 3ij, Alcohol, 3iij. Mix. 
The spine may be bathed twice a day with this, and continued until the patient complains of nausea, or an unpleasant acrid taste in the mouth. The surface of the body must be bathed once or twice a week with an alkaline wash ; all acidulous and greasy articles of food must be avoided, and the mind kept perfectly free from excitement of any kind. In acidity of the stomach, he prefers the use of the Carbonate of Ammonia in this disease to any other alkali. 
In pursuing the above treatment, it should be recollected to proportion the doses according to the ages of the children. In young infants, the Antispasmodic Tincture is preferred to the Morphine and Quinine. 
Genus II.—Chorea. 
Chorea Sanoti- Viti — St. Vitus' Dance. 
This affection is characterized by irregular and involuntary motions of one or more limbs, and of the face and trunk. It 


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occurs generally before puberty, and more frequently before the age of ten years than afterward, and is generally associated with torpor of the system, and particularly of the digestive organs. It usually exists for a long time, and without danger to life, and with a complete exemption from it during sleep. 
We are apprehensive that there prevails a very general want of correct information on the character of this affection, and it is possible that we may leave it as much beclouded as we found it; nevertheless, the suggestions we maysadd may result in some good, by directing observation to a new channel of investigation. 
We have found no evidence to satisfy us that this affection depends upon a diseased condition of any organ, but rather upon a feeble or debilitated one. It should be remembered that extreme muscular feebleness and tardiness, or comparative torpor of the digestive functions, characterize one of the human temperaments ; and this one, furthermore, is associated with a feeble endowment of the lateral, or motor and sensitive, portions of the cerebellum. In such persons, the power of volition is feeble, but still more feeble is the motor portion of the cerebellum, hence the latter has not the power to execute the mandates of the former. 
In infancy, the cerebrum merely vegetates, and all the vital power is expended upon the lower and most common functions, but at five years of age, and even younger in some cases, the cerebrum manifests all or nearly all of its functions, the vital forces have not strengthened in proportion to the expenditure upon both the lower and higher faculties. So long as the patient did but little more than vegetate, the function of animal motion was normally manifested ; but when that large number of powers which place us in relation to all that surrounds us, is brought into action, we are forced to the inquiry, where is the power to come from to effect a normal action of all the instruments common to humanity ? These reflections may be foreign to any utility, in relation to the subject before us; nevertheless, the fitness of the coincidences, as we have seen them, induce us to believe that the suggestions we have thrown out deserve some attention. 
Prof. Wood says, that "The regular motions are often 


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greatly increased by any emotion ; and it has been noticed that the patient is generally worse when conscious that others are observing." 
This manifestation, to a certain extent, may be observed every day about us, in society, among those who have much caution, little destructiveness, and feeble vital forces. The man who cannot refrain from betraying perturbation and a tremulous motion of his knees and hands, is just so far a subject of chorea. 
" It appears that," continues Dr. Wood, " if the will cannot accurately regulate the movements of the muscles, it has the power of calling them into abnormal action; for the spasmodic contractions are much more frequent when the patient endeavors to execute any movement with peculiar precision, than when the will is quiescent." 
We think that Dr. Wood is mistaken in supposing the patient capable of calling the muscles into abnormal action—he calls them into action, but has not the power to render their action normal. When a man, who is perturbed, attempts to write, or to do anything else that requires precision, he is certain to fail. 
The doctor continues: "By the exertion of a strong determination, the patient can also often control the muscles in some degree, so as to keep them quiet for a time, though, if he allows or encourages them to move, it is impossible to prevent them from moving in their own way." 
What observer has not witnessed all this in men of feeble vital force, under the excitement of responsibility ? Drunkards, and those laboring under an ague chill, present the same phenomena. 
The preceding remarks of Professor Wood, go very far to strengthen the suggestions we have made; and it is possible that this feeble condition of the motor system of nerves may be increased or rendered more deranged by an imperfect discharge of the digestive functions. 
Professor Wood again states, that "An unsteady, excitable state of the nervous system, constitutes a predisposition to chorea. Such a state is apt to attend a feeble condition of the general health." 
If this observation of the doctor is reliable, and we think 


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that it is, then we are sustained in referring chorea to a very feeble endowment of the vital forces—an extreme degree of that feebleness which is exhibited every day in mental perturbation and nervousness. 
Causes.—Remotely, the cause may be, in many instances, that division of labor which has assigned to many sedentary habits, and in very many instances it has resulted, beyond doubt, in intermarriages with blood-relations and incompatible constitutions ; if the statistics could be had, we would not be surprised to find that the latter is the most frightful source. We knew one family in which four or five of the children were thus afflicted, and the parents were of the bilious encephalic constitution. Prof. Wood says, that, "In many instances, the disease has come on in many persons previously healthy and robust." This language is usually applied to those who are obese, and we have shown (page 20) that an accumulation of fat is as clearly a manifestation of organic relations, as an accumulation of tuberculous matter—they are both produced by an imperfection in the sources of pulmonary action. 
Until we made these discoveries, we could not conceive how it was that obese men sometimes died of phthisis pulmonalis, but now, it clearly appears that any cause calculated to arrest the fat-depositing process, may cause an eruption to appear on the skin, diarrhea, a deposition of tuberculous matter, and therefore it is possible, that by some other modification of action, chorea may result. 
Treatment.—Professor Wood teaches, that " Constipation should be promptly corrected by purgative medicines." This precept, standing unqualified as it does, we hold to be exceedingly dangerous. We have seen that this malady, if such it should be regarded, is founded in debility, and in all such constitutions the normal condition of the bowels is one of much torpidity, and so are all the excretions and secretions, and, consequently, to force them into a more active condition than suits the constitution, is to increase the affliction of the patient. 
It should be the first business of the physician to ascertain the normal habit of the bowels, and the second is to maintain them in that condition. Purgatives, in this case, as in others, are indicated when evidence is manifested that alvine torpidity 


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is occasioning irritation — is aggravating the malady. We would suggest, that to the maintenance of all the organic functions, there should be added such exercise as will most promote the further development of the thoracic viscera, and to have this effect, it must be enjoyed. 
In chorea, the bowels should be kept regular by small doses of Leptandrin and Podophyllin, so combined as to produce one alvine discharge daily ; in connection with which, either the Compound Pills of Macrotys, the Compound Pills of Valerian, or the Compound Tincture of Cramp Bark, of the Eclectic Dispensatory, may be used. The surface should be bathed often with an alkaline wash, and considerable friction used in drying. Electro-magnetism may be used, daily, with advantage. 
If the disease is complicated with rheumatism, or the patient is of a strumous diathesis, the employment of the Compound Syrup of Stillingia and Iodate of Potassium, heretofore referred to, will be found serviceable. 
In cases of obstinate constipation, Prof. J. King recommends the use of Extract of Belladonna, one-eighth of a grain, and the Alcoholic Extract of Nux one-twentieth of a grain, in form of pill, three of which are to be given daily to an adult, and in proportion to children over six years of age; below this age, he thinks, it has an injurious influence upon the brain, and should not be administered at all. 
The diet should be nutritious and of easy digestion, avoiding tea, coffee, all stimulants, acids, and greasy food. 
Genus III.—Paralysis— 
Palsy. 
This form of disease, when complete, consists in a loss of sensation and of the power of motion. In some instances, there is a loss of sensation, without the power of motion being affected—the affection is then called ancestliesia ; and when the condition is reversed, that is, the power of motion is lost, while that of sensation is retained, it is called acinesia. When a particular part of the system, as an arm, the muscles of an eye, or the face, have lost the power of motion and sensation, the affection is called local palsy ; when the same condition happens to one lateral half of the body, it is called 


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hemiplegia; and when to the lower half of the body, including the inferior extremities, it is then called paraplegia; when both powers are lost in any given part, it is denominated complete paralysis ; and when either or both powers are in part retained, it is called partial paralysis. 
As we have shown that the functions of motion and sensation are performed by two distinct and independent organs, it can be readily understood how it is that either may be lost or palsied without the other; and further, the same discovery renders intelligible all of the preceding definitions. 
That loss of motion and sensation, which attends coma, apoplexy, syncope, epilepsy, etc., is not included in the above definitions; nevertheless, paralysis may succeed to either of them, as a sequent. "We have seen all the voluntary muscles, except those of the neck and face, paralyzed, and yet life continued twenty-four hours. Our observations upon one case of this kind, induce us to believe that life could not continue a minute after a complete paralysis of all the voluntary muscles should happen. 
"When palsy takes place, in adult life, it comes most frequently as a precursor to a final dissolution, but such a consequence is not to be apprehended when it seizes upon infancy and childhood ; and yet it may prove quite incurable, or entirely so. In infancy, it sometimes appears to depend upon some original defect in the organization, because it so operated before birth, that the affected part is, at birth, less developed than the unaffected ; but, in such cases, it is more apt to appear as acinesia or anaesthesia, than as complete palsy. 
But the disease, either partial or complete, is much more frequently occasioned subsequent to birth, by some variety of assault upon the brain or spinal cord. When it is the result of spinal irritation, it may be attended by nausea and vomiting, but more frequently by flatulence and diarrhea—and by such manifestations of the body as show a disposition to avoid resting the weight of the body upon the spine, and which, upon the appearance of the disease, becomes impossible. The gastric and alvine symptoms above named, have been mistaken for cholera infantum, and hence the propriety of looking out for the spinal manifestation, above noted, in all cases of bowel derangement. 


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In many instances, the assault appears very trivial—such, possibly, as a day or two's manifestation of unusual dullness and heaviness of the head, which appeared, perhaps, too unimportant to command medical attention, or possibly by a single convulsion, or perhaps by some dental irritation, which, so far as ascertainable, produced no cerebral disturbance. 
In three-fourths of the cases of paralysis, that occur during the period of dentition, there will be found no local signs of difficult dentition, and yet there can scarcely be a doubt that it was occasioned by the irritations incidental to this period. This is only another illustration that physicians have been in the habit of referring too much to the local circumstance of dentition, and not enough to that general condition that prevails during this period, especially with those children who have but feebly endowed vital forces. Paralysis may succeed to spinal irritation, occasioned by a constipated condition of the bowels. It is reported also to have been produced by the child's sitting upon a cold stone, and therefore it is not improbable to suppose that it may be occasioned by wet and cold clothing. 
It is worthy of remark, that it matters but little as to what form of disease that disturbed the general health, previous to the manifestation of paralysis, nor how soon it may subside or disappear, yet the paralysis will so far continue as to produce much inconvenience as to the comfort of the patient, and the appearance and usefulness of the affected part. 
Whatever maybe the cause, remedies addressed to the general health sometimes very readily give relief, but at other times, it persists for weeks, months, years, and even for life, in defiance of all the profession can do. 
The most important point connected with this subject, is diagnosis—to distinguish it from indications of impending mischief—such as organic disease of the brain. Sometimes the history of the disease will be sufficient to determine its character. If the paralysis has suddenly seized upon both extremities, on the same side, unattended by any cerebral symptoms, we may conclude that it indicates no serious mischief; but if the paralysis has secretly and slowly made its invasion upon some given part, we may find it very difficult to come to a conclusion. 


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Connected with a disease of the brain, there is usually involuntary tremor or nervous twitchings, with a contraction of the fingers and toes. In case of convulsions, the paralysis that succeeds may render the cases still more obscure. But we may state, as a general fact, that when the paralysis succeeds to a single fit of convulsions, there is no local mischief in the encephalon ; but when such a lesion does exist, there will be a succession of convulsive assaults before paralysis will become manifest, and the part that will manifest it, will, during the convulsions, be probably the only or the most convulsed part. 
In cases of incomplete paralysis of an inferior extremity, the sensibility of the limb is sometimes exalted ; and but for this circumstance, there could be no liability of confounding hip-joint disease with incomplete paralysis—but the almost, if not invariably, fixed pain in the knee, in hip-joint cases, will distinguish it from paralysis. In the latter, that extreme pain can never arise, which is occasioned in the former when the head of the femur is made to strike against the acetabulum, which is apt to follow a slight blow upon the heel. 
Treatment.—Upon this subject, Dr. Wood says: "It may not be amiss to state, in general terms, that the remedies in cases of active congestion, active hemorrhage, or inflammation, are bleeding, general and local, proportioned to the energies of the system, purging, refrigerants, low diet, rest, and if these fail, blisters and a mercurial impression." 
Dr. West says, that " Purgatives and tonics are the remedies which I have most frequently employed; for the bowels are usually constipated, and the child often debilitated." 
The above extracts embrace the doctrine, on this subject, of all the writers whom we have consulted, and as we hold it to be entirely erroneous, it is proper that we should make it the subject of some criticism. 
In the first place, we do not believe that two per centum of the cases of infantile congestion and hemorrhage are active in their character—but exclusively passive; and this opinion is sustained by the closing remark of Dr. West, "the child is often debilitated." We believe, that if he had considered obese children as " debilitated," he would have found no exception—his language would have been, the child is always 


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debilitated. The case of the child which we extracted from him, under the head of Phthisis Pulmonalis, is a thorough illustration of this point. We conclude then, that in all cases of palsy, which originate in functional derangement, the child is feeble—feeble because of those organic conditions which we have exposed, that constitute almost a sine qua non to the production of infantile palsy in general. 
Now, what is the practice ? The child is feeble, therefore bleed it and purge it, and if these fail to kill it in due time, then try blisters and mercury. We are aware that this course generally succeeds in effecting its—death. If there can be adopted a course of practice, with a feeble child, better calculated to produce paralysis, than the preceding, we cannot imagine its character. 
The affection generally consists in debility, and this debility is certainly increased by both bleeding and purging. Irritation in the gums, bowels, etc., have also their origin in debility, and purgatives are certain to produce irritation in some part of the system. To speak truly of this practice, we must say that it is not enlightened by one ray of common sense. 
Whatever may be the obstruction that has occasioned paralysis, the system is making an effort to remove it, and for the purpose all of its energy is concentrated upon the one object, constipation must result, for the time being—it is then, a favorable indication; and, if in its stead, diarrhea should ensue, it might justly be regarded as a fatal indication. 
So long as constipation gives no evidence of producing irritation, we should not only let it alone, but co-operate with the system in removing that disease or obstruction which has occasioned the paralytic symptom; and, therefore, the equalization of the circulation and the support of the child's energies, should constitute our first duty. 
When we have indications that the fecal contents of the bowels are becoming a source of irritation, they should be removed by injections, because the difficulty is always in the large intestines, and thus we avoid the irritation consequent upon the action of cathartics upon the alimentary canal. 
If the paralysis has been occasioned by inflammation, or rather by that disease for the removal of which inflammation was set up, cerebral congestion, or any similar affection of the 


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spine, the initiatory treatment will be found under these respective heads. If it have originated in some obstruction or irritation incidental to the dental period, it will be centripetal in its character, and therefore may be removed by revulsives. When the malady is connate, no plan of treatment, it is generally thought, can avail anything. This may be true, but as an abstract conclusion, we cannot assent to it. Connate organic conditions can be changed—we have proof of this in the history of every man who has lived an active life, and as disease depends upon organic conditions and relations, no case should be declared incurable before the mechanical or the chemical laws have declared it to be impossible for the vital forces to regain an ascendency. When it shall be discovered that the palsy has resulted from a tumor pressing upon a nervous trunk, the remedy must be obvious. 
In this disease, among children, the stimulating liniment, mentioned under Epilepsy, should be applied to the spine, and tonics given internally, with gentle stimulants, such as Myricin, Xanthoxylin, etc., and a nutritious and easily-digested diet. 
Genus IV.—Night Terrors— 
Frightful Dreams. 
That set of manifestations which we designate night terrors, are, perhaps, never occasioned by any permanent disease <k the brain, but rather through the instrumentality of intestinal derangements; and when from these, they are sometimes too slight to admit of detection. Children, who have apparently an every-day good health, go to bed, sleep soundly an hour or so, and then (we cannot say awake, because entire consciousness is rarely, if ever, present with them at the moment), start suddenly and in great terror, giving a piercing cry or scream. When attention is given to it, the child is found sitting up in bed and betraying the utmost alarm—crying for his nurse or the one who most attends to his wants. When spoken to, it will answer, and yet appear unconscious of the presence of any one, or of what it is doing, but still screams under the influence of its frightened imagination ; at length, and gradually, it becomes both conscious and awake. 
In most instances, as soon as aroused to consciousness, the 


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child is quiet, and again returns to sleep as though nothing had happened; but in other instances, and occasionally at other times with the same individual, it seems to have a deep trouble, weeps passionately, but finally sobs itself to rest. 
In some cases, it is said, that when the fit passes off, a quantity of limpid fluid is voided, but we have not seen it. These attacks very rarely occur more than once upon the same night. As the affection obeys no law of periodicity, it cannot be foretold when the terrors will be likely to return—they may return the next night, and they may not — they may occur almost every night for a year, or only a few times. The paroxysms are all alike—and are founded upon the idea of some impending danger. 
Parents at first are very apt to be alarmed, fearing that some serious malady is threatened; but after a time they come to regard these terrors as nothing more than the child's frightful dreams. But this indifference may result to the injury of the child, because by indulging such an irritation, it might result in some very serious affection, such as convulsions, and their frequent recurrence may produce death—and yet a post mortem examination might detect, in neither the brain nor spinal marrow, the slightest indication of disease. 
It is not best to force such children to bed in the dark, and if they be alone—no one to cling to as being capable of protecting them, the light should not be extinguished before they fall to sleep. So long as the child manifests no intolerance of light, complains of no headache, the pulse regular, head cool, and no drowsiness, there will be no occasion to apprehend the approach of hydrocephalus, more especially if the abdomen be full and hard—indicating the presence, perhaps, of constipation, which very frequently attends, more or less, these night terrors. The irritation attendant upon both the first and second dentition, may prove an exciting cause in their production. 
Treatment.—This affection, perhaps, is founded entirely upon gastric or intestinal irritation. Children, who are permitted to eat anything, particularly of a trashy character, and those who are passing through either the first or second dentition, are those who are the most liable to be afflicted in this way — but there is another condition which, so far as our 


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observation has extended, may be regarded as a sine qua non in the premises — it is a very moderate expansibility of the lungs, as indicated by small and contracted nostrils, with an absence of respiratory motions in the chest; this circumstance, particularly, makes it essential that the malady should be attended to. 
No other treatment is required, than to confine the patient to simple and nutritious diet, more especially of the azotized variety, and to keep the bowels in a normal condition by the use of mild aperients. 
If worms are present in the intestines, remove them by the proper agents: if there should be irritation of the gums from teething, pursue the course herein recommended for such irritation. 
In some instances, a pill composed of Hydro-alcoholic Extract of Macrotys, one grain, and Sulphate of Quinia, onefourth of a grain, may be administered once or twice a day. 
If the child is permitted to sleep lying on its back, it will be more liable to these attacks. Late suppers and meats for supper must positively be prohibited. 
Genus V.—Trismus Nascentium— 
Infantile Tetanus. 
This very generally fatal disease has hitherto been but little understood, so little indeed, that we should probably have passed it over in silence, but for having found a very valuable paper on the subject in the "Nashville Journal of Medicine and Surgery," by Professor Watson. He has, in our judgment, handled the disease in all its aspects, knowingly and intelligently. We shall not, in what we shall say, go beyond his paper, nor shall we follow him any farther than he pursues the disease; that is, we shall not meddle with his comments upon the opinions and doctrines of others, further than to remark, that he has handled them with as much ability as he has the subject. In commenting upon the opinions of Dr. Sims, he says: 
"This reminds me of Dr. Cullen's acknowledgment: 'I have, in my Nosology, put the trismus, or lock-jaw, as a genus distinct from the tetanus ; all this, however, I now judge to be improper, and am of opinion, that all the general terms 20 


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denote, and are only applicable to, different degrees of one and the same disease.' Surely trismus, in the infant or adult, is a mere variety of tetanus, and like the other varieties depends upon a pathological condition of some of the cerebrospinal centers. 
" It is a great misfortune that the term trismus nascentium was ever adopted ; tetanus nascentium would have been a better, though a less euphonious, one. There was no greater necessity for changing the name of this disease, in the case of infants, than there is to change that of pneumonia, dysentery, or colic, when they attack children." 
He thinks it probable that there may exist, in the constitution of some individuals, a sort of tetanic predisposition, and that cold or damp air, indigestion, exposure to solar heat, "foul and badly-ventilated lying-in-hospitals," a want of cleanliness, etc., may serve as predisposing causes. 
" The exciting cause of Tetanus Nascentium. —A traumatico-tetanic condition of the umbilicus, is, with a very few exceptions, the constant exciting cause of this disease. The analogy between traumatic tetanus, as it occurs in the adult and infant, is both striking and instructive, and well deserves our most particular consideration. In the adult, this disease generally comes on about the eighth or ninth day after the reception of the wound, and in the infant, it attacks so frequently on the ninth day after the cutting of the umbilicus, that it has been termed ' nine-day fits.' That portion of the cord which, after its division is left in connection with the navel, is as liable to degenerate into an exciting cause of tetanus in the infant, as is a common wound in the adult. 
" C. M. Billiard's explanation of the separation of the funis is quite satisfactory; he very properly maintains, ' that desiccation of the cord is altogether a physiological phenomenon, belonging to the assemblage of vital phenomena, and entirely dependent on them. That part of the cord attached to the placenta, does not exhibit the phenomenon of desiccation, like the portion remaining with the child, but shrinks and decays like a dead substance, while the abnormal portion is not so affected. Here the desiccation ceases as soon as life is extinct; it either does not proceed in still-born children, or is considerably retarded. In place of dying and separating at the end 


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of a few days, as is observed during life, the cord undergoes in the dead body a perfect decomposition, differing entirely from its normal desiccation.' He further contends, that ' the umbilical cord may, under favorable circumstances, separate from the navel, just as the stem of a cucurbitaceous fruit is separted,' or by what he terms ' a proper suppuration.' Of eighty-six infants examined by him, nineteen had redness and tumefaction of the umbilicus, without suppuration. The period for the detachment of the cord varies from the second to the seventh day." 
He thinks that the liability of infants to irritation, inflammation, and sloughing of that portion of the cord which remains attached to the abdomen, has been greatly overlooked by medical writers. It is his opinion, furthermore, that there exists a variety of causes which may induce a normal and healthy action to degenerate into a morbid one, and that some children are more exposed to all of them than others. The professor lives in a slave country, and has had extensive opportunities for observation, in both the white and slave population, and he states, as a result of such observations, that the slave children are more exposed to all these causes than the white, and hence the disease is much more frequent among them. 
These common causes, which apply to the blacks more than to the whites, he says, " are bad dressings of the umbilicus, improper handling of the infant, wet and soiled dressings, which become alternately wet and dry for several days ; to which may be added, unsuitable applications to the navel itself after the detachment of the cord, that are more calculated to inflame and irritate the part, and in that way to provoke lock-jaw, than to soothe, heal, and prevent its suppuration." 
From the facts presented by the professor, the conclusion is irresistible, that this fatal morbus is more common to the black than to the white population of the south; and here, let it be remembered, there are no paupers, as in the free states of this and other countries. It is furthermore ascertained, that the same difference, as to this disease, exists between the poor and pauper classes, on the one hand, and the affluent, on the other, that obtains between the black and white of this country. 


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Those conditions of life, as regards personal comforts, which exist with the blacks, exist also with the poor of all countries. Now, what is the condition which is common to the infants of the poor and the slave infants ? A want of every personal comfort. 
The professor's description of negro infants, as he has frequently seen them, is that which we have witnessed in the wretched families of the free states, viz: 
" Their clothes wet around their hips, and often up to their armpits with urine — the umbilical dressings not only wet with urine, but soiled likewise with faeces, freely giving off an offensive and fecal odor, combined at times with a gangrenous fetor, arising from the decomposition—not desiccation —of the cord." 
Under such circumstances, it will readily be admitted that the normal physiological desiccation must be interrupted, arrested, or degenerated into a most foul and morbid condition. The professor has presented a large amount of evidence in support of his conclusions — and we think that he has sustained them. He has concluded, that " the infant is no sooner born than it becomes a traumatias, a trauma must of necessity be inflicted upon its umbilical cord; a wound on a part which is very prone to pass into a pathological condition, and thereby excite irritation and inflammation of the umbilicus." 
Two objections have been urged to the professor's conclusion, which we will name, and append his answer, lest others may conclude that they have not been anticipated. 
1. " That the navel may be badly inflamed, and yet not cause tetanus." 
2. " That cases of trismus have occurred where there was no imflammation of the umbilicus." 
" But for these considerations, many would doubtless have entertained a much greater dread of a morbid state of the umbilicus, and would oftener have employed tetano-prophylactic measures in such cases. Indeed, with no little astonishment have I heard well-informed physicians say, that they did not believe that inflammation of the navel is the exciting cause of trismus, merely because they had seen very badly inflamed ones, without the occurrence of lock-jaw; or, that they had seen cases where the umbilicus had healed over. Verily, my 


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surprise would be equaled by the assertion, that they did not believe that a wound was the exciting cause of tetanus in the adult, because they had seen very bad ones fail to produce it, or had seen cases occur after the healing over of wounds. Almost every practitioner knows, from personal observation, that an adult may receive a deep, dangerous, and painful wound without incurring lock-jaw as a consequence ; also, that a wound may cause the disease after having healed over; then, may not severe inflammation, or extensive ulceration, of a child's navel run its course without causing trismus ? and may not the part heal over, and yet, by an occult pathological condition, excite the disease ?" 
The professor has not treated of the symptoms, varieties, or therapeutics of this disease, which we very much regret; he states that his purpose, mainly, has been " a reliable prophylaxis, by which a disease that cannot be cured, may be prevented;" and so admirable and practical are his remarks upon the purpose of preventing the disease that we feel it to be due to young practitioners, to extract them at full length. 
" Physicians have generally given up the dressing and management of the funis, too much into the hands of unskillful nurses, lest by a careful attention to such small things, they might compromise their fancied dignity. But every one who is properly impressed with a dread of tetanus from bad management of this part, will rather try to maintain his professional character and dignity by preventing a disease which he knows he cannot cure, however trifling the means may seem, in the estimation of the ignorant, inexperienced, and prejudiced." 
" The umbilical cord should be divided as usual about two inches from the abdomen, and well tied with a suitable ligature before its division. After the child has been washed by the nurse, another ligature should be applied lest the first one should become too slack from the contraction of the cord. A hole of a proper size should then be made through a piece of soft old domestic or linen, four inches wide and six inches long, through which the funis should be passed, and afterward carefully wrapped with another soft piece of cloth two inches wide and three or four long. The cord should then be turned up toward the child's breast, and the cloth which was first 


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applied, should then be folded in on it from above and below, and from side to side. A soft flannel bandage should then be carefully put around the abdomen and pinned with moderate tightness. After this, should the navel-dressings become wet with urine or soiled with faeces, they should be carefully removed and dry ones employed. This should always be done by an experienced and careful nurse, lest the cord should be prematurely detached. On a careful examination, should there be any signs of irritation, inflammation, or ulceration of the navel, the piece of cloth, through which the wrapped funis passes, should be removed, by cutting with a pair of scissors from without into the opening in the middle ; this being done, it may be removed without hurtfully disturbing the cord. After this has been done, it will be necessary to apply another piece of cloth like the one just removed, unless the inflammation be considerable; in that case, the part should be gently washed with warm milk-and-water, and a soft emollient poultice applied over the wrapped cord and surrounding surface to the extent of two or three inches. The application, removal, and renewal of this poultice will require great care. 
"The chief advantage of wrapping the cord, is that of preserving it from adhering to the cloth through which it passes, and thereby preventing its removal when necessary. All awkward, rough handling of the cord should be avoided, as the navel string may be, in that way, stretched, torn, or prematurely detached. After the funis has separated, the umbilicus should be carefully washed with castile soap-suds, and if there be the least appearance of irritation or inflammation, a soft mush-poultice, somewhat larger than a dollar and about twice as thick, throughout its whole extent — lest the edges become dry—should be neatly spread on a soft piece of cloth, then moistened on its surface with a little lead water and olive oil, and laid with care immediately over the navel, and should be retained in its place by a proper application of the bandage previously employed. This poultice should be removed in six or eight hours and another applied, and so on until all signs of a morbid state of the part entirely disappear. It will sometimes be necessary to continue this course of poulticing for five or six days, to the entire exclusion of all other topical applications. All predisponent, accessory, or accidental causes 


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should be removed with great care as far as possible; the general health of the child should be closely watched, and internal remedies employed if necessary. 
" Soft, emollient poultices, certainly afford even an adult suffering from a wound greater protection than any other means. Who ever saw a patient attacked with traumatic tetanus, who had had all the prophylactic benefits of good poultices, a well-regulated temperature of his room, and appropriate remedies ? The soothing action of the poultice seems to prevent a wound from passing into that condition which excites lock-jaw. The terminal extremities of the wounded nerves, or those that have been exposed by ulceration, or irritated by inflammation, are protected by a poultice against that tetano-pathological condition into which they pass sometimes, when not thus guarded, with great facility. 
"But, alas! because the inflammation of the navel is trifling, or the ulcer on it small, the physician does not consider either worthy of his attention, when, really, the very elements of death are more actively at work than in many other cases which so readily engage his closest attention and greatest skill. It is probable that a greater amount of human life might be saved by these simple preventives, than most physicians or nurses are aware of; and it is always far more difficult to procure the employment of such prophylactics, than those uncertain remedies which are so zealously administered sometimes for the relief of an incurable malady. 
"Nurses should be properly directed to employ these preventive means, especially among our negroes ; and every practitioner should constantly urge their adoption on all large plantations and negro quarters. When these means are faithfully employed, negro children escape tetanus to as great an extent as do white children. It should be the resolve of every practitioner never to allow an infant to be attacked with trismus that may be delivered by him, or placed under his care at birth, since, by a patient and careful employment of appropriate prophylactics, it may be prevented. These means, simple and unpretending as they are, require some foresight and tact for their beneficial employment; if the poultice be not well applied, of proper consistence, or becomes dry and hard, it may do more harm than good. Beside, if the child be not 


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protected against wet and soiled clothing, bad air, variable temperature of its body, bad feeding and nursing, these pre disponent, accessory, and accidental causes, may cause the morbid umbilicus to pass into a traumatico-tetanic condition in despite of poultices or any other topical applications whatever ; so it is highly necessary that all these things—little in themselves, though great in their effects—should be scrupulously regarded by every conscientious practitioner. 
" The writer of this treatise, while faithfully discharging his duty to infants in the employment of these prophylactic measures, has often experienced the jeers and taunts of the nurses on such occasions. Every practitioner should, however, perform his duty to his little patient, be it white or black, in protecting it against an attack of a disease which he may prevent but cannot cure, and thereby impress nurses, parents, and even communities, with the great utility of such a course. In that way our prophylactics may be raised above the contempt of the ignorant or those too wise to learn." 
As the Nashville Medical Journal may not be within the reach of our readers generally, the opinions of several writers, on this disease, may be found in Dr. Wood's Practice of Medicine. 
So far as a child can manifest the general symptoms of tetanus, they may be expected in this. If the opinions of Dr. Sims are to be credited, it is quite a curable disease; but other extensive practitioners assert that they never knew a case to be cured. This, we suppose, to be about the fact, hence the great value of Professor Watson's prophylactic measures. 
When an infant is attacked with trismus nascentium, to the gangrenous umbilicus, apply daily a solution of Sulphate of Zinc, one drachm to an ounce of water, and cover this with a poultice of Slippery-elm, to two drachms of which a solution of the Extract of Hyoscyamus, twenty grains to an ounce of water, must be added, and renew the poultice two or three times a day; the solution of Zinc to be applied until healthy granulations appear. The bowels are to be kept open by the Compound Powder of Rhei, in decoction, or by enemas; cold water must be applied to the head ; and bathe the whole spine two or three times a day, with the liniment recommended in 


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chorea. Internally, administer an infusion of one drachm each of Ictodes Foetida, Cypripedium Pubescens, and Scutellaria Lateriflora, to six ounces of water, of which a teaspoonful may be given every hour or two. 
Genus VI.—Convulsions — 
Infantile Fits. 
" These are clonic spasms of the muscles, producing visible motions of the limbs or other parts of the body, and generally attended with unconsciousness. When the contraction is slight, feeble, and of short continuance, so as to occasion a mere catching of the tendons, with very little observable movement of the parts into which the tendons are inserted, the affection is denominated subsultus tendinum. It may or may not be accompanied with unconsciousness."—Wood. 
Convulsions are but rarely independent of some of the forms of disease over which we have passed or are yet to consider; and, therefore, if we had passed the subject by, as an independent one, we should not have been guilty of anything like considerable omission. The importance of treating of it, as a separate subject, consists in bringing under one head its various features. 
A convulsive liability of the system is one of increased irritability, and a paroxysm is usually anticipated by more than ordinary restlessness—readily excited into a fretful mood of feeling and a peevish temper. At night, the convulsive approach is frequently indicated by an incapacity to sleep, or if sleep should supervene upon going to bed, it will be disturbed or broken by sudden starts and cries. 
The iris is generally very dull and unimpressible by light, or else exceedingly sensitive to it. In the presence of light, the pupil will suddenly contract, and then probably as suddenly dilate—sometimes one pupil will dilate while the other contracts. 
Mr. North is of the opinion, that when this unequal sensibility of the iris exists, that the brain is probably seriously involved. Dr. Good says, that when children are strongly liable to convulsions, they lie, when asleep, "with their limbs rigidly extended, the great toes and thumbs being turned inward." 


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The face, superior and inferior extremities, and the respiratory muscles, are the most liable to convulsive movements, but no part, endowed with muscular fibers, is exempted. The countenance varies in both color and expression—at one moment, it is flushed, at another, pale—at one time, it is«sad, at another, cheerful. These changing feelings affect the respiration, producing deep and lengthened inspirations, which are followed by a short and interrupted respiration. When the respiratory function is thus disturbed, it is thought by some, that a paroxysm is near at hand. In this state of strong liability, the fingers are subjected to sudden and frequent motions. 
The face, in some instances, is about the only part that is convulsed —in others, different parts of the body are convulsively seized, but most generally every voluntary muscle and many of the involuntary are spasmodically excited, and attended by a staring of the eyes, protrusion of the tongue, frothing at the mouth, labored breathing, and distortion of the eyes. Frothing at the mouth is but rarely attendant — it is perhaps present only in such cases as will most likely prove fatal, and then, before dissolution, the skin becomes of a purple color, and so continues until the close of life. 
The Infantile Constitution in relation to Convulsions and kindred affections. — In Chapter VIII of the preceding Book, we exposed some of the errors that prevail on this subject, and as enlightened views, in relation to disease, constitute the only proper guide in practice, we must be permitted to comment a little on prevailing opinions with reference to infantile convulsions. We shall begin with an extract from Prof. Eberle, " On Children." 
"Both the anatomical and physiological peculiarities of the infantile system, are, indeed, such as to account for the especial aptitude to convulsive maladies during this tender period of life. The mind and body of an infant, not yet inured to the impressions of internal and external causes, possess the most lively susceptibility to the various perturbating and exciting influences to which it is unceasingly subjected. 
"All children, however, are not equally disposed to convulsions. Mr. North observes, that ' the children of parents, who marry at too early or too advanced an age are more 


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susceptible of convulsions than the progeny of those persons who marry in the prime of life.' I have met with several instances of aptitude to convulsions in families which accord entirely with this observation. That the predisposition to convulsive affections is sometimes hereditary, appears to be highly probable. Boerhaave and Berry, mention instances which strikingly illustrate this fact. We often meet with families, in which the occurrence of convulsions, is almost a matter of course in all the children as they successfully pass through the process of primary dentition ; and, on the other hand, in very many families, blessed with a numerous offspring, such affections never occur, although the ordinary exciting causes, may be conspicuously present. It would appear also, that convulsions are much more common in cities, and particularly in the higher and more luxurious classes of society, than among those who ' are regular in their mode of living, and who enjoy the calm tranquillity of country life.' The fresh and pure air of the country, has an especial tendency to invigorate the infantile system, and to diminish nervous irritability, and thus to render the ordinary causes of convulsions less apt to excite such affections. It is, probably, mainly from the want of pure and wholesome air in hospitals, that convulsive diseases are so much more common in these institutions than elsewhere. The children of mothers, endowed with a very susceptible physical and moral constitution—with a quick and lively imagination, great sensitiveness, and mobility of temper, are in general peculiarly apt to suffer convulsive affections, during the period of dentition. Mauricean, Leuret, and others, assert, that children who have very large heads are more liable to convulsions, than those who are less liberally furnished in this way. This observation, however, appears to be wholly without any foundation, with regard to children who are healthy. In rickety children, the size of the head is disproportionately large; and from the general symptoms of rachitis, it is evident that the head and spinal marrow are considerably affected ; the brain increases rapidly in size, the senses are usually very acute, and convulsions are very frequent attendants of this distressing malady. It not unfrequently happens, when some children of the same 


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parents are affected with rachitis, that others who are exempted from the disease are at a very early age destroyed by convulsions." 
If this long extract contain one clear or one useful idea, we have failed to find it. Two ideas, however, may be interred from it: first, children have convulsions; and, second, Prof. Eberle does not know why they do; and yet, so far as we have been able to discover, he is about as wise as his colaborers. One reference will show that this remark is correct Prof. Wood says : 
" The peculiar state of the nervous system, in infancy and early childhood, may be considered as a predisposing cause. Very impressible from the necessities of the organization at this age, it must of course feel more sensibly than at other periods of life the influence of disturbing causes. But there is also a great difference in children in this respect. In some, the nervous system is peculiarly liable to this mode of derangement, either from inheritance, from powerful impressions, as some suppose, upon the nervous system of the mother during pregnancy, or from inappreciable causes, which often determine, in all the children of certain parents, a predisposition of this kind. Nothing is more common than to see all or most of the children of one family peculiarly subject to convulsions, though the parents may have exhibited no such tendency in their own persons. Children, thus predisposed, show themselves more impressible than others by ordinary causes, start frequently, are usually excitable, if not properly controlled, are apt to be fretful or irascible, and occasionally exhibit great precocity. . . . The anaemic condition strongly predisposes to convulsions." 
It will now be perceived, that no difference of opinion exists between these two distinguished writers, and that neither of them has one clear idea on the subject. Both of them set out with the idea that convulsions (see Chapter VIII, Book II) are founded upon the abstract imperfections of infancy, and both whittle entirely away this leading idea, before they conclude, and then close by knowing nothing about the subject. These extracts entirely justify the remarks we made in the chapter and book above cited, and afford us another opportunity to 


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treat of a subject that constitutes the foundation of nearly all the forms of disease which are incidental to infancy, and, indeed, to early and middle-aged manhood. 
Divines and speculative philosophers have frequently referred to man, as an evidence above all the balance of creation, of the wisdom and design of his Creator; pathologists are constantly, by inference, contending for the contrary. If we are to believe them, Deity bungled more in designing the organization of man, than in all the balance of the organic world ; and, as a consequence of this bungling, one-fourth of the human progeny die before the close of the first year, another fourth, before the close of four more years, and another fourth, before the attainment of manhood. Does such a mortality mark any other department of the animal creation ? Why does it so happen with man ? Prof. Eberle answers, when he states that " both the anatomical and physiological peculiarities of the infantile system, are indeed such as to account for the special aptitude to convulsive maladies during this tender period of life;" and Prof. Wood, with much more brevity, answers: " The peculiar state of the nervous system in infancy and childhood." The inference from these answers must be, that children possess a nervous peculiarity which is incompatible with life, health, and longevity. 
Our divines seem to think, and very correctly, that man's unfortunate condition, as concerns morality and religion, has resulted from his countless violations of moral and religious laws ; but medical writers seem not to have suspected that his physical condition, as regards disease and premature death, holds any relation to his numberless sins or outrages against his organic laws. No, in this respect, he has not sinned—his premature sufferings and death result from peculiarities incidental to his infancy, in the abstract and necessarily. This is the true and legitimate meaning of our professional writers, and yet none of them seem to believe it—at all events, they do not seem to be satisfied with it; for Prof. Eberle says, that " all children, however, are not equally disposed to convulsions." What a fortunate discovery this is! every child is not doomed to have convulsions, notwithstanding their " anatomical and physiological peculiarities," which produce an "especial aptitude to convulsive maladies," during infancy. 


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Prof. Wood, too, admits that there is " a great difference in children in this respect." Does this difference depend upon the necessary infantile peculiarities ? He informs us again, and Prof. Eberle confirms it, that some children inherit a convulsive disposition. This may be true —but how did the parents come by it ? He further states, that some children have this predisposition, whose parents never exhibited anything of the kind. We admit this to be probable, under circumstances. He ought to have informed us whether the children were born in the country that the parents were—a material point this 
" Mauricean, Leuret, and others," says Prof. Eberle, " assert that children who have very large heads are more liable to convulsions," than those of a contrary condition ; but the professor thinks this observation to be without foundation, and we agree with him, so long as it stands without qualification. The observation should have been thus stated: Children who have a large cerebrum, or mental organization, with a small cerebellum, or animal one, are the most liable to have convulsions —they are, indeed, almost the only ones who have them. In harmony with these remarks, are two which Dr. Wood has incidentally dropped, namely: children thus predisposed " occasionally exhibit great precocity," and, he adds, " the anaemic condition strongly predisposes to convulsions ;" but what are the organic features of the anaemic "condition ?" No writer has yet informed us—we suggest then, that all those who constitute the third class, page 20, are anaemics—and among them are frequently found extraordinary specimens of precocity. 
Dr. Eberle informs us, that Mr. North teaches that the children of parents who are too young and of those who are too old are more liable than the progeny of those who marry in the prime of life. We shall not dispute that the fact may so exist, in many instances, but we shall deny the presumed cause. If the parties did not marry before they were capable of procreating, then they did not marry too young, because it was never intended in the plan of creation that man or any other animal should have a power and not rightly manifest it, unless indeed, that the Author of all things bungled in this matter, as he did in the constitution of children if medical writers are to be believed. 


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But, as we are much more disposed to attribute human misfortunes to human transgression of wisely-ordained laws, so we are disposed to admit that many persons have married both too young and too old, because they should not have married at all. In the former, there was not a sufficient viability, and in the latter, transgression may have impaired that viability which originally may have been good. We have seen as healthy and viable children from mothers of fourteen and fathers of eighty years of age, as we have ever seen. It will not be denied that this is not sometimes the case, consequently it cannot be contended that youth and age produce, necessarily, unsound children, and a single exception destroys the rule. 
We conclude then, that the liability possessed by Some children does not depend upon any of the necessary peculiarities of infancy—that the plan of their existence, in the abstract, is as perfect as that of adults, and, cceteris paribus, they are as little liable to convulsions. 
Remote Causes. — Strictly speaking, we can acknowledge the existence of no predisposing cause—causes produce modifications of organization to a certain extent, or to an extent compatible with life ; in these modifications exist liabilities to certain family forms of disease, and upon the exciting cause and present circumstances, depend the particular member of the family which shall be developed. 
Upon this department of our subject, Prof. Eberle writes with much propriety and correct discrimination, but when reviewed in detail, or as a whole, he completely contradicts the whole of that doctrine which we have had under review. He shows, in effect, that infantile convulsions do not depend upon inherent peculiarities of the infantile constitution, in the abstract, but are produced by causes acting through the parents to the effect of unbalancing the organization of the progeny. It is true, that he knows nothing of the organic changes which the causes produce—and, without being justly vulnerable to the charge of egotism, we may safely assert, that our first book contains the first revelation that has ever been made on this subject. 
He says, that it is the opinion of some writers that infantile convulsions are much more frequent now than formerly, 


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and the assigned cause, in meaning, is about this: that in modern times too much attention has been bestowed upon the mental functions, and too little upon the animal; and this opinion he very appropriately and forcibly illustrates by a reference to our Indian tribes, among whom infantile convulsions are measurably unknown. 
This paragraph embraces pretty mucn his whole idea of the subject, and though correct as far as he goes, he has not fully embraced the idea—his remarks apply too much to the present training of children, and not enough to the peculiarities of organization that is entailed upon them. Many children die of convulsions before their organization could have been materially affected by training. He seems to have no idea of the vital exhaustion which is effected in parents, by their impassioned pursuits of pleasure or business, by which a large and preternaturally active cerebrum, and an equally preternatural smallness and feebleness of the cerebellum, or vital forces, are entailed upon the progeny. This difference, in very many instances, amounts to an absolutely unviable condition, even for a week, and beyond this, it is graduated to manhood. 
Exciting Causes. —These are necessarily varied and numerous—all causes of irritation in the sources of vital action, in early infancy, may produce convulsions in those who are organically liable; and at a later period they may be occasioned by sudden impressions made upon the mental department of the brain, and for the reason, that a turgescence of the cerebrum cannot be produced without the sources of vital action becoming similarly circumstanced. These views enable us to comprehend how it is, that even intermittent fever is sometimes, in children, introduced by convulsions. 
The irritations in the animal and mental systems of the brain, which produce convulsions, are not generally engendered in them, but are transmitted to them from other parts. A fright, by acting through the external senses upon the intellect, and through it upon the protective faculties, may result in convulsions ; and irritations, produced by worms in the intestines, acting upon the extremities of the spinal nerves, and through the spine transmitted to the sources of vital action frequently produce them. 
The ueriod of the first dentition, with anaemic children, is 


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fruitful in convulsions, because of the many irritations which are generated by the numberless developments in progress during its existence. Dentition is generally regarded as the cause, but this we are satisfied is an error—the vegetative system, in its troubles, selects the parts which are directly involved in the dental process, as organs through which to make known to our consciousness, its true and suffering condition. Further than this, the dental process has no more agency than others of equal importance. 
Sanguineous turgescence will produce convulsions as well as nervous irritation, and as the treatment in the two forms is very different, it is proper that neither of them should be mistaken for the other. Under the head of Cerebral Congestion, we have treated of the former, and the other frequently occurs in nervous affections of the pulmonary system. The former is distinguished by sanguineous phenomena, as a flushed and turgid countenance, a contracted, frequent, and tense pulse, dilated pupils, a hot and dry skin, and strong arterial action in the temporal arteries. When the affection is of the latter, or nervous character, the pupils are contracted, the countenance is pale, the skin is cool, at least, it is not heated, and the pulse is small, frequent, quick, feeble, and irregular, and very probably results from worms, or some other cause of alvine irritation, as indigestible food, or gastric irritation from inappropriate food. 
Convulsions may, and sometimes are, occasioned by the repulsion of cutaneous forms of disease or other morbid drains of the system. We have shown, in another place, that the exanthemata are sometimes introduced by convulsions, and that they also follow a repulsion of these forms of disease. The milk of the nurse, after violent mental emotions, or excessive fatigue of the body, has been known to produce fatal convulsions of the child. Convulsions may also be produced by mechanical causes, as blows or falls upon the head, and they result rather from the concussion produced, than the local injury inflicted. These concussions have been known to occasion morbid developments of the internal table of the cranium and consequent epilepsy. 
Prognosis. — Although convulsive paroxysms not unfrequently prove fatal, yet more is to be apprehended from that 
21 


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particular cerebral organization which occasions a liability to them. Such children may escape convulsions, but die of cerebral or pulmonary congestion, and they may escape these, and die of phthisis pulmonalis. No matter how circumstanced, such is their inevitable condition, organically, that they have the gauntlet to run, and will finally drop before attaining the meridian of life. Our cities are replete with such living monuments of parental transgression. Ought we to marvel that the progeny of such people should meet with an early grave ? 
According to the custom, we have digressed, for writers, in treating of prognosis, confine their remarks to the existing invasion ; but, with us, a useful idea or admonition is never dropped out of place. 
Convulsions, originating in remote irritations, as the helminthic, are, cceteris paribus, less dangerous than the proximate, or such as originate in the brain or its spinal prolongation ; but the former may produce such a structural lesion of the brain as to prove fatal. 
Sudden convulsive seizures, such as happen without premonitions, are to be regarded as more dangerous than those of a contrary character. When the paroxysm is attended by paralysis, or squinting, the existence of severe mental lesions may be suspected ; but convulsions, however occasioned, should so far be regarded with apprehensions as to command the most prompt and vigilant attention. 
Treatment.—Many forms of disease produce infantile convulsions, and hence the first duty of the physician is to ascertain the particular form of which they are a manifestation, and then, to treat the case accordingly. 
If they have resulted from cerebral congestion, the treatment will be found under that head. 
If they have been caused by the repulsion of some rash or cutaneous eruption, it should be reproduced by such revulsive measures, as emetics, followed by diaphoretics, and warm drinks, with the application of rubefacients to the spine and extremities, occasionally preceded by warm baths. The most suitable emetic for an infant is the Compound Tincture of Lobelia, or the Acetated Tincture of Bloodroot. 
If occasioned by indigestible food, or by the indigestion of proper food, the indication will be to empty the stomach by 


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emetics, followed by a small dose of the Compound Powder of Jalap. Cloths dipped in hot water, should be applied over the stomach and bowels during the convulsions, repeating their application every few minutes. 
If alvine obstructions have occasioned them, purgative enemata should be freely administered, and for the purpose of revulsive influence, they should always be of a stimulating character; thus, Castor Oil, Molasses, and warm water, of each one ounce, to which may be added one or two fluid drachms of the Compound Tincture of Lobelia and Capsicum; to be employed for a child six or seven years old. 
If worms have occasioned the convulsions, their expulsion becomes the proper remedy. 
In cases of strong determination of blood to the brain, it is quite common to bleed, but the physician who will reflect that more or less of anaemia is always present, and more or less constitutes the foundation of the malady, will never resort to such a measure, but will relax the surface, and equalize the circulation, by the same means as recommended above, in cases of recession of cutaneous eruptions. 
When dentition is ascertained to be the exciting cause—as the difficult or retarded protrusion of a tooth, we are advised to cut down to the tooth, but to do this with a view of facilitating its exit, is, in our opinion, betraying an ignorance of every physiological principle, but it must be done, however, for the purpose of relieving turgescence. 
In such cases, our reliance, mainly, should be placed upon revulsives, such as cool or evaporating lotions to the head, pediluvia as hot as they can be borne, and the hot or very warm alkaline wash; — the warm bath so used and repeated, in the event of much cerebral turgescence, as to keep down all excessive arterial action, will generally succeed in counteracting the spasmodic tendency. Absolutely cold applications to the head are objectionable, first, because they irritate, and second, because they may produce collapse. When even moderately cool or evaporating applications are used, we should give attention to the appearance of the face, so that we may discontinue their use, in the event it should become pale; the pulse at the same time being frequently examined, for, 


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should it decline or intermit, such revulsives should be discon tinued. When there exist decidedly inflammatory symptoms and a strong determination of blood to the brain, we approve of immersing the feet in very warm water, and then to use effusions of moderately cool water upon the head, shoulders, and thorax. In such cases, rubefacients to the ankles, legs, and back will frequently be advisable, but all vesication should be avoided, because it is liable to result in sphacelation in anaemic infants. 
In all cases of infantile convulsions, the Compound Tincture of Lobelia and Capsicum will be found one of the best agents for speedily allaying convulsive action; it should be given by pouring it into the corner of the mouth, and repeating the dose every ten or twenty minutes, until the convulsion has ceased. For a child one year old, twenty drops may be administered at a time. As soon as the child can swallow othei agents, then pursue the treatment as above directed. 


CLASS II. 
MANIFESTATIONS OF DISEASE IN THE SPINAL APPARATUS. 
INTRODUCTION. 
"We know that life can be continued for twenty-four hours after the destruction of the spinal cord; therefore, it may be inferred that it is not so indispensable to existence as the basilar portions of the brain ; nevertheless, when we contemplate the quadruple character of its functions, no doubt can be entertained as to its permanent importance in the animal economy. It receives from, and transmits influence to the brain ; and it receives impressions from and transmits them to all other parts of the system, and thus, as a prompt and faithful telegraph, it maintains unity and harmony of action throughout the entire domain of the animal economy. It acts in conjunction with the ganglionic system, and thus, so far as nervous influence is concerned, it regulates a large majority of the organic functions—exciting alike such as may be demanded by the nutritive, respiratory, digestive, circulatory, secretory, motory, sensory, and procreative functions; any disturbance of its normal condition produces derangement in all of them. The range of its influence is great, and not more great than complicated, and we regret to add, that we know by far too little of its multiplied forms of disease. So true is this, that we shall omit to treat of many of its so-called u diseases " — selecting only two, which are the most strongly marked and destructive. 
325 


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ORDER I. 
INFLAMMATORY FORMS OF SPINAL DISEASE, 
The pathological relations of the spinal cord and its membranes, very much resemble those of the brain and its membranes — its several forms of disease partake of the same peculiarities—those of the one frequently extend to the other, and with both there is a similar obscurity in the symptoms. This, indeed, we might expect from its known complexity of function. Through it, mostly, we become conscious of the ill or good health of our animal and automatic systems. It conveys sensitive impressions from most parts of the body to our source of consciousness, and transmits impressions of volition to the muscles of a large portion of the body. Morbid conditions of the cord produce deranged manifestations in all parts of the body below the point of disease. 
Genus I.— Spinal Meningitis— 
Inflammation of the Tunics of the Cord. 
Under this head, we propose to treat of an inflammatory form of disease of the membranes which invest the spinal marrow. In this case, the inflammatory action may or may not extend to the substance of the cord, and it may or may not involve those of the brain. Of the three investing membranes, it is the fate of the pia mater to be the most usual seat of the morbid action. 
It appears from medical history, that this variety of disease prevailed in some parts of France, in 1843 and 1844, as an epidemic, and in many instances it proved fatal in twenty-four hours; it did not, however, attack children, so much as those who had passed the age of puberty ; and, although the inflammation was very extensive, and the effusion beneath the membranes copious, yet it but seldom happened that the nervous substance of the cord became invaded. Its course was rapid, rarely extending beyond the fourth day; it was attended, in the outset, with severe pain in the abdomen, vomiting, purging, and general collapse, but reaction speedily succeeded, when the pulse became full and frequent; the face acquired a tetanic 


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expression with a firmly fixed retraction of the head. To these symptoms succeeded convulsions, coma, and death. 
With adults, it may not be difficult to ascertain that a diseased condition of the spine exists, because they can communicate their feelings, but such is not the case with young children. When pressure is made upon the spine, and they cry, we cannot be sure that the cry was occasioned by any unusual pain; they totter in walking when well, and therefore we cannot be sure that any spinal affection has produced it. 
Mons. Billard informs us, that this affection gives rise to convulsions of the limbs, and occasionally of the face, more especially if it be located near the base of the brain. He further informs us, that in twenty instances of convulsions, out of thirty, he had detected well-marked inflammation of the spine, and in these twenty cases there were six with inflammation of the meninges of the brain and of the spinal cord, so that it is probable that convulsions of infants are almost always the result of an irritation or inflammation of the rachidian meninges. The following case exhibits the development and the progress of the symptoms of meningitis : 
'Louis Russal, aged three days, entered the infirmary on the 3d of September. During the preceding night, he had been attacked with convulsions, which continued until morning. His limbs were rigid and violently bent; the muscles of the face were in a continual state of contraction ; the pulse was full, strong, and frequent. The convulsions diminished, without ceasing altogether, immediately after the application of leeches. The child was very feeble, and respired with difficulty, and discharged a quantity of frothy saliva from the mouth. On the morning of the 4th, the convulsions returned with increased intensity; the pulse was quickened, the integuments very hot. The feeble condition of the child forbade the application of leeches, and the treatment was confined to the application of cold to the head. The convulsions continued during the whole day ; the body remained rigid, and the vertebral column, which the weight of the trunk will cause to bend with the greatest ease in the young infant, remained straight and immovable whenever the child was raised. The cry was very acute, the muscles of the face contracted with the same force as before, and they appeared a little more 


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drawn to the left side. In the evening, the child sunk, became cold, with a small, intermittent pulse, and died during the night." 
"Post mortem examination. —General paleness of the integuments, spotted redness of the stomach, a discoloration of the mucous membrane of the small intestines, tumefied and red follicles in the large intestines. A large quantity of effused blood appeared on the surface of the right hemisphere of the brain, and a sanguineous serosity in the lateral ventricles at the base of the cranium. The meninges of the brain were pale, those of the spine very much injected, and on the surface of the tunica arachnoidea appeared a very thick pellicular exudation ; this coating was very easily removed, leaving the membrane beneath covered with red points without any alteration of tissue." 
" Such," continues Mons. Billard, " are the symptoms and lesions usually presented by spinal meningitis ; yet it is possible that there may exist simple irritation, without exhibiting, on opening the body, any apparent inflammatory lesions. It is not unusual to find after convulsions, in children, nothing more, as in adults, than simple injection of the meninges ; but ought we to doubt that this is the seat of the disease ? and do we not see that there is, in this case, only a difference in degree from the slightest irritation to the highest stage of inflammation, the progress of which generally leads to lesions, which afford incontestable proof of the nature of the disease ?" 
" The spinal meninges may participate in the inflammation of all the serous membranes. I once found, in a child that died three days after birth, peritonitis, pleuritis, and rachidian meningitis." 
This inflammation, although it may be very circumscribed, is frequently attended with the most serious symptoms; and then again, very extensive lesions may be produced without being attended with a single well-marked symptom. Hence it follows, that great difficulty exists in forming a diagnosis. The speedy progress of this malady, its numerous complications, the sudden change it makes from exacerbation to remission, and the uncertainty that attends the nature and duration of all the symptoms, tend to confuse the physician and to render his treatment inefficacious. 


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Treatment. — During the months of April and May, in 1844, a similar epidemic to that of France, prevailed in the southern and central portion of the State of Ohio, at which time a large proportion of the inhabitants of one neighborhood were at first attacked, after which the disease gradually extended itself over various parts of the country. In many cases, the persons attacked died within six hours from the appearance of the first symptoms, and mostly in a comatose condition, a few having death preceded by convulsions; the greater number of those attacked, however, died within thirty-six hours from its commencement, unless relieved at an early period. 
The plan of treatment adopted by the physicians at the commencement of the epidemic, was copious venesection, Calomel, and Opium, which, with the bare exception of one solitary individual, invariably resulted in death, so far as our observation extended. The treatment which we adopted, was the application of Granville's lotion the whole length of the spine, until free vesication was produced; Quinine was likewise administered in large doses, in connection with Aqua Ammonia, and Tinctures of Castor and Valerian; and where this failed to produce relaxation of the rigid condition of the muscular system, we employed enemas of Tincture of Asafcetida and Tincture of Lobelia. The above, with applications of warm water to the extremities, strong alkaline baths to the surface generally, and rubefacients to the stomach and abdomen, resulted in the cure of every case thus treated. The observation and experience afforded by this epidemic, clearly proved to our mind, that it did not depend upon inflammatory or excessive vital action. We would observe that this epidemic was confined entirely to adults. 
Genus I. —Myelitis— 
Inflammation of the Spinal Cord. 
This affection of the spinal cord occurs much less frequently than spinal meningitis. As nerves of sensation and motion are supplied by the spinal cord to most parts of the body, it may be readily supposed that disturbances in the functions of sensation and motion will become manifested in those parts 


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which are thus connected with the invaded portion of the cord, and such is found to be the case. 
Beside derangement of motion and absolute pain, there is very generally present a sense of numbness, tingling, formication, and coldness in the limbs. These may occur in one-half of the body, or only in a part of one half. The power of the muscles is also affected, and with this an impairment of the voluntary control over them, which may end in complete paralysis. 
As the anterior portions of the cord distribute motor nerves, and the posterior, sensitive nerves, so it follows that either motion or sensation may be separately destroyed, depending upon the special seat of the inflammation. A rigidly contracted or a convulsive condition of the muscles may succeed the paralysis. The automatic system of nerves, sympathizing with the animal, is often attended with much derangement of the automatic or vegetative functions, such as constipation of the bowels, retention of the urine, palpitation of the heart, dyspnoea, hiccough, etc. 
If the inflammation be located about, or at the origin of, the respiratory nerves, life is soon extinguished—at most in one or two days; but if below that point, as the abdominal organs are not so immediately essential to life, death may not supervene for several days, or the disease may pass into the chronic state, and continue for weeks, and even for months or years. 
It is taught, that the occurrence of rigidity or tonic spasms indicates the existence of meningeal inflammation, and that paralysis may be considered to generally denote inflammation of the substance of the cord ; but this diagnosis is of but little importance, as the treatment in both, so far as we now know, is, and must be, the same. 
A softening of the medulla is the principal anatomical character of this disease, and it may be partial or diffluent, white, or mixed with sanguineous effusion. A partial softening may exist in a part of the cord, with induration of another part; and when this condition obtains, the softening is at the superior extremity and the hardening at the inferior. When these two extremes exist, we may pretty safely infer, that they were produced by disease, but considerable softening sometimes 


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exists without our being able to infer that it was diseased; and yet it may, perhaps, be set down as a law, that extreme softening is attended by paralysis of motion or sensation. Post mortem examinations of this disease, not unfrequently disclose sanguineous congestion of the lungs, effusions of blood in the abdomen, cranium, or spine. 
Diagnosis.—It is important that we do not mistake either myelitis or meningitis for rheumatism, and with infants it is difficult to obtain a clear diagnosis. With adults, pressure on the spinous processes will give the most pain when the disease is in the cord, and upon the side of the spine when rheumatism exists. When the disease has so far advanced as to produce tonic spasms, or paralysis, then we need have no further doubt. 
Causes.—The most certain causes of this form of disease are strainings of the back and falls, which sometimes happen with children in the hands of awkward nurses, and we may add, atmospheric vicissitudes. It may also result from other diseases of the spine, and likewise from inflammation of the corresponding tissue of the brain. 
Prognosis.—This form of disease must always be regarded as dangerous, though by no means necessarily fatal. The words epidemic myelitis and death, appear to mean the same thing—to be assailed is to be destroyed. When the common form passes into well-established paralysis, death may be anticipated with much certainty.. 
Treatment.—" In the acute affection," Dr. Wood recommends, " bleeding as freely and as frequently as the pulse and general strength will permit; copious and repeated local depletion by cups and leeches along the spine, purging with calomel in the beginning, and subsequently with saline cathartics," etc. When a patient can bear all this and the disease too, the constitution may be said to be proof against both doctors and disease. 
Fever and inflammation are essentially the same—accumulations of vital force or action to remove obstructions to secretion and absorption. The indications then, must be to relax the system, establish an equilibrium of the fluids, to stimulate the obstructed or diseased parts to action, and lastly, to tone up the general system to a state of health. 


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Now, we beg leave to inquire, whether it is possible to meet these indications by the treatment of Prof. Wood ? It must now be obvious to every reader that the difference between the Eclectic and the Allopathic practice, is not merely a difference of therapeutic agents, but one of plan—one that conforms to the organic laws, and sustains the organs of their manifestatation. But to proceed: 
As, in these inflammatory forms of disease, it is common for the feet to be cold, while the diseased part is hot, and attended by much febrile action, it will be proper, under the circumstances, to commence with a warm pediluvium and rubefacients to the feet and ankles ; sponge the heated surface with water, not too cool to be agreeable, and administer by the stomach and by enema some bland and antispasmodic tea. If the stomach shall reject the tea, administer a mild emetic to allay irritation and cleanse the stomach; when, by this course, the fever has nearly subsided, it will be proper to give the patient a tepid or vapor bath, with antispasmodic enemas and drinks, and this should be pushed to emesis. If this antispasmodic course should not sufficiently impress the system or reduce the febrile action, recourse may be had to stimulating and relaxing alteratives. 
In the meantime, the kidneys should not be neglected—in this and similar forms of disease, as much depends upon an active performance of their function as upon that of the skin. 
Rice-water, corn-gruel, chicken-soup, etc., may constitute the food at this time, provided the patient is not at the breast. As a drink, water with any of the sub-acid fruits will be pleasant and agreeable. 
To answer the last indication, such stimulants and tonics should be administered as will maintain a proper depuration. 


CLASS III. 
MANIFESTATIONS OF DISEASE IN THE RESPIRATORY APPARATUS. 
INTRODUCTION. 
In entering upon the consideration of the respiratory forms of disease, we shall find death equally urgent in his demands, and perhaps no less successful in his enterprises, but we shall have a little less doubt and uncertainty in arriving at a correct diagnosis and prognosis—we shall feel that we are more in the path of science than in that of uncertainty and hypothesis. 
We shall find, in our course, many occasions to lament that our predecessors have been so disobedient to the organic laws, as to have made it necessary that so much life must, in defiance of our skill, be wasted through the imperfection of the respiratory apparatus ; and when we contemplate the immediate indispensability of a faithful and prompt performance of the functions of this class to the continuance of life, we should not feel surprised, that if exceedingly few of a faulty organization should be spared. 
In these reflections, furthermore, we may find some excuse for ourselves—some consolation, that the fatality depends more upon the necessity of the function and imperfection of the apparatus, than upon any relative deficiency of professional ability. 
The great cause of infant mortality must not, and should not, be sought in the normal peculiarities of infantile organization, as has been done, more or less, by all writers, or their manifestations of disease, but in those imperfections of organization which were entailed on them, and in consequence of which they become, to an extent, more or less, non-viable. 
This is not all; many peculiarities incidental to the infantile 
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functions, are referred, by different writers, to different abnormal conditions, and consequently, an error of this kind may lead to errors of pathology and practice. Every physician should, therefore, study in the infants themselves, the normal peculiarities of their functions. This duty will become apparent before we conclude these introductory remarks. 
The respiratory apparatus of infants is as indispensable to them at birth, as it ever will be, and yet between its functions in infancy and in adolescence there are some very strong points of difference, which claim our attention in this place, rather than in any other. 
If we take seventy-five pulsations and twelve respirations, per minute, as representing the normal standard of the pulmonary and circulatory actions in adults, which probably is very nearly correct, and thirty-nine respirations and one hundred and two, as the normal motions of the same apparatus in children a week old, we shall discover in them, respectively, a remarkable difference, and one which will greatly deceive us, if we attempt to draw from them, a priori, conclusions in respect to any of the known results of respiration. 
It is, for instance, well known that the respiratory function is indispensable to the calorific function, and that it is usual for a rapid respiration and circulation to produce an increase of temperature, and yet the temperature of an infant is much below that of an adult. 
If we were to admit as true, a common impression, that infants have a sort of double duty to perform—to provide for their daily waste —to eliminate this waste in the form of effete matter, and also to build up their systems and repair the waste —we say, upon the admission of this proposition, we might contend for a double portion of function in the respiratory and circulatory apparatus ; but while it is true that they perform one duty from which adults are exempt —the building up of the system —yet it is not true that they do as much in the repairment of waste. 
In infancy, there is very little waste in the animal system, all of the emotional and intellectual portions of the brain are almost or wholly idle, and the same is nearly as true of the locomotive —producing scarcely any waste. In their digestive system there is, relatively less waste, because their food is 


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already assimilated to their purpose. Their whole duty then, is scarcely equivalent, indeed it is not equal, to the adult repairment of waste. In harmony with these conclusions we will find the results of their respiratory and circulatory functions. 
Although infants breathe much more frequently than adults, they generate much less animal heat. The explanation of this we do not think so difficult as it has appeared to some writers on this subject. Men of active habits have usually an abundance of animal heat, and the activity of their habits occasions much waste. Now, if we contemplate the amount of oxygen requisite for the elimination of the effete matter, and for the supply of the daily waste, we shall discover an ample source of their animal heat; but in infancy x there is but little waste, and of course there is not much effete matter to be eliminated ; now, if we include these two processes with that of building up, we shall not have an amount of demand for oxygen in the infant, equal, cceteris paribus, to that of the adult. This is not the end of the argument: the adult receives, as ingesta, more carbon and hydrogen, than the infant, and yet, by the aid of the respiratory function, he, as a general fact, uses it in the production of animal heat; but the infant, notwithstanding its rapid respiration, cannot use, for this purpose, the little it receives, but stores it away in the adipose tissue. How shall we account for this ? We will give our explanation of it presently. 
It is now an ascertained fact, that the amount of carbonic acid evolved at each expiration is diminished in the ratio of its increased frequency; consequently the conclusion is authorized, that we cannot compute the quantity of the pulmonary function by the activity of the respiratory movements; then, what is gained by the activity of the respiratory apparatus in infants, and wherefore the necessity of it ? These are the questions we have now to answer. 
In the outset of this inquiry, it must be remembered that the infant manifests very few animal functions ; and these few are, comparatively, of but little importance to it; from this fact, it is to be inferred that that portion of the brain which was intended to preside over the animal functions is not in a condition to discharge its assigned duty, and will not be until 


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the functions that constitute the duty shall be required—that its power of volition is exceedingly feeble. 
In the next place, we must consider the respiratory function as being, in a measure, when perfect, an animal or voluntary one. Highly concerned in this function are a great number of the voluntary muscles, and to the respiratory apparatus, as a whole, are sent many of the animal nerves. In the last place, the infantile lungs are of a pale red color—not the color of mature, adult, or perfect lungs. 
The conclusions that appear to be justified by the preceding facts, are these: 1. The lungs being imperfectly developed, are incapable of appropriating to the use of the system all the oxygen that may enter them at any given moment. 2. The incapacity of infants for volition renders them unable to bring to the aid of this function the many muscles which were intended to aid it at a future period ; because of this imperfection, the chest or thorax is never, ordinarily or voluntarily, fully expanded. 3. The preceding difficulties create a necessity for rapid respiratory movements, that is, rapid under the necessities of the case, to obtain that oxygenation of the blood which both health and development require. 
The above conclusions are, it would seem, more satisfactory than those presented to us by Dr. West, who says: " There seems good reason for believing that the rapid breathing of the child is to some extent the result of its more delicate frame, rendering it unable, at a single effort, to inspire as deeply as the more robust adult, so that it is compelled, by the frequent repetition of its efforts, to make up for their comparative feebleness." 
We do not like this language—it seems to convey the idea that the infant is not as well adapted to its mode of being as the adult is, which we can never admit. A healthy child is, vitally, just as strong as a healthy man — it can resist disease as well, and is as well adapted to its age. As their lungs are not fully developed, and therefore might be injured by extensive impressions of atmospheric air, and as their functions do not require that high state of oxygenation that is indispensable to the mental functions, the full expansion of their lungs is not required. For some time after birth, they appear to exist, in some measure, in conformity with the laws 


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that governed their intra-uterine existence. This conclusion is sustained by the imperfect condition of their lungs, and the low state of their temperature. 
In adult life, the voluntary portion of the respiratory function, by long practice, becomes habitual and unconscious, as do many of the voluntary functions. That this is not the case in infancy, may be clearly inferred from their manner of breathing, which is intermittent or by pauses. Dr. West regards this manner of breathing as " another token of the feebleness of the respiratory power." " This respiration," he says, "is almost entirely abdominal; the chest moves but little and its walls are but little expanded." These facts do not support his idea of feebleness, but our conclusion, that the child has no power over the voluntary muscles, for if it had, the chest would both move and expand. 
In the investigation of the morbid manifestations of the several parts involved in the respiratory function, we shall find it to be our duty, frequently, to add physiological remarks for the elucidation of symptoms or pathological conditions— therefore we will now close these general considerations. 
ORDER I. 
INFLAMMATORY FORMS OF DISEASE IN THE RESPIRATORY APPARATUS. 
Genus I. —Catarrh— 
A Cold. 
This form of disease, though very frequent and often troublesome, scarcely needed a formal notice—it very rarely does, directly, much mischief, and everybody has remedies for it, which are generally efficacious ; we notice it merely because it is an affection which is probably more common to early than to adult life, because the mucous tissues are more vascular in the former period than in the latter. 
Catarrh, when unattended by any other word to give it a special signification, is used to designate an inflammatory affection of the mucous membrane cf the respiratory passages. 
22 


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We shall have occasion to treat of individual portions of this membrane, but as the whole of it may be the subject of inflammation, at one and the same time, the word catarrh is used to express it. 
It is difficult to determine why a catarrhal inflammation should be generally diffused in this mucous membrane, white those of which we shall treat should, in a very great degree be confined to particular portions of it. In catarrh, the cause appears to be general, while in the other forms of disease of this membrane, it seems to be specific. The facts connected with catarrh give it the character of a vicarious function, rather more than that of disease—which is really in some other part. Cold, acting upon the skin, under certain circumstances, so as to check its secretion, produces catarrh. The same is very frequently verified of the mucous membrane of the alimentary canal—a want of secretory action in this membrane often results in catarrh. The manifestations of disease in special portions of the respiratory membrane, must be accounted for by a reference to special predispositions or to specific causes. Prof. Wood says, that he has " never been able to discover anything specific in its (catarrh) character." We think it to be specific, in being uniformly general, and not confined to any particular portion of the respiratory membrane. 
Sneezing, though frequently occasioned by other causes, than those of catarrh, is very frequently the first indication of an assault by the latter, to which succeed, very rapidly, coryza, laryngitis, trachitis, bronchitis, and lastly, the tubes of the bronchia are involved ; but it may commence in the bronchial tubes and travel in the contrary direction. In general, the grade of inflammation is low and about equal in all the parts assailed. Its seizure upon the pulmonary ramifications of the bronchia is apt to induce catarrhal fever. 
When the catarrh is of a pretty violent character, it is quite apt to make a special assault upon the lining membrane of the nostrils, producing ozacna narium, from which is discharged offensive and often bloody matter, or it may specially assail the superior maxillary sinuses, producing ozsena antri highmori; in either event much pain will be complained of, until the ulcers break. It is often difficult to cure these ulcers, and much time is usually required for it. 


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Treatment. —In the treatment of this, usually simple, affection, it is proper to direct our attention to the cause. If it has resulted from a suppression of the cutaneous function, then the indication is to restore this function—and if from a suppression of secretion in the liver or alimentary mucous membrane, then our attention must be respectively addressed to them. If the morbid affection shall commence or run into the form of coryza, angina, laryngitis, or bronchitis, the treatment will be found under these respective heads. When it makes its assault in either of these forms, it should meet with prompt attention, that such further consequences as are frequently known to ensue may be prevented. In general, the indications are, to equalize the circulation—remove all causes of irritation, and lastly, to restore the general tone of the system. 
To meet the first indication, a tepid bath, or a vapor bath, which is preferable, aided by diaphoretic and antispasmodic agents, will generally be sufficient, more especially if the affection result from a suppressed secretion of the skin. 
If the bowels have been at fault, aperients or stimulating enemas will be indicated. 
The utmost attention should be given to the skin—it should be well cleansed and moderately stimulated ; and this mav be done by friction, stimulating liniment, Cayenne or Mustard, poultices, etc., more particularly to the feet, and foot-baths, with the internal use of warm diluent drinks, and in severe cases, expectorants and emetics. 
Genus II. —Coryza— 
Inflammation of the Nostrils — Cold in the Head. 
In treating of this subject, we shall incidentally embrace the maxillary and frontal sinuses, because the general treatment of them is the same, and because they are generally, though not always, implicated at the same time. With the unlearned, the affection is generally denominated " a cold in the head." 
Coryza is an inflammation of the schneiderian membrane lining the nose and the sinuses communicating with it, and attended with an increased discharge of mucus. It is very generally introduced by frequent sneezing, which is soon followed by a discharge of thin, ropy mucus from the 


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nares. If the irritation pass into inflammation, the mucus will become yellow and then purulent. 
This affection, in adults, very seldom demands medical attention, but the case is frequently very different with infants. The nares are not, to those above the age of infancy, necessarily air passages—the mouth may be substituted for them. Children cannot suck and breathe at the same time through the mouth—to them, the nose is indispensable—the nares are the true respiratory passages—infants always breathe through them, instinctively and spontaneously when they can, but when they are closed they are spasmodically forced to breathe through the mouth. When the nares are closed, no matter by what cause, infants, not having any reflective ability, do not open the mouth voluntarily to create an air passage to the lungs, but it is, by pauses, spasmodically opened by the vegetative demands of the system. 
In this wise, a proper oxygenation of the blood cannot be effected, nutrition must cease, because they cannot suck and breathe at the same time, consequently, death must soon terminate their existence, and sometimes it does, even before death becomes imperative from marasmus. 
Prof. Meigs has introduced, in his work on children, a case of this disease, and he has done it in a manner so well calculated to arrest the attention of a young practitioner, that we deem it proper to extract his account of it: 
" Being notified, by an urgent message, of the dangerous condition of the young infant, I hastened to the house, and finding the friends solemnized by the approaching event, I, also, was at first convinced that the child was about to perish. 
" It breathed after very long intervals, during which there was no apparent attempt to respire, and I noticed, that when it did make its aspirations, they were very sudden, rapid, and violent, after which it relapsed into its non-respiring condition. 
"I did not understand the nature of the case, but I remarked that it could not be spasmodic nor pseudo-membranous laryngitis, nor, indeed, any laryngeal affection, because, when it did respire, it did so with full freedom and perfection, which could not be predicated of any affection of the larynx, of the bronchi, or the lungs. 
" In the doubt in which I was placed, I took the child on 


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its pillow upon my knee, in order to inspect it more closely ; an inspection which left me no room to doubt that the obstruction was in the nares, and upon a closer examination, I found that the nares were entirely stopped up, as I before remarked. By means of the head of a pin, I removed the plug from the external nostril, but I could not free the deeper parts of the passages. 
" Seeing that the child was about to die—and I have, at this moment, no doubt that it was, but for the rescue, within half an hour of its death—I lifted it in my hands, and applying my mouth to the nostrils and blowing violently into the openings, I loosened and discharged the plugs into the pharynx, after which it was in a few minutes perfectly well, and I had no further trouble with it." 
However unimportant this disease may be with adults, this case carries with it the strongest conviction, that, with neonati, it may be attended with death, and often, too, as it is a malady of considerable frequency. 
Every adult knows how difficult it is, sometimes, to breathe through the nostrils in this disease, and, admitting the nares not to be entirely closed, but even in a small degree so, it must to an infant be very distressing and injurious, inasmuch as it is not capable of converting the mouth into an air passage. 
Infants usually sleep with the mouth shut, but when suffering under this malady, they cannot do it, although such is the effort to do it, that their rest is broken and unrefreshing. The respiration is noisy and attended with a sort of whistling sound in the nasal fossae ; the respiration becomes more difficult as the nasal mucosities become more copious and consistent. The orifices of the nostrils should be closely watched, as the mucus, by drying, is constantly making an effort to close them. 
There is, in some cases, such a rapid increase of the symptoms as to destroy the infant in three or four days; but in general, as it does not prevent the child from sucking, it is not dangerous. It is with the tumefaction of the pituitary membrane that difficult respiration begins, and with it the danger. 
The inflammation of the pituitary membrane sometimes 


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throws out mucus of such a quality that it concretes and forms a pseudo-membranous covering in the nasal fossae. As this is preceded by all the symptoms of coryza, we may conclude, that the formation of the membrane only indicates a more violent form of the disease. It is rarely ever possible to diagnose the existence of this membrane. Post mortem examinations have shown the pituitary membrane to have been intensely inflamed. Such cases are generally, if not always, fatal. 
Coryza may pass from the acute to the chronic form, and to harass the patient for many months, and finally destroy it by the disorganization it produces ; very frequently implicating the brain, producing acute hydrocephalus more likely than any other disease. Such an event is preceded by drowsiness, prostration, and other signs of cerebral irritation. 
Causes. — The most frequent cause of this malady, with children, is, no doubt, exposure to wet and cold —an exposure which requires vigilance to prevent. It is thought to be occasioned by a sudden check of cutaneous perspiration, more particularly when the application of the cold is partial, as to the feet and back of the neck. From the cause we have assigned, it may be inferred that the complaint is more common in winter than in summer. It is furthermore true, that some persons are more liable to it than others. 
Treatment.— This form of disease is frequently so very mild as to require nothing more than such prudence as may be requisite to prevent an increase of it—it will be sufficient for this purpose to keep the patient still, its feet warm, and person comfortable, with some reduction of the food. But should it be so violent as to cause considerable complaint, it will only then be necessary to cleanse the surface by a tepid or vapor bath, or simply by washing it thoroughly with a weak lye; and while this is being done, the patient should drink a warm infusion of Nepeta Cataria, Salvia Officinalis, or Scutellaria Lateriflora, and have the feet in a tepid bath rendered stimulating by the addition of ashes, salt, mustard, or capsicum ; and then, after being dried with a warm cloth, to be covered warmly in bed with a hot and moistened brick, or a few ears of boiled corn, to the feet. "Warm lemonade is frequently very beneficial as a drink while the patient is in bed. 


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In this stage of the malady, there is some tendency to constipation, which should so far claim our attention, by enemas, as not to permit the fecal accumulations to become a source of irritation. In the milder forms of the disease, this course of treatment will generally be sufficient. 
Should the symptoms be more severe and attended with fever, the Powder of Ipecacuanha and Opium, in small doses, or Compound Tincture of Virginia Snakeroot, with a free use of warm diluent drinks, may be added to the above treatment. 
If there should be much headache, with a full, strong pulse, poultices of Mustard should be applied to the feet, and the head may be bathed with the Cooling Lotion. 
In case of much inflammation of the frontal or maxillary sinuses, the inhalation of vapor of Vinegar will be found useful, and which may be accomplished by placing a towel over the child's head, in such a manner as to retain sufficient vapor for inhalation, when the nostrils and mouth are placed over it; the steam or vapor may be obtained by throwing the Vinegar on a hot brick or shovel. 
The pain in the frontal and maxillary sinuses is sometimes exceedingly severe, and for its mitigation many experiments have been tried. Dr. "Wood states, that he knew an individual who obtained instant relief by snuffing powdered Cloves, and for the same purpose powdered Cubebs have been used in the same way. It is said that Camphor held to the nose often affords relief. It is further stated, upon the authority of Dr. Harrington, of Philadelphia, that the inhalation of Chloroform gives immediate ease. 
The discharges from the nares are sometimes exceedingly excoriating, and for the purpose of protecting the nasal orifices and the lip, a little Suet or Spermaceti Cerate may be rubbed on them. It is stated that these discharges depend upon the serum of the blood, and as it becomes diminished they cease; and upon this principle, Dr. Williams prohibits the use of all fluids, and with much advantage, as he conceives. The disease, under this treatment, rarely lasts more than a day, and hence, after two or three days of suffering, the patient is quite relieved, and may again return to the moderate use of liquids. 


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Genus II.—Laryngitis— 
Inflammation of the Larynx Species I.— Acute Laryngitis. 
There is, among writers, considerable variety of opinion upon the subject before us, and after bestowing upon it considerable attention, it seems to us that Prof. Wood has manifested the clearest discrimination; and therefore, we adopt his divisions of it. Under the above head, he has three varieties: 1. Mucous Laryngitis; 2. Sub-mucous Laryngitis; 3. Pseudomembranous Laryngitis—to which we have added, Spasmodic Laryngitis. 
Variety I.— Mucous Laryngitis — Cold in the Chest. 
This is an erythematic inflammation of the mucous membrane of the larynx, which, though of frequent occurrence among infants, is much more frequently met with in children of a more advanced age; but no age is exempt from it. It sometimes exists alone, but frequently follows coryza, and frequently arises in the course of scarlatina, variola, etc. It is not uncommon for it to descend and involve the trachea and bronchia, but more frequently extends upward to the fauces, and sometimes invades all. We usually find, by looking into the fauces, the velum, uvula, and fauces to be somewhat red. 
The progress of this disease is usually rapid, but its symptoms are frequently obscure at first; the patient, however, will always be found manifesting more irritability and restlessness than would be expected from the existing signs of disease. 
In infancy, the cry is sufficient to diagnose the disease when it is violent. It is frequently so faint as scarcely to be heard, while the reprise is, on the contrary, acute and predominant. This inflammation, even in its mildest form, is attended with an abundant secretion of mucus, which at first is clear and thin, but it soon becomes thick and yellow. 
When the child sleeps, a quantity of mucus is apt to accumulate in the larynx, which may cause it to wake with a sudden start and threatened suffocation; it coughs, makes an attempt to cry, but cannot do it, until after a powerful effort, which dislodges the mucus that obstructs the passage to the 


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glottis. Although the air passage is very narrow, it is scarcely probable that an inflammation of the mucous membrane of the larynx could close it up so as to produce asphyxia; but, that tough mucus may so collect or accumulate in the larynx, as to produce such a result, is very probable. Asphyxia is produced by one cause or the other. 
In the post mortem examinations of such asphyxied cases as we have been able to find of this disease, we have not found that the asphyxia was caused by tumefaction of the mucous or sub-mucous tissue; we infer, therefore, that it resulted from an accumulation of mucus. 
This disease is frequently so mild as to attract but little attention, and even this mild form of it, in adults, is apt to destroy all audible voice, a whisper is the loudest sound the patient can make; in infants, the cry may be similarly affected. But the helplessness of infants renders the disease, however mild, dangerous to them, because of the mucous accumulations, which they cannot readily throw off—it is then, always dangerous to them. 
Some degree of fever usually attends this disease, and it may appear simultaneously with the other symptoms, or not until they have appeared. It usually runs its course in five or six days, terminating in resolution, the secretion of mucus, or it may pass into the chronic state. 
Species II.— Sub-mucous Laryngitis — Cold in the Chest, 
This is said to be the disease of which General Washington died. This circumstance not only distinguishes it, but gives it, almost, a diagnostic character. 
Sub-mucous laryngitis is thought to be more common to adults than to children ; and furthermore, it is thought to be only a violent stage of the mucous or erythematic variety. Some of the symptoms, such, for example, as commencing with a chill, which is followed by fever, attended with alternating sensations of chilliness and heat, would seem to indicate a disease of a more extensive invasion and consequently of more danger. 
That an erythematic inflammation can be mild or violent, is not a matter of doubt, but when.it leaves its proper residence, the surface, and seizes upon a sub-tissue, it is no longer 


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the same form of disease; consequently if the sub-mucous tissue of the larynx constitute a part of this affection, it is not simply an inflammation of the mucous surface, though it may have been originally. We do then, regard this as an essentially different form of disease, although an observance of the distinction may be of no diagnostic or therapeutic importance. 
That there is not more than one or two per centum of fatal cases in the previous disease, is very probable, and if there be less than fifty in this, it is not so violent as we think it to be. We speak with reference to that kind of practice which General Washington had the misfortune to have. Many of the cases supposed to be of the previous variety, which terminated fatally, may really have passed into this, and effected the mischief, but to us, it is more probable that laryngeal accumulations of mucus did the mischief, because both varieties appear to maintain an independent consistency from beginning to end. In the treatment of infants, there must generally exist more or less of doubt, because, as they cannot communicate their feelings and sufferings, the means of a clear diagnosis must be greatly reduced. 
If the patient be old enough to communicate his feelings, among the first symptoms of which he will complain, is sore throat —difficult and painful deglutition — and it should be remembered that this symptom should always excite alarm, unless we are satisfied that the inflamed condition of the fauces is sufficient to explain the full extent of the symptom, which it cannot do, when it is occasioned, mostly, by an inflammation of the epiglottis. 
The function of expiration is perhaps always easy, but that of inspiration is exceedingly painful and difficult, because of the inflamed and swollen condition of the membrane of the glottis, which causes it to close against the entrance of the air, consequently the acts of inspiration are greatly prolonged and attended with a whistling, wheezing sound, as though the air was drawn through a reed. 
When the air passage is very narrow, as it usually is with infants, it is not unfrequent, and it sometimes happens to adults, that the tumefaction of the mucous and sub-mucous tissues may produce suffocation, and then we have added to 


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the phenomena which usually follow such an event, the facial expression of great pain and suffering. 
Yomiting very seldom attends this disease, but as the child sucks badly, it sometimes happens that at the moment of deglutition, the pain occasioned by the movement of the pharynx, will induce it to quit the breast and suddenly to cry, which will cause the fluid, in the oesophagus, to reflow toward the mouth, and in this movement of it, a little may enter the larynx and cause a sudden, suffocating cough that may greatly endanger the patient. Accumulations of mucus in the larynx may take place during sleep, and produce similar results. 
In this disease, the epiglottis sometimes becomes so inflamed and swollen as to become incapable of a normal adaptation to the glottis, whereby particles of substances, in the process of deglutition, obtain access to the larynx, and produce intense irritation, which is succeeded by paroxysmal coughing and a painful difficulty of breathing. 
In this stage of the disease, the child is exceedingly restless and distressed, never able to sleep but a few minutes at a time, so urgent are the demands for fresh air; its system begins to show signs of insufficient oxygenation—the surface becomes cool; the pulse becomes small, frequent, and feeble; the lips bluish; the face livid, and, in the respiratory efforts, the shoulders rise, the chest heaves, the skin becomes covered with a clammy, cold sweat, and then succeeds delirium, coma, and death. 
But death does not'always come on thus gradually—life is sometimes suddenly arrested by a complete closure of the airpassage to the windpipe; but without this event, so rapid is the course of the disease sometimes, that death may supervene at any time between seven or eight hours and three or four days ; and yet, when the attack is mild and slowly progressive, it may continue three or four weeks, and then terminate in death, in resolution, in the chronic form, or by serous effusion into the sub-mucous tissue, and thus death may result from a recuperative process of the system, and it may not — depending entirely upon the extent of the effusion. 
Cases have been witnessed, in very feeble infants, of an (Edematous affection of the throat, in which the only marked symptom of laryngitis was the cry, the debility being, as was 


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supposed, too great to produce the inflammatory symptoms to an appreciable extent. But in these cases of cedematous laryngitis, oedema was found to obtain on various parts of the body. 
Diagnosis. — Constitutional results, resembling those of laryngitis, do sometimes attend manifestations of disease in the chest; but still, we cannot consider it as scarcely possible that either can be mistaken for the other. The seat of the pain, the change of voice, and the peculiar cough should always distinguish laryngitis from pectoral affections. 
Treatment.—The treatment of the mucous and sub-mucous forms of laryngitis will be similar; it should be commenced with a mild emetic, as the Compound Tincture of Lobelia; after which, some slightly stimulating liniment should be applied to the neck and throat, two or three times a day, followed by the application of cloths wet with warm water, or a warm fomentation of Hops and Mullen leaves, around the throat. The feet and legs should be placed in a vessel of warm lye-water for ten or fifteen minutes, and which may be repeated daily, or even twice a day. Expectorants must be administered, such as the Compound Tincture of Lobelia, in small doses, repeated several times a day; or, 
Syrup of Squills, 
Syrup of Senega, aagj, 
Camphorated Tinct. of Opium, 3ij, 
Tinct. of Lobelia, 3j. Mix. 
Of this, ten or fifteen drops may be given to a child five years of age, and repeated three or four times a day. 
When children are sufficiently advanced in years to inhale vapor, the warm vapor of vinegar should be inhaled several times a day. The bowels should be kept open by laxatives, and if there be much febrile disturbance, the Compound Tincture of Virginia Snakeroot may be given in sufficient doses to maintain moderate diaphoresis, with warm diaphoretic infusions. Mustard plasters to the feet should not be omitted. 
When these two forms of disease become more active, and consequently more serious, they demand a prompt and energetic course — the emetic may be repeated daily for several days; diaphoresis should be constantly kept up, and some 


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rubefacient applied to the back of the neck and between the shoulders. 
The room should be kept warm, being careful not to allow a current of cool air to pass over the patient, and the diet should be extremely meager. / 
In the case of adults, the only variation in treatment is in the adaptation of the doses, the more active medication, and the use of a gargle composed of an infusion of equal parts of Hydrastis Canadensis, Myrica Cerifera, and common salt, to half a pint of which may be added a drachm of black pepper, and two ounces of vinegar;—the throat may be gargled with this four or five times a day. 
After the severe inflammatory symptoms have subsided, leaving a troublesome cough, with irritation of the fauces, glottis, etc., the following compound will prove very beneficial: 
Saturated Solution of Alum, Syrup of Balsam Tolu, aa 3ij, Camphorated Tinct. of Opium, 3j. Mix. 
An adult may take a tablespoonful of this compound several times a day, especially when the cough is very troublesome ; children may use it in doses proportioned to their ages. 
Species in.— Pseudo-membranous Laryngitis — Group. 
In commencing the consideration of this form of disease, we have found ourselves considerably perplexed by the widely different opinions which are entertained by different writers. Dr. Cullen locates the disease in the trachea or windpipe, and Dr. Watson follows him; Dr. Billard and Prof. Wood locate it in both the larynx and the trachea; Rilliet andBerthez locate it in the larynx, and Dr. West locates it in either or both of these organs, and says, that " the chief morbid appearances are always discovered in the trachea, and air-tubes." In treating of the post mortem appearance presented in this disease, he says: 
" In cases of croup that have come under my observation, the formation of false membrane in the larynx has seemed almost invariably to precede its deposit in the trachea." 
It has been our conviction, since being a student of medicine, having at that time a special motive for an investigation of it, that it is essentially a disease of the larynx, but it may, 


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and probably does, very generally, involve the trachea, and may even extend to the bronchia. Prof. "Wood very properly remarks: 
" Croup is not essentially an inflammation of the trachea; it may exist without disease in that portion of the respiratory passage, and inflammation of the trachea often takes place in infants, as in other catarrhal affections, but the same is not true of the larynx, without producing the symptoms of croup. The complaint may be confined to the larynx, though it generally embraces also the trachea, and not unfrequently extends deeply into the bronchial tubes. It may, therefore, occupy one or several divisions of the respiratory passages. If any one part is necessarily affected, it is the larynx; for a case would scarcely come under the designation of croup, in which this organ should not be disordered, at least in its functions." 
If an inflammation of the trachea cannot produce the symptoms of croup, then an inflammation of that tube is not a necessary part of the disease; but if an inflammation of the larynx does produce the symptoms of croup, the croup is laryngitis —therefore, it appears to us a great want of philosophical accuracy to include the trachea in the definition of the disease. 
In the above extracts, the professor has, and he has not, made an inflammation of the trachea necessary to the disease. His definition of the disease, which follows, when deprived of the italicised words, will be correct: 
"Croup maybe defined to be a disease, in which inflammation or high vascular irritation of the laryngeal or laryngotracheal mucous membrane, is combined with spasm of the interior muscles of the larynx, giving rise to peculiar modifications of voice, cough, and respiration." 
Notwithstanding our disposition to regard croup as a laryngeal affection, and notwithstanding that we find ourselves, in this respect, to be in harmony with the weight of the profession, more especially if numbers can give weight, yet we are disposed to confess, that there are some circumstances which favor the opinion of Cullen, which has been adopted by Prof. "Watson —the first is an exemption from pain in deglutition, and a second is, there does not appear to be spasmodic action enough for it to be a laryngeal disease. "With such authority, 


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however, as that of Relliet and Berthez, to say nothing of others, we may feel pretty safe in the conclusion to which our investigations and observations have drawn us. 
As there is, perhaps, no disease that has given the profession more trouble than this, and as it is one which is attended with great fatality, we will be excused for having devoted so much attention to the precise and definite location of it. Without precision of idea there can be no precision in practice. 
But our trouble is not yet concluded. There is another form of disease, or a modification of one, or, at all events, another set of symptoms, which are vulgarly and professionally mistaken for croup, but which is not the same as that above defined ; and like croup, its precise location or character has not been agreed upon, by medical writers; some regard it as an inflammation of the trachea, but more generally it is treated as an affection of the larynx. It is designated by several names, as, spasmodic laryngitis, stridulous laryngitis, stridulus angina, false croup, and by Prof. Wood, catarrhal croup, to distinguish it from true croup, or pseudo-membranous croup. As neither of the other names is calculated to keep us clear of confusion, it is best, we think, to adopt his names. Spasmodic laryngitis may be confounded Math the other, as both are attended with spasms, and so, also, of the other symptoms. With these remarks we return to the consideration of pseudomembranous croup, or laryngitis. 
Croup is an inflammation, essentially of the larynx, but it may extend through the trachea, and even into the bronchia, and according to some writers, even into the bronchial cells. It is attended by the rapid formation of a pellicular concretion, which is spread over the walls of the larynx, and, in some cases, lines the trachea and extends into the bronchia. Before the production of this pseudo or pellicular membrane, the mucous membrane is always much inflamed, red, and gorged with blood; the sub-mucous tissue also participates in the injection, and when the inflamed membrane is at the same time the seat of sanguineous exhalation, this exhalation is seen to be accompanied, or followed, by the concretion before named. 
From these circumstances, it may be inferred, that croup is a catarrhal inflammation, or holds some striking affinities with 


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it, and the blood, normally destined for mucous secretion, becomes plastic by the inflammation, and thereby imparts to the mucus, a portion of its fibrin, and hence, by concretion, comes the pseudo-membrane that distinguishes this modification of disease. 
Upon the general features and manifestations of this disease, the profession are pretty well agreed, but in many circumstances related to it, there is considerable contrariety of opinion, which, perhaps, is entirely referable to the difference of topography, latitude, telluric, and atmospheric conditions. All agree that it is not a disease incidental to the earliest periods of life, and yet, essentially a disease of youth, or early life, most frequently occurring between the ages of two and five years, sometimes younger, sometimes older, and among adults in the ratio of about one-tenth of one per cent. 
In the commencement, the symptoms are precisely like those of catarrhal croup, and so they continue, until the voice begins to become whispering and the cough husky; up to this time, it is possible that there is only an engorgement of the respiratory passages, with a high state of irritation—the existence of inflammation is barely possible, at all events, no exudation has taken place. If the disease do not begin in the larynx, the introductory cough may, in nowise, differ from a common catarrhal one, and the voice may be equally of the same character; but after a while, the voice sinks to a whisper and no efforts of the patient can raise it; from sonorousness it becomes husky and apparently stifled in the throat, and appears in paroxysms; —following the cough, the inspirations are short and whistling. 
Sometimes the disease begins in the bronchia, and then the introductory symptoms are those of bronchitis; sometimes its outset is in or about the fauces, and then the symptoms are catarrhal, and attended with sore throat and more or less painful deglutition, hoarseness being the first indication of an invasion of the larynx.* 
* It is said that the colds or catarrhs of children are never attended with hoarseness. If this be true, and we believe that Cheyne is the authority, parents should give particular attention to it—it will give them a timely admonition of the impending danger. 


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But 110 matter where the disease began, the breathing at length becomes labored, and sounds as though it was passing through a contracted and unyielding aperture. All audible voice now becomes extinct, and any effort to speak produces paroxysms of a low and smothered cough, with pain in the throat and superior portion of the thorax; an anxious expression of impending suffocation covers the face; the disposition is restless; the features are swollen and darkened, the breathing very difficult, and the extremities cold. Sooner or later the paroxysm relaxes—the patient obtains some rest; but before his wearied system becomes refreshed, he is roused by another paroxysm of, probably, increased violence—the respiration is hurried to three or four times its normal standard. 
Sooner or later in the disease, febrile action sets in, and always in the ratio of the other symptoms; sometimes it appears at the very onset, and runs high. 
Between this disease and laryngitis, proper, there is this analogy: both run their course rapidly, proving fatal sometimes in twenty-four hours, but more frequently in forty-eight; and then, again, it may continue five or six days. Dr. Craigie states, that whether fatal or favorable in its termination, it is never protracted beyond the eleventh day. 
Upon the event of a favorable turn in the disease, the cough changes and sounds as if something had become loose in the trachea, and with this change there is a general mitigation of all the symptoms; the coughing brings up viscid mucus, sometimes patches, strips, and even tubes of the pseudo-membranous concretion. Finally, this membranous matter is either absorbed or discharged, and the patient recovers. 
But, on the contrary, should no change have been manifested for the better, the sonorous and wheezing respiration will become so increased as to be heard to a considerable distanc —every muscle that can aid the respiratory function is brought into requisition, the arms are spread asunder, the head is thrown back, the nostrils are extended, the chest drawn up, and the facial expression tells that it is all for breath— every expression of agony is impressed upon it, and it is manifested through every muscle of the chest and neck—the skin becomes cold and clammy, the pulse increases in quickness 
23 


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and feebleness, the lips become livid, the face cold and pale, the brain, not being reinforced by properly oxygenized blood, ceases to superintend the struggles for relief, and the curtain of stupor or drowsiness drops before the scene, or it rallies the remaining elements of life into a last effort which results in convulsions and death. 
It is not, however, always the case that the patient is permitted to struggle while there is strength, for life is frequently cut short by suffocation. 
When the cry is so changed that the reprise portion of it can only be heard, and when, heard, it is acute and sudden, like the crowing of a young cock, and when the voice is lost, we may safely conclude that croup is present; but we cannot have an absolute certainty of it, until we see detached portions of the false membrane thrown up by expectoration. 
Causes.—Croup is much more common to northern than to temperate and southern latitudes —much more common in dry, cold weather, with northern winds, than in any other; more common to a sea-coast, lake, or river situation than to interior ones. 
It is now generally admitted, that not less than one-half of all the cases which obtain in cold latitudes, terminate fatally. 
In this country, it obtains, but not frequently, and its fatality is not much less than it is in higher latitudes. The cases here, which are generally called, treated, and saved, as croup, are of the catarrhal variety. When croup does occur here, or further south, it is usually during the prevalence of northern winds and storms. 
This disorder is not contagious, but in some situations it is reported to be endemic; its attacks are generally in the night, and during the one immediately succeeding the exposure of the patient to cold weather, insufficiently protected. Dr. Alison says, that it seems to be, not unfrequently, produced by the child's sitting or sleeping in a wet room. 
In some families there seems to prevail a sort of croup diathesis, as it is common for many or all of the children to have it as they arrive at the proper age. It is also more frequently met with in males than females, and with sanguine lymphatic, sanguine-bilious lymphatic, and sanguine encephalo-lympha tic temperaments than others. 


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Diagnosis.—Spasmodic, cerebral, or catarrhal laryngitis or croup, is the only form of disease with which pseudo-membranous laryngitis or croup can be confounded, and between these the diagnosis is so well marked that such a mistake should never be committed. This form of disease comes on slowly, more or less like a common catarrh ; that, the spasmodic, attacks suddenly, and is but rarely, if ever, preceded by catarrhal symptoms. The former may appear suddenly, in some instances, but then its character is so essentially febrile, while the latter is not, that they need not to be confounded. 
Febrile intermissions never attend the former, except occasionally after vomiting; but complete intermissions do attend the latter — remissions only characterize the former. The stridulou8 sound of the cough and inspiration so peculiar to the former, is absent in the spasmodic form. In the former, the pulse is excited and irritated, generally quick, tense, frequent, and full, with an increased or febrile elevation of the cutaneous temperature; but, in the latter, the pulse is small and contracted, and the cutaneous temperature continues natural. 
Prognosis.—This form of croup is always to be regarded as dangerous, and the extent of the danger is always indicated by the violence of the inflammation; —its danger, furthermore, as a general fact, is in proportion to the suddenness of the attack. , 
At one time a majority of the cases of this form of croup terminated fatally —it is still attended with much fatality, and necessarily must be so long as fever and inflammation are treated as forms of disease—so long as the idea of sustaining vital energies consist in breaking them down by bleeding and purging. 
Treatment.—Bleeding, puking, and purging, with calomel, constitute the usual practice in this form of disease—and this, at one time, was our practice —we have given large doses of calomel to a child a year old, and sometimes we approved of the results so much that we abandoned the practice with much caution, fearing that we could not do better; long since, we rejoice, however, we not only abandoned the practice, but also the principle upon which it is founded. 


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We are required, in aiding nature in this form of disease, to relax the constricted or spasmed organs —the skin is in this condition, as indicated by its heated and febrile condition. In the second place, we are required to strengthen the debilitated organs, which are the larynx and probably the trachea, for otherwise, they would not have become the seat of obstruction or disease, and as a proof of the fact, they are highly excited and labor under an excessive action. 
To meet the first indication, an emetic should be promptly administered, and which should be as promptly repeated, as often as the peculiar croupy inspiration occurs ; and the most efficacious articles that can be used for this purpose, are the Compound Tincture of Lobelia, or the Acetous Emetic Tincture. After having produced free emesis, either of these tinctures must be continued in doses sufficient to produce expectoration, and in severe cases, even nausea. Hot water should be applied to the throat constantly, and the skin should be thoroughly cleansed, and as far as possible relaxed by the warm lye-wash. 
In the meantime, or as soon as some cutaneous relaxation shall have been effected, the second indication should be attended to. For this purpose, Cayenne or Mustard poultices should be applied to the extremities and the neck, or as near to the weakened parts as possible. For this latter purpose, various poultices have been recommended ; we knew an intelligent gentleman who regarded a poultice of roasted onions as an infallible remedy; Dr. John D. Goodman, says Dr. Gunn, regards dry Scotch snuff, sprinkled on a plaster (which may consist of a piece of greased linen, or it may be sprinkled over the face of any poultice), as a reliable remedy. 
We think it very probable that the roasted onions have been very useful in some cases, and that Scotch snuff may have been so in others, but we are far from being able to regard any one application as being uniformly infallible. One drop of the Oil of Stillingia, placed upon the tongue, has in the practice of several Eclectic physicians, as well as in our own, rendered immediate relief, and ultimately, by its repetition, cured cases of this disease, which had absolutely resisted all previous treatment, and the cases were supposed beyond the influence of medication—thus fulfilling all the indications 


IN THE RESPIRATORY APPARATUS. 
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claimed to be produced by the employment of calomel at the hands of the old school physicians. We have, also, found it beneficial, when applied externally, in the form of a liniment: 
Oil of Stillingia, 3j, 
Oil of Lobelia, 3ij, Alcohol, giij. Mix. 
The throat, neck, and chest must be bathed with this three or four times a day; and after each application, a fomentation should be applied, composed of two parts of Hops, one part of Lobelia, with equal parts of vinegar and water; boil together and apply the herbs. 
The Nitrate of Silver, in solution, has been highly recommended as an application to the fauces, glpttis, and even to the larynx, upon the plan proposed by Dr. Green, of New York, but as far as our own experience and observation have extended, we consider the treatment above-named as superior to any other with which we have yet become acquainted. 
We have remarked that both bleeding and purging are quite universally practiced in the treatment of such forms of disease as produce inflammation, for their removal, and we have, in several places, intimated that both are enfeebling or prostrating—destructive of the vital forces, while neither of them is depurating, and consequently neither of them can be properly indicated in the removal of disease, because disease most frequently has its origin in defective depuration. 
According to these views, and we hold them to be sound, we should direct our efforts to the renal and cutaneous secretions first, and then to those of the glandular system in general. The bowels, therefore, claim our attention no further than to see that their accumulations do not become a source of irritation. 
Although we regard proper external applications to the neck as being of much service, by relieving the part of much of its capillary congestion, yet we should not neglect the use of stimulating gargles, such as the one recommended in the mucous forms of laryngitis, and if the child cannot gargle, this should be applied to the fauces and throat by means of a swab, and a small portion of it may be occasionally swallowed. 
It often happens that when the croupy symptoms have been relieved, the evidences of constitutional irritation still exist; 


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in such cases, we may safely suspect that the liver, and probably other glands, have not resumed their proper functions. In such cases we may have recourse to aperient and stimulating alteratives. 
The child should be kept warmly clothed, and the diet should be light, until convalescence, when, if prostration takes place, stimulants, tonics, and nourishing diet should be used. 
Variety IV. — Spasmodic Laryngitis — False Croup, Catarrhal Croup. 
This form of disease is never attended with the production of a deciduous or pseudo-membrane in any portion of the respiratory passages — the initiatory usually consists of such catarrhal symptoms as coryza, suffusion of the eyes, chilly sensations succeeded by those of heat, some hoarseness and cough. 
These symptoms may continue for several days, or only for twenty-four or forty-eight hours, without much modification, which usually occurs at night and during sleep, consisting of the strongest indications of impending suffocation; such as cough and dyspnoea, with struggles of the muscular system in aid of the respiratory function. 
Sometimes it is introduced by a croupy cough, some fever, and hoarseness, which may continue a few hours or even days, before the arrival of a paroxysm such as above described. The paroxysms, as they obtain in different cases, present two great extremes: in some they are quite mild, and excite no particular fears—in others, they are so violent as to produce the strongest apprehensions of immediate suffocation. Between these extremes every grade or degree of violence will be observed in practice. 
During a paroxysm, the face is forced into those conditions and expressions which mark a case of strangulation—it is swelled, of a violet or dark red hue, the eyes are humid and projected in their orbits, the expression of the face is anxious, the respiration is hissing and protracted, the voice is reduced, but never to a whisper, the surface is hot, the pulse quick, and the cough, if present, which occurs at intervals, is hoarse. These are the usual phenomena of a paroxysm, and when concluded, sleep ensues. 


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A single paroxysm may terminate the disease, at ail events, the patient will only be troubled with hoarseness and a dry, barking cough until the next night, when, if the disease have not terminated, the patient will have another paroxysm, possibly two, and thus the disease continues to its close, with one or two paroxysms per night. 
In some cases, however, the paroxysms recur more frequently, and each one is characterized by more violence than the preceding, until finally a greater degree of violence becomes incompatible with life, and death, by asphyxia, closes the scene. 
But in the midst of a paroxysm a change for the better may supervene, and when it does, it is usually indicated by signs of secretion, as a loose cough and the throwing up of some mucus; the violence of the symptoms is mitigated, the cough loses its harsh ring, the inspiratory sounds have a mucous character, the croupy and febrile symptoms disappear, and between three or four days and two weeks, the patient is well. 
But, instead of a favorable turn, additional and more exhausting symptoms may appear, as great restlessness, nausea, and vomiting, followed by a small, frequent, and vanishing pulse, cold extremities, clammy sweats, coma, and death. 
Predisposing Causes.—However difficult it may be to determine, precisely, the pathological differences between the several forms of laryngitis, over which we have passed, the diagnoses, in general, are quite unmistakable. When we consider the fact, that they are all more or less inflammatory and involve the same parts, it would seem possible, and even probable, that catarrh might be provoked into the mucous laryngitis, and that the milder forms of this might likewise be converted into the more severe; and yet we have no reliable evidence that they do thus merge into each other. 
The only explanation we have for this remarkable fact is this: certain telluric and atmospheric influences, peculiar to certain localities and latitudes, so dispose or constitute the system, that a cause which produces croup in a northern child, could not, caeteris paribus, produce the same form of disease in a southern one. To this law occasional exceptions may be admitted. 
The admission of this principle, although we cannot com- 


INFLAMMATORY FORMS OF DISEASE 
360 
pretend its modus operandi, enables us to come to a conclusion, as to why it is that croup is frequent in one situation, and pseudo-croup in another. To contend that the south has no weather cold enough to prove an exciting cause, will not do, because the croup is produced in the north by weather more mild than some by which the south is visited. 
There appears, furthermore, to be a croupal organization in some families, and that this organization does not exist in early infancy, and when produced, it does not continue usually into adult life, and thus it is that a liability to croup is measurably confined to a definite period of life. 
Croupal symptoms and pseudo-membranous concretions are sometimes occasioned by scarlatina, but we have not, from any writer, learned that spasmodic laryngitis is ever produced in the same manner; and if it be not, then this circumstance adds to the evidence that croup and pseudo-croup are not different degrees of the same form of disease—that they are not varieties of the same species. From what we have been able to learn, we deem it to be as impossible for one form to pass into the other, as it is for catarrh, in early infancy, to pass into croup. 
Exciting Causes. — These are usually such as occasion catarrh—such as an improper or unprotected exposure to a cold and damp atmosphere, or sudden atmospheric changes. 
This form of croup is liable to a frequent recurrence — as frequent as may be the exposures to the cause that usually produce it. All the forms of laryngitis may be regarded as being produced by the ordinary causes of catarrh. 
Diagnosis.—The diagnosis between the two forms of croup we have given under the head of pseudo-membranous croup, and therefore, in this place, we will barely add, that the seat of the pain, the change of the voice, and the peculiarity of the cough should always distinguish both forms of croup from all pectoral forms of disease. 
Prognosis.—All the forms of laryngitis, must be regarded as dangerous, if permitted to run their own course, but this form is much less dangerous than the pseudo-membranous, and therefore it may be regarded as generally favorable; and yet, when prolonged beyond the third day, and is still increasing in violence, and more especially when attended by 


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nausea and vomiting, an unfavorable termination may be expected. 
Treatment. —When the affection is characterized by much inflammation, the treatment recommended for pseudo-membranous croup should be adopted. Lehman recommends us to apply a sponge, dipped in hot water and then squeezed out, upon the anterior part of the neck, and frequently repeated at short intervals, until the skin becomes red and a general perspiration follows, which should be promoted by the use of some mild, tepid diluent. In many instances, this means will arrest all the symptoms and cut short the disease. 
With the exception that this form of the disease requires a liberal use of antispasmodics, the treatment should be very much as in the preceding form. 
Genus III.—Bronchitis— 
Inflammation of the Bronchia Species I.— Acute Bronchitis. 
Under the above title, we include every case of inflammation of the bronchial tubes, which is of short duration, without any reference as to its precise location. 
This form of disease in new-born children, may be of very short duration, and may originate in inappreciable causes, and in a few days spontaneously disappear. In such mild cases, there is frequently no other symptom than the mucus rale, or short, noisy, and frequent respiration without the rattle. Its beginning, sometimes, is that of catarrh—affecting the nostrils, fauces, or larynx, and from these parts descends to the bronchia. 
In its mild form, it is vulgarly called a cold in the breast — manifesting its existence by hoarseness, mild cough, slight sensations of heat or possibly a little soreness in the thorax. It very rarely demands medication, and as rarely occasions any notable inconvenience. 
After the age of infancy, the disease becomes more obstinate, and between the mild stage of it, and the severe, there is every intermediate shade of difference. It frequently shows its threatening tendency in the onset — and, no matter as to its precise location, the difficulty with which the air enters the 


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lungs occasions very serious symptoms. In such cases, it is apt to commence with coryza, sore-throat, sensations of lassitude, chilliness, and febrile reaction. Cough, being one of the first symptoms, soon becomes one of the most troublesome of its attendants. The symptoms, increasing in magnitude, soon give rise to such as threaten suffocation, a result, possibly, of a serous infiltration in the pulmonary tissue, or it may arise from some modification of the inflammation in the air-passages ; but, as the cause may not always be the same, it is sufficient for the present that the lungs are not freely penetrated by the air. 
"When the disease has entered the smaller tubes, it is apt to invade the air-cells and produce pneumonia. In duration, the attack varies from four to ten days, and though frequently severe and threatening, its termination is not generally fatal. After two or three days a transparent, frothy, or ropy mucus, occasionally streaked with blood, is thrown up by painful and often convulsive coughing. The secretion increases, becomes more opaque, and ultimately yellowish or greenish, and with this change in the secretion the other symptoms become meliorated. 
Causes. —A cold atmosphere, and more especially when moist, is, beyond doubt, the most frequent cause of this complaint ; it can, also, be occasioned by both mechanical and chemical causes ; among the first may be named fine dust of almost any kind, and of the second, acid vapors. The class of persons most liable to it is the sanguine encephalo-bilious, in whom animal sensibility is frequently found more developed than muscular motion. Those who are thus sensitive and liable, may be seen, in cold weather, with their necks muffled up—particularly behind the ears. We think it very probable that those children who are particularly liable to it are of the same constitution. 
Diagnosis.—This form of disease may be distinguished from most, if not all, others by the great oppression and tightness in the chest with but little or no pain; by the wheezing, rattling respiration; pallor of the countenance; by uneasy sensations in the recumbent position; severe pain in the forehead, which is much increased by coughing; and by the frothy, transparent, and viscid mucus 


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in the bronchia, attended with a moderate febrile excitement. 
Prognosis.—Under judicious treatment, the prognosis cannot, generally, be regarded as unfavorable, but still it is a dangerous affection—in some instances terminating fatally as early as the third day; but in most fatal cases death is protracted to the sixth day. Coma almost always precedes the fatal termination. 
Treatment. — In the treatment of this form of disease, Prof. Eberle recommends a highly antiphlogistic treatment. We candidly confess that we know of no form of disease that justifies what is uniformly understood by such treatment— which mostly consists of bleeding, purging, mercurialization, etc. 
We have shown in the introduction to this Book, that the immediate cause of fever and inflammation really constitutes the disease, and that it consists in an inability of the part to perform its function, and that this inability, when not occasioned by chemical or mechanical causes, can only be relieved by secretion and depuration, and as bleeding and purging incapacitate the system, and also the affected part to perform either of these functions, they must, as they really do, retard instead of promoting these functions. If debility is required, which is never the fact, it can be effected through secretion— if relaxation be required, and it generally is, it can be effected without these agents, and that, too, without breaking down the system. 
In this form of disease, our efforts should be to produce centrifugal action in the system —the surface, therefore, should be relaxed—stimulant applications should be applied to the surface as near the inflamed parts as possible, as upon the back between the shoulders, upon the breast, upon the arms, and to aid centrifugal action, they may be applied to the feet and ankles; and, as adjuvants, diaphoretics should not be neglected. When an equalization of the circulation and excitement shall have become so far effected as to admit of secretion, the function of the skin and kidneys should be rendered particularly efficient, in order that the disease maybe removed by depuration. Let this course be pursued with energy, and the fatality of bronchitis will be reduced fifty per centum. 


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Species II. — Chronic Bronchitis. 
In general, this form of bronchitis need not be considered, in children as a serious one, so long as the functions of the system, generally, are normally manifested. Some children will have it during the whole period of sucking, without any manifest detriment to the general health. 
The acute form may pass into the chronic and occasion for a long time a mucous secretion from the trachea and bronchia, and, in children, it appears, sometimes, as symptomatic of inflammation of the pulmonary tissue. In such cases, there is a pretty constant cough, thoracic oppressions, noisy and quick respiration, attended with a very appreciable mucous rattle; the face is pallid and tumefied, and the skin is constantly hot. Under such a state of the respiratory system, the alimentary canal is not always exempted from a mischievous participation ; its mucous membrane becomes so intensely inflamed as to be attended with disorganization. 
As the disease usually exists, the symptoms are cough, short breathing, and the expectoration of an unnatural mucus; but the symptoms from which we are to draw our conclusions, as to its mild or mischievous character, must be sought in the quantity and quality of the expectorated mucus, and in the existence or non-existence of hectic fever and a tendency to marasmus. When the affirmative of these symptoms is present, a recovery is scarcely to be expected—there is less room for hope than in some varieties of consumption. But, notwithstanding the strong simulation of phthisis, which chronic bronchitis frequently presents, it may still be within the reach of medical aid, provided no organic change has been effected in the bronchial tubes or their mucous lining. 
In a vast majority of the instances of this affection the patient appears in other respects pretty well—usually no fever is present, and with slight interruptions, produced by atmospherical vicissitudes or irregularities of life, which may occasion slight febrile paroxysms, it may continue for a very long time, presenting such abatement in warm weather as to give proper treatment a chance to effect a cure. But as the disease is, generally, closely identified with a feeble endowment of the vital forces, there will exist a great liability to a return of it. 


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In the event that, while in such a condition, it is not arrested, it may become more aggravated, because it is not in the nature of disease, nor, indeed, of anything else, to remain stationary; in such an event there may be expected to ensue a copious and purulent expectoration, containing probably a little blood, attended with debility, emaciation, impeded respiration, increased by exercise, night sweats, quick pulse, and such other symptoms as may constitute that form of disease which is usually denominated catarrhal consumption. This unfavorable condition of the disease, however, very rarely obtains among children, and yet, it is sometimes the case. 
Causes.—It is thought by some, that the greatest number of cases of this disease have resulted from the acute form. We are inclined to a different opinion: it more frequently obtains with those who belong to the third class, page 20 — those of feeble vital forces, and with them it is rarely ever acute —and when it is, it is generally mild. 
Prof. Wood says, that a liability to this form of disease is frequently associated with "rheumatic or gouty habit of the system." He should have made this remark under the preceding head. This variety is more common to those of a phthisical organization ; it occurs occasionally as a sequel of hooping-cough and measles —in other instances, it occurs for a vicarious object, to fill the purpose of some suspended drain of the system. To the preceding, may be added those causes which usually occasion the acute form. 
Treatment.—The principle that governs the treatment in the acute form, governs in the chronic, but the practice will differ in its details ; in the latter, the same necessity for local applications does not exist, nor does there exist the same necessity for antispasmodics; secretion and depurition are going on, and therefore, they are not to be established in this form of disease—but the difficulty is, that they are performed by an abnormal structure —in other words, a diseased structure is vicariously performing them. In proof of this, we have but to refer to the excessive expectoration that characterizes the complaint. 
Our treatment must aim at the establishment of a general centrifugal action, and a strong depurating one on the part of 


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the skin, kidneys, and liver, but more particularly the two former, and we may add, still more particularly the kidneys. Dr. Watson says: "I have seen the excessive expectoration diminish, and the patients gain strength, under the use of the balsams, the Compound Tincture of Benzoes, for example;" but he seems to be entirely uninformed as to the modus operandi of the agent. The disease originated in a want of depuration, and finally it takes upon itself the depurating process, and balsams, by acting upon the kidneys and other depurating apparatuses, relieve the bronchi of this labor, and they return to their natural function. 
Balsam Copaiba has been equally efficacious, and in the treatment of catarrh, we know of no more appropriate agent. Dr. Watson again adds, that he has found the Sulphate of Iron very useful in this complaint. Iron does not directly promote depuration, but without oxygen depuration cannot go on, and as iron carries oxygen to all parts of the system, it becomes indirectly an indispensable agent. In cases of much anaemia, therefore, it will be judicious to administer iron separately or in combination with the balsams, or such other depurating agents as may be employed. 
If the bowels should be in an abnormal condition, an aperient should be administered — as Rhei and Bicarbonate of Potassa. 
Genus IV.—Pneumonia— 
Inflammation of the Lungs. 
Inflammation of the lungs, in children, may be of the lobar or lobular variety, or it may consist of both. The first is an inflammation of the pulmonary lobes, and the second of the small lobules of the lungs. The inflammation may be confined to one lung or to a small portion of it, or it may involve the whole of one or even of both, in either form of the disease. 
The malady, in infants, instead of being idiopathic, a result of developed pulmonary irritation, from atmospheric causes, appears to result from stagnated blood in the lungs; and, as this blood is unfit for, and really does not perform any function, it must be regarded as foreign animal matter, capable, 


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under the circumstances, of becoming combined with, and of altering the pulmonary tissue, to the formation of a new product, known as hepatized lung. 
A brief recurrence to facts will show that it is very probable that infantile pneumonia must, generally, result from previous congestions and engorgements of the lungs. Pulmonary engorgements, in infants, more frequently occur in the posterior border of it, than anywhere else. All this is represented as being the case with infantile pneumonia. 
Again, pleuritis is very generally associated with pneumonia in adults, but such is not the case in infants. Every variety and degree of hepatization and disorganization may result from the inflammation when once established. 
A majority of writers, at least many of them, refer pneumonia, in infants and children, to the same causes that produce it in adults. To this opinion we cannot yield our assent, and for this reason: in infancy, and almost to the period of dentition, the mucous tissues possess less irritability than at any subsequent period of life. But during the dental process, that is, during the period of active development of all parts of the system, the mucous tissues are peculiarly impressible by atmospherical and all other causes which can exert an agency upon them. At and after this period, we admit that children are more liable to pneumonia from atmospheric causes than even adults; and we admit that a catarrh, in childhood, demands more concern and attention, than it would in an adult, because there is more liability of its producing mischievous consequences in the former than in the latter. 
In infants, the symptoms are sometimes very obscure, so much so, that in the care of the best physicians they have died without exciting a suspicion of the existing malady; but when they are obscurely developed, they are, in the beginning, those of bronchitis, to which supervene a chill, and then an increase of heat and dryness of the surface, the pulse and respiration become accelerated, cough short and dry, and breathing difficult. 
These symptoms, though well marked sometimes, are frequently so obscurely manifested, as scarcely to be observed. They are, however, greatly modified by age—the older the patient the more distinctly they are marked. The symptoms 


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above-named do not prevail long before their intensity is augmented ; the lips become red, the tongue florid and more dry, with a thick white fur along its center. Sometimes vomiting is present, at other times, diarrhea. 
In pneumonia, the pleura is liable to be involved—the two constituting pleuro-pneumonia, but as the symptoms cannot be readily distinguished, in infancy, and as such a diagnosis would not modify the treatment, very little will be required to be said upon the subject. This implication, however, is very rare with infants, and hence it is not the result of pulmonary congestion. When, usually, it does occur, it is with children advanced beyond infancy, and then it is caused by atmospheric influences or other agents — such as produce pneumonia in adults. 
It may be profitable to recapitulate a little the symptoms which occur with infants, and also with reference to pleuropneumonia. 
In infants, febrile reaction is, perhaps, never manifested — this is a phenomenon of a more advanced age; in the former, the surface is usually cold and livid, and the extremities cedematous. 
In pleuro-pneumonia of infants, percussion of the chest gives a dull sound, auscultation of the diseased or hepatized lung discovers no respiratory motion, and the breathing is labored and short. The cry is imperfect and smothered— the cough is a mere circumstance, which may or may not be present, and as to expectoration, it is never practiced by infants. 
Such is the irritability of the mucous membranes, during childhood, particularly that of the respiratory system, as to render pneumonia, three times out of every four cases of it, a supervening sequent upon other forms of disease, and in this circumstance consists its most dangerous feature. 
It has, inherently connected with it, another unfortunate feature : those whom it has once assailed, it will assail again in preference to other persons. But these recurrences, as well as the first attack, may all be referable to an original organic liability, and not to any increase of susceptibility from having had it once or frequently—depending upon that organic condition of which we have treated at page 20. 


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Treatment.—In this form of disease we should avail ourselves of every possible means to overcome the constriction of the surface, and to unload the lungs by inviting the circulation to the surface and extremities. The former may be effected by the lye-wash and the use of antispasmodic and stimulant adjuvants, and the latter by the use of sinapized sponging of the hips and chest, and what would be still better, a sinapized bath for the whole person, or a vapor-bath so hot as to render the skin quite red. 
This form of disease, in infants, depends upon a mechanical obstruction — stagnant blood in the lungs, and the object should be to remove such as is not stagnant —to save one lung or as much of both as possible. But we should not neglect to establish secretion and depuration as soon as possible, because if the obstruction should happen to be vital, instead of mechanical, we may equally reach the case; therefore our attention should be directed to the kidneys as well as to the skin. 
In this form of disease, Dr. "West speaks in strong terms of the use of mercurial inunction ;* but upon what principle, we confess that we do not know. Dr. "Watson says, that our " chief dependence is upon revulsives, applied either upon the chest, or upon the surface generally, and perhaps upon a judicious mercurial course, particularly by inunction." About the mercurial part of the practice he seems to entertain some doubt, and very justly, we think. 
In addition to the means already named, in the early part of the disease, one or two emetics should be given, and as the 
* During the early part of our pupilage, we had a little girl in a poor family laboring with congestive chill, and not knowing what to do, we hastened to our preceptor for instructions. He told us to give calomel and to use mercurial inunction upon every tender surface of the body, and to apply heat as extensively to the surface as possible. We asked for the principle upon which he prescribed calomel and the inunction ; he answered, " to stimulate—to stimulate." 
As we were returning, we came to the conclusion that we could stimulate with more rapidity and certainty with French brandy and cayenne, and so provided ourself, and so practiced, and so succeeded. We have adhered to this practice, and as yet we have not lost a case of congestive chill. When our good-natured preceptor, Dr. Pierson, learned what we had done, he had, what he much enjoyed, a hearty laugh. 
24 


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disease progresses, the patient should be kept under the influence of nauseants and expectorants, as the Compound Tincture of Lobelia, to be given in small doses often repeated ; and if the inflammatory symptoms run high, the Compound Tincture of Virginia Snakeroot, may be administered in combination with Sweet Spirits of Nitre; of this tincture, to a child three years of age, three to five drops may be given in water every two or three hours, with about double the quantity of Spirits of Nitre, until the severe inflammatory symptoms have subsided. 
To children of highly nervous and irritable temperament, the Compound Powder of Ipecacuanha and Opium, or some other opiate diaphoretic, may be given with advantage to reduce inflammation and lessen cough. 
A warm poultice applied over the whole chest, will always be of benefit to children laboring under this disease —it may be made of Flaxseed, Elm-bark, or Hops and Hoarhound. 
The bowels must be kept regular by mild purgatives, and excessive catharsis must be especially avoided. 
For drink, warm infusions of Asclepias Tuberosa, or Ptorospora Andromeda, may be freely given. 
"When there is much difficulty of breathing, the effect of congestion, ligatures applied to the limbs, even of very young children, will be found very serviceable; and in the more severe forms, dry-cupping over the chest may be employed in addition. 
Toward the latter part of the disease, when signs of debility present themselves, tonics must be given, with generous and nourishing diet, as milk, soups, weak brandy and water, wine, whey, and Arrowroot. 
The best tonic is a combination of Quinine and Cyanuret of L*on ; and for stimulants, Myricin, Xanthoxylin, and Hydrastin may be advantageously employed. 
In this disease the diet should be very rigid, confined principally to demulcent drinks and acidulous draughts; no solid food whatever should be allowed, and the position of the patient should be gently and carefully changed from time to time, in order to prevent a stasis of blood in the dependent portion of the lungs, and which would increase or perpetuate the disease. 


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After the symptoms have lost their severity, and as fever disappears, the food may be gradually increased in its nourishing character, until the usual diet can be taken. 
Genus Y. — Pleukitis — Pleurisy — 
Inflammation of the Pleura. 
Billard states that this disease occurs more frequently with infants than is generally believed, and without any complication with the lungs. As indications of the malady at this tender age, he names " restlessness, cries, sleeplessness —a dull sound of the chest, although the cry may not be altered. Prom the circumstance of the unaltered cry, he infers that the lungs are not implicated—that air enters freely the pulmonary cells, otherwise the cry would be altered. 
To the above symptoms, after another post mortem examination, he adds, " painful expression of the physiognomy, difficult respiration, coldness and lividness of the extremities, while the body was at a high temperature." In this case the lungs were, to some extent, involved, which may account for the difficult respiration, but he adds, that the cry was not altered in proportion to the increase of the disease. Of the pulse,he says: "I will not speak, in this disease, as in almost all others, of new-born children, it is very uncertain, and of little use in diagnosis." 
As nothing, comparatively, is to be found among the writers at our command upon the pleuritic inflammation of infants, we cannot do better than to follow Mons. Billard. He proceeds : 
"Notwithstanding all the care I have taken to ascertain correctly the symptoms, I am not able to offer anything of sufficient importance to enable us to make a correct diagnosis of pleurisy; but the symptoms mentioned are at least enough to satisfy us that there exists a great probability of the presence of the disease now under consideration, and this is all we can obtain at the bedside, when we wish to ascertain the seat and nature of the disease. 
"Chronic Pleurisy. — Pleurisy may pass into a chronic state even in very young children, and give rise to changes in the tissue similar to those observed in adults. A little girl, aged three months, who had been feeble, pale, and sickly 


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from birth, and who had been several times in the infirmary with the most uncertain symptoms, died at last on the 18th of April, 1826. She had insensibly arrived at the last stage of marasmus, and had not been affected with diarrhea except in the latter period of life; she had never been affected with fever, and although the respiration was short, the tone of the cry did not exhibit any alteration, and the nurse remarked that the child died of languor. 
"Upon opening the body, I found the small intestines red, tumefied, and filled with a large quantity of black blood in clots; the large intestines were healthy. There also existed a very violent pleurisy on the left side. Both the costal and pulmonary pleurae were covered with a layer of plastic lymph, at least a line and a half in thickness. When this lymph was removed, the pleura beneath was found rugous and very much injected, while the lungs under its coating were found crepitant and perfectly healthy. When the lungs were cut transversely, a well-marked red line could be seen at the circumference of this organ, indicating the separation between the inflamed pleurae and the healthy pulmonary tissue. The heart and large vessels were exsanguined; the fetal openings obliterated; the brain, although healthy, contained a small quantity of serum in the ventricles. 
"From what has been related, we have seen that the emaciation and languor of this child were caused by an obscure pleurisy, the progress of which insensibly led to the death of the patient. In every instance, therefore, in which we see a child languishing, and becoming thin and feeble, we ought carefully to search for the cause of this condition, and endeavor to ascertain whether it does not arise from some obscure organic lesion; we ought not to remain in a security which would leave us tranquil spectators of a disease which perhaps might not have terminated fatally if we had examined with scrupulous attention into its cause, seat, and nature." 
The information acquired by this post mortem examination is peculiarly interesting. It shows conclusively that even the pleuritic covering of the lungs may be, for a long time and fatally, inflamed, without, in the least degree, involving the lungs. It illustrates, too, the difficulty of diagnosis in this affection in infants. 


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As children above the age of infancy—an age in which the symptoms are developed, as in adults, are, if anything, more liable to this disease than adults, it may be well to define and treat of it in that relation. 
Pleurisy, or pleuritis serosa, is perhaps, most generally preceded by chill and fever, oppression in breathing, but in a less degree than in pneumonia—but the pain is greater and more definitely located in one of the sides. When severe, it is rendered intolerable by a deep inspiration and by pressure upon the intercostal muscles. In consequence of pain upon inspiration, the respiration is short, and lying upon the affected side next to impossible. If the disease be located in the posterior portion of the pleura, all movements of the spine will give pain. 
If the disease terminate in serous effusion, and it frequently does, there will be a considerable change in the symptoms— the breathing becomes more anxious and short, and a feeling of suffocation prevents the possibility of resting upon either side. 
Inflammation of the pleura does not thicken it, if it do, it is very slightly, nor does this membrane readily soften or ulcerate ; but, as we have stated, it throws out serum, and it throws out coagulable lymph, which spreads over adjacent surfaces, becomes organized, and false membranes are thus formed, or contiguous surfaces are united together by what is called adhesion, or adhesive inflammation. When the inflammation is of moderate severity, it usually terminates by resolution ; when more violent, by an effusion of serum, or coagulable lymph; in cases of more violence, or in modified cases, it may terminate in suppuration. 
Chronic pleurisy frequently simulates hydrothorax by a serous or purulent effusion; sometimes, phthisis pulmonalis ; sometimes, without definite symptoms, it forms slowly; at other times, it succeeds the acute form. In the former variety, vague pains are complained of in the chest; the cough, which is usually present, is small and dry; oppression is felt at intervals, and so are febrile symptoms, as shivering, heat, thirst, and an inelastic or hard pulse. 
In this form of the disease, the chest undergoes changes which it will always be important to investigate for diagnostic 


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purposes: the diseased side is more smooth, round, and motionless ; the intercostal spaces may protrude, but more frequently they are only dilated ; if the case be very chronic, the affected side may be the smaller; when the patient speaks, no vibration will be felt by the hand; the thoracic parities are sometimes oedematous; percussion gives a dull sound, except at the superior part of the chest, and the usual sounds from the diseased parts, as per auscultation, no longer exist; but no indication has been discovered to determine which , is present in the chest, serum or pus. 
Indications.— In this form of disease, there is a pretty general rigidity of the system, and therefore, a general relaxation must be effected; and, in the next place, all obstruction to free vital action must be removed, and lastly, when an equilibrium is obtained, it must be vigilantly sustained. 
Treatment.— A warm pediluvium, the lye-bath, aromatic and antispasmodic drinks or teas, and enemas, if promptly employed, will satisfy the first indication, if at the same time recourse be had to revulsives, as warm poultices, heavily sprinkled with Cayenne, which should be applied as warm as the patient can bear, over the region of the pain, and frequently changed. 
If the attack has been violent, antispasmodics and diaphoretics should commence the treatment, with the use, at the same time, of diffusible stimulants, and a gentle cathartic. An energetic perseverance in the use of these means will generally achieve success. 
If physicians will bear it in remembrance, that in the treatment of all thoracic inflammations, the general system must be relaxed, and that all excess of vital action upon the affected part must be directed to the surface and inferior extremities, they will certainly achieve general success, without giving themselves any particular trouble as to the particular part affected. 
They should, furthermore, remember, that a cure cannot be effected without active depuration, and consequently the renal and cutaneous secretions should be effectively brought into requisition and sustained by the administration of such tonics as the peculiarities of the constitution may indicate. 
In congested cases, the failures we have witnessed were 


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because of the inefficiency of the revulsive measures—a tepid, bath, a few bottles of hot water or hot bricks will not be sufficien —a more powerful and a more permanent impression must be made upon the cutaneous surface, aided by a liberal use of diffusible stimulants. 
When the congestion is beyond the power of reaction, we have found Mustard and Pepper poultices, tepid bathing, and pediluvia but little better than nothing—they do not appear to act with sufficient promptitude. We have resuscitated the congested patient after death had fixed his seal upon every feature of the face, by the use of the hot vapor bath and the diffusible stimulants, followed by the use of tonics; and in such cases, we are not prepared to trust any other course of treatment. 
In chronic pleurisy, we must mainly rely, for success, upon renal and cutaneous depuration, well sustained by appropriate tonics, expectorants, and stimulants. Revulsives and antispasmodics can only be occasionally indicated, though in obstinate and long-standing cases of chronic pleurisy, the Irritating Plaster may be applied with advantage on the chest over the diseased portion of the pleura; or Croton Oil may be applied once a day, until free pustulation is produced. 
Genus VI.—Phthisis Pulmonalis— 
Consumption. 
Phthisis pulmonalis consists of tubercles formed in the lungs, which, after an indefinite time, inflame and ulcerate; hectic fever universally attends it, and persists in gradually wearing down the patient, until, ultimately, death ensues. 
Symptoms.—Uneasiness is complained of in the chest, with paroxysms of coughing, or perhaps the cough is dry and short and attended with difficult respiration. Its next stage becomes indicated by the cough becoming very troublesome in the early part of the day —the dyspnoea is much increased upon the slightest exertion. There is a circumscribed redness of the cheeks, purulent expectoration, with fever in the evening, with wasting and colliquative sweats in the morning. The disease may now be regarded as confirmed. 
The hectic continues and is constant, with pungent heat, 


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small pulse, colliquative sweats, diarrhea, and extreme weakness. In the forming stage, while miliary tubercles still exist, the only change that has become effected upon the exterior of the thorax consists of restrained movements under one or both clavicles. It is usual to discover, by percussion, a diminished sound at the top of one lung. Auscultation will discover that inspiration presents a murmur that is either more weak, rough, or confused, with a more distinct sound of the expiration. More wheezing and resonance attend the cough and voice, or instead thereof, mucous rales will be heard in the same part. 
The motion of the chest is more discoverably diminished under one or both clavicles, when the tubercular disposition has become increased in quantity. The resonance of the cough and voice is increased; the expiration is more loud and superficial; upon auscultation, the inspiration will be found to be bronchial; on percussion, the sound will be less distinct. Whatever of the lung is left, is probably sound, or a puerile respiration will be manifested. 
During the process of tubercular softening, auscultation presents a sub-crepitant rale about the apex of the lung, reaching downward from above. At the close of a deep inspiration, during or after a cough, this sub-crepitant rale is most to be heard. As the disease advances, a tracheal or cavernous sound attends both inspiration and expiration. As the cavern increases, the sound emitted, by percussion, becomes gradually clearer, and in some cases, tympanitic. 
We have now, as briefly as possible, presented the condition, symptoms, and physical signs of this form of disease, as it usually occurs in adults, believing that we could not with more brevity and precision expose the variations which characterize it in childhood. 
The disease as above defined, and as it occurs in children, are essentially the same, yet we shall find the symptoms and physical signs as obscure in the latter as they are lucid and distinct in the former. 
A striking anatomical difference exists with reference to the distribution of the tubercularization. In about twenty-five per centum of adult cases, tubercular deposition will be found in 


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the bronchial glands, but its importance, even in these cases, is secondary to that of the lungs; but, with children, the tubercular disease of these glands is sometimes of more importance, than that of the lungs. This is not all. In very nearly one half the cases among children these glands contain tubercles. 
In adults, the apparent perfection of the tubercles in the clavicular region of the lungs, and their immature and incomplete condition in their inferior portions, indicate that the disease began in the former and gradually extended downward; but in young children, the tubercles, in all parts of the lungs, indicate the same age, so much so that no particular one point can be selected as that in which tubercularization began. 
The next anatomical difference worthy of note, is with reference to the cavities, or caverns, formed in the lungs at the two ages respectively. Their existence in children is much more rare, and when they do occur they are rather small excavations, than caverns, such as obtain in the adult lungs. They communicate with each other and with the bronchia. They are sometimes very numerous, and are occasioned by the softening of small tubercular deposits. They are not attended with that destruction of tissue which marks the disease in adults. 
As regards the symptoms of this disease in childhood, we have to remark, that as age advances the differences between them and those of adults diminish. But during childhood, there are some obvious differences:—one is, that during this period there is not attending the disease haemoptysis, and very rarely any expectoration. In young children the cough, in the commencement of the disease, is generally very slight, and the Colliquative sweats are so inconsiderable as to pass frequently unobserved. Sometimes the child complains for weeks, loses appetite, flesh, and strength, before the cough arrives to excite any fearful apprehensions, and when it does come, it is so mild, short, and dry, that, but for its frequency, it would scarcely attract a notice. Indeed, the early symptoms are frequently so indefinite as scarcely to claim a careful diagnostic investigation. So true is this, that the complainings are referred to worms or to some other inconsiderable ailment. 
Diarrhea attends this disease in children, as in adults, 


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but it does not seem to be attended with so prostrating an effect. 
Tubercularization of the bronchial glands is, by no means, uncommon to infancy, but obtains much more frequently between the ages of two and six years. When it does occur in infancy, the special symptoms of it are lost in those of the lungs, and they, too, are as likely to be lost in those of a generally deranged nutrition. 
A slight cough, accelerated breathing, diarrhea, vomiting, aphthous mouth, and red tongue, may be the symptoms attendant upon a large cavern or excavation in one of the lungs, and quite naturally might be mistaken for some disease of the digestive system. 
Such cases illustrate the great importance of very special examinations into all the complaints of children. In every instance where it is possible for a doubt to exist, every important organ of the system should be investigated by all the means in possession of the profession. But we have not concluded our purpose of indicating the differences that exist between the signs and symptoms of this destructive malady in adults and infants, respectively. 
There exist some strong differences in the auscultatory signs of the existence of this disease in the two periods of life before named, and though we should describe them with entire accuracy, the advantage would be exceedingly trifling to those who have no experience in the practice of auscultation, consequently, we shall be very brief upon the subject 
We.remark, then, in the outset, that auscultatory signs of phthisis, in infants, are much less reliable than in adults; so much so, that they can, in our judgment, be of very little advantage to the physician who has not an immense practice, or very extensive experience in the subject. 
With adults, the first indication of tubercular deposit in the lungs consists in what is usually denominated "coarse breathing," and the importance of this is augmented if it be attended with a dry rattling or gurgling sound; and it is rendered still further diagnostic by being heard with more distinctness in the infra-clavicular district of the chest. But, in children, this useful information cannot be had—we cannot decide whether the sound emitted is occasioned by pulmonary tubercle or other 


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source of irritation. If the sound above described should be obtained, it should cause us to suspect phthisical mischief, but we should remember that it may obtain from a cause of very inconsiderable importance. These remarks are equally true of the prolonged expiratory sound under the clavicle. These two symptoms, though of important diagnostic import in adults, are not without great distrust in children. 
In adults, we are enabled to draw important inferences from the modifications of the voice, which is not the case with children, although they may be able to talk. It is not enough that we shall hear them pronounce a monosyllable—and they do not use sentences. 
The voice of children, furthermore, has not acquired a characte —it has not become fixed, and hence causes which could not affect the voice of adults, might greatly change that of children. 
The difference between the breathing of the two lungs is often an important symptom in adults, but it is one upon which we can place no reliance in children, except from repeated experiments. However strong or coarse the breathing of a lung, in infancy, it may, in twenty-four hours, change sides. But if, after repeated experiments, we find the same lung to emit the same sounds, then they may be relied on. 
We have thus found that those symptoms which pretty clearly indicate the existence of phthisis, in adults, are really of minor importance in children — this, indeed, we should expect from that extensive range of active sympathies which, at this age, prevail. The progress and rapid development of every tissue and organ in the system, constitute in them a plexus of such delicate irritations, that one diseased point must excite morbid action in every other; hence, in the treatment of infantile phthisis, we should at all times be ready to anti-. cipate many varieties of complication. 
Causes.—Upon this subject so little is known as to be almost equivalent to nothing—vague and uninstructive conjecture appears to be about the sum of what is obtainable— nothing that approaches a rationale of the malady has been discovered. Under such circumstances, we can certainly be excused for venturing to attempt, to some extent, a solution of the difficulty, even at the hazard of committing some errors. 


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If there be any one point in the entire field of pathology, in which our discovery of the relations that exist between the lungs and cerebellum is likely to be of any avail, it is in this. In our introduction to this Book, we have shown that this form of disease, no more than any other, is hereditary, but depends upon, or results from, the influence of attending circumstances, upon a particular and broadly-marked variety of organization. In a majority of cases, the medulla oblongata preponderates, in development, over the cerebellum, particularly its lateral portions; and in the minority of cases, a reversed development of these organs obtains. 
Tubercle is very far from being the only diseased manifestation that results from this organization—the whole tribe of passive congestions belong to it, more especially those of the brain. 
Death, from cerebral forms of disease, is more common to children than to adults —but tuberculosis is more common to adults than to children, and both have, as the primary cause, the same organic conditions. 
This peculiar organization is the remote result of that division of labor which is incidental to civil society—caused by sedentary habits and excessive mental application. The present time appears to be specially engaged in the production of cachectic subjects —all is being done for the advancement of mind, and nothing for the development of the physical system. Such influences, acting upon the sanguine-bilious, sanguine-encephalic, bilious-encephalic, and sanguine-bilious encephalic constitutions, will produce that organic condition which is a sine qua non to phthisis pulmonalis. We have never found this peculiar organization, in a single instance, among four hundred savage crania—this is a strong fact in support of the opinion that this organic condition is peculiar to civil society. 
When we reflect, that a vigorous pulmonary function results more from necessity than from volition, or even the vegetative influence of the medulla oblongata, we must perceive the reasonableness of the preceding conclusions. By exercise, the blood is forced forward in the circulatory system, and of course into the lungs, and by this necessity they are forced to act. By a constant repetition of this necessity, not only the lungs 


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but all parts of the animal system, and indirectly the vegetative, must become strengthened and developed. 
In sedentary life, the lungs act only through the vegetative necessity —through the action of the diaphragm • this explains why tubercular deposit begins, in adults, in the clavicular portions of the lungs. The vegetative influence upon the lungs can never promote, in a high degree, the development of the respiratory apparatus; to effect this end, we must resort to the exercise of the animal muscles in general, and this conclusion is sustained by all experience. 
In infancy and childhood, when the circulatory and respiratory functions are ably performed, there is no danger of tubercle—whatever of morbid condition circumstances may occasion in the system, will be forced upon the skin in the form of eruptive disease, or taken out of it by depuration ; but when a contrary condition of the vital system exists, we may justly apprehend danger from pneumonia, convulsions, chronic hydrocephalus, or phthisis—they all originate in a modification of the same organic conditions. 
It is now a well-ascertained fact that feeding, without exercise, produces tubercle — this is well illustrated in stall-fed cows, and cage-fed rabbits, poultry, monkeys, and other animals. Now, at this point, we would like to be informed of the difference that exists between a cage-fed rabbit, or bird, or monkey, and a cradle-fed child ? If the one is productive of tubercle, why should not the other be ? We have elsewhere remarked, that children who become obese are not usually those who become tuberculous; nevertheless, we have taught that the exceptions are liable, and have named the condition under which it takes place. 
A remarkable case of this kind is reported by Dr. West, which we shall introduce as confirmatory of our conclusion, and as an illustration of what we shall presently attempt to teach. 
"A remarkable instance of this came under my notice some years ago, in the case of a little boy, nine months old, who was fat and ruddy, and had always had perfectly (?) good health, until the 10th of April. On that day he was taken with symptoms which his mother supposed to be those of a bad cold. On account of this, he was kept in the house, and 


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various domestic remedies were employed, though without any improvement, and on April 24th, he came under my notice. There did not then appear to be any urgent symptom, though the child seemed much oppressed at the chest. The case appeared to be one of rather serious catarrh, occurring during the period of dentition. The gums were lanced, and a mixture containing the Vinum Ipecacuanha was ordered, to which, finding the symptoms not to abate, small doses of Antimonial Wine were added on the 27th. On the 30th, I was informed that the child was much worse, that his dyspnoea was greatly increased, and that his hands and feet had been swollen for the last forty-eight hours. I found the little boy breathing fifty times in the minute, with great oppression at the chest, the face much flushed, the skin dry, the trunk hot, the limbs cool, and the hands and feet much swollen. Auscultation detected generally diffused small crepitation through both lungs, with indistinct bronchial breathing at the upper and back part of the left side. Three hours after this visit, the child died without a struggle, on being lifted out of bed for its mother to apply some leeches to its chest. On examining the body after death, a very thick layer of fat was found every where beneath the integuments. The lungs presented an extreme degree of tubercular degeneration, and many of the bronchial glands were enlarged by the morbid deposit to the size of a pigeon's egg. Some of the tubercle in the lungs was softened, but it existed both in the form of yellow tubercle, of tubercular infiltration, and of masses of crude tubercle, formed by the agglomeration of many separate deposits. The pulmonary substance, in the intervals between the tubercular deposits, was of a bright red color in the first stage of pneumonia, and in many parts bordering on the second stage, and there was very considerable injection of the bronchial tubes. The various abdominal viscera contained tubercle, but it was not far advanced in the mesenteric glands." 
It is proper to add, as a further illustration of such cases that infants of this kind have small contracted nares—chest and neck appear large enough, but the latter has but little expansibility, and that they usually cry but little, and hence, at this early age, it may be said, they have no exercise. In reference to the case just cited, it may be interesting to remark 


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that the child had beeD apparently in good health up to the 10th, and that in twenty days it died with tubercles as large as a pigeon's egg. It will scarcely be doubted, that while it was looking well and acquiring fat, tubercles were being developed. 
Now, by a proper application of the developments which we made in the first book, and in the introduction to this, the solution of this and all similar cases will be found easy. 
The child had had, comparative!) 7 , no physical exercise, and as the medulla oblongata had imparted but little energy to the diaphragm, it follows that the respiratory function was but feebly performed, and yet, nutrition does not appear to have suffered during the formative stage of the tubercle. The venous blood had been depurated more by the conversion of carbon into fat, than into carbonic acid in the lungs. 
Now, if oxygen enough was not inspired to depurate the venous blood, enough was not received to prepare the chemical elements, that resulted from metamorphosis, for elimination, and tubercles resulted. 
As it is possible that all of the superfluous carbon could be converted into fat, we are not prepared to say that tubercle is a carbonaceous compound—we are inclined to think that it is not, but would be exceedingly pleased to know certainly what it is ; —but that it results from an insufficient pulmonary function, we have not a single doubt. In fat infants and children the liver performs but feebly its assigned function. 
In those whose organic condition is the reverse of this—a large medulla oblongata and a small cerebellum, we have a different play of functional affinities. The liver and skin, in some measure, even in this latitude, aid the lungs in depurating the venous blood, while oxygen enough is not received to fit, for elimination, other chemical elements that result from metamorphosis. 
We are far from being sure that consumptives do not receive as much advantage, in the south, through the renal secretion, as through any other. A fault in this function causes serious mischief, in the rheumatic organization, in one way, and it may do as much in an other, in this. 
We think it quite probable, as in the preceding form of phthisis, an abundance of carbon is obtained, that in this, 


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because of a very feeble nutrition, there may not be enough in this, for the indispensable purpose of animal heat; and hence the reason why ardent spirits and sugar have been found to be beneficial in many instances. 
In many subjects, no doubt, the lungs, though actively engaged in the respiratory motion, are incapable of much respiratory function. Oxygen enough to insure the elimination of the metamorphosed tissues is not received—animal heat is not maintained —the venous blood is not depurated, and, in a cold climate, the liver and skin can render but little aid, and therefore tubercular deposits. 
By the use of brandy, the animal temperature is elevated, and consequently the nutritive process is increased, while the carbon and hydrogen of the brandy are converted into fat. We have but little faith in the ultimate utility of brandy or sugar as remedies. 
Finally, we do not pretend to understand all of the affinities in this form of disease—but sure we are, that it depends upon those organic conditions in the brain which we have indicated. 
The exciting cause in children is, very generally, an improper exposure to cold and damp weather or clothing. 
Indications. —Obtain for the circulation a permanently centrifugal action, and rouse into activity the principal depurators of the svstem. 
Treatment.—If we had to treat of this form of disease in adults, we should have much to say, but as it is, we shall be brief, because it is our conviction, that with children, it must very generally be fatal—because, as we have shown, it depends upon a fault in the organization, which, at this early age, does not admit of a remedy. 
It is known that a southern climate secures a mitigation of all the symptoms in this form of disease; and it is also known that cold weather developes tubercle much more rapidly than warm, in those climates where the malady is produced. Now, if we connect these facts with that organic condition which we have shown to be a sine qua non in this disease, the inference becomes clear as to the special indications of treatment. 
In such cases as that quoted from Dr. West, it is obvious that oxygen enough was not received by the system —that the 


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carbon of the venous blood was not combined with it, to the formation of carbonic acid gas, but with hydrogen to the production of fat. 
From this circumstance, we are allowed to infer, that other ultimate or proximate elements, derived from metamorphosis, were not, by oxygenation, prepared for elimination, and being retained in the system, were converted into tubercles. We may admit that oxygen enough was received, but in consideration of defective depuration, more especially on the part of the kidneys, tubercles resulted. 
In the other form of phthisical organization, the absorbing system is very active—the person is always lean, but the chest is contracted and the lungs are feeble, and while the depurating apparatuses readily prevent serous or aqueous plethora, the matter metamorphosed is not sufficiently depurated, as may well be supposed from the feebleness of the pulmonary function, and tubercle is again the result. 
As, in the south, the renal and hepatic functions are much more developed than the cutaneous, and, as in the south phthisis can scarcely be developed, we conclude, that, in the treatment of this malady, we should, in a special manner, address our remedies to the liver and kidneys; consequently, we should place more reliance upon mild alteratives and diuretics, and particularly the latter, than diaphoretics. 
By way of prophylaxis, Dr. Eberle recommends that the patient should live, measurably, on farinaceous food. This is certainly unsound doctrine, because it creates a necessity for an increased pulmonary action. 
Dr. Watson says: " One man gives all his phthisical patients beefsteaks and porter." This selection is equivalent to none at all—the first is nitrogenous, and the second is carbonaceous. "Another," adds the doctor, "restricts all his to vegetables and asses' milk." In this instance, the milk is equivalent to the beefsteaks, and if farinaceous vegetables shall be selected, then they are equivalent to the beer. 
Dr. Watson says, for himself, by the way of treatment, that we must keep the patient "on low diet and take blood." He next recommends emetics, and lastly, counter irritation. 
Now, it must be obvious, that, if phthisis exists in consequence of imperfect depuration, and can only be cured by it, 
25 


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there is no cause of surprise, according to the usual plan of treatment, that so very few, if any, ever recover from it. Indiscriminate low diet and bleeding are directly opposed to recovery —the balance of the treatment may promote an equilibrium of the circulation, but none is resorted to for the purpose of effecting a special depuration. 
In this form of disease, we are hostile to the whole class of expectorants, because they promote an increase of action in the diseased part, instead of determining the fluids to other legitimate depurating apparatuses. We would suggest, that, after a relaxation of the whole system shall have been effected, and the circulation equalized, the patient should live, mostly, upon azotized food, and by pediluvia, alkaline baths, and revulsives should maintain a centrifugal action in the system, and at the same time maintain a pretty active depuration of the kidneys, by the use of Terebinthina Yenita, or Oopaifera Officinalis, and, as an adjuvant, some preparation of iron will frequently, and indeed generally, be required. 
We must confess, that we are not, exactly, making these suggestions for the benefit of more than a small number of phthisical children, because we view their case as hopeless— they were doomed, by their organization, to a brief existence. The physician may aid in repairing a lesion, but in the short space allowed him by children thus afflicted, he cannot remodel the organization. 
ORDER II. 
NON-INFLAMMATORY FORMS OF DISEASE IN THE RESPIRATORY APPARATUS. 
Genus I.—Absent or Imperfect Respiration. 
During Uterine existence, the lungs are organized and developed with reference to a function which will not be required of them, until the atmospheric mode of being becomes requisite ; but anterior to this event, they may become the subjects of disease, and even of disorganization. 
As a very general fact, the lungs discharge promptly the function for which they were intended, and at the proper 


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moment of time; but in some instances they do not, and it becomes the duty of the physician to ascertain why they do not. 
The condition cannot be one of asphyxia, because respiration has not been established—the case is not one of suspended function, but it is one in which the air has not penetrated the air-cells — the congestion is not such as constitutes true asphyxia. Such infants are marked with exceeding paleness and debility. 
Upon the birth of such an infant, the larynx and bronchia should be immediately examined for such* mucosity as may exist to the obstruction of the air in its passage to the air-cells. If this should be discovered to be the case, as it frequently is, it must be removed with a feather, or with the finger armed with a piece of fine rag; at the same time, the infant should be placed in such a position as to leave the mouth and nose uncovered, and in a position to receive fresh air. 
In our efforts to establish the function, the lungs should be inflated, or rather, the attempt should be made to inflate them by closing its nostrils and blowing into its mouth, and then, by pressure on the chest, force it out; this exercise may be frequently repeated — dry friction, at the same time, upon the thorax may prove of much advantage. 
In the event that there may be disengaged mucus in the trachea, the child may be held up, with its head down, and shaken a little, that it may pass down and out of the mouth. This effort should not be too readily abandoned, as the mucus, which may have been tough at first, often becomes thin and will run out, more especially if there be life enough to produce a few pulsations in the heart or in the cord, in the event that it has not been divided. 
It is the practice of some to endeavor to excite cries in the child as a means of promoting respiration; but it is not unattended with a suspicion of mischief, because the efforts produced by crying may increase the current of blood to the lungs and augment the difficulty. 
After each effort to establish this function, the ear should be applied to the region of the heart, to discover if any action has been produced. By these or other means, respiration has sometimes been thoroughly established, but in others, 


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too partially so, to sustain existence more than a few days or even hours. 
When a sufficient strength of atmospheric life has obtained, it will be manifested by a short and deep sob, which is generally repeated at longer or shorter intervals, and when deferred too long, we may promote its return by again inflating the lungs. 
When the function has become established, no matter to what extent, much subsequent care will be requisite—the child must not be fatigued — it must be attended to with warm applications, and be as little disturbed as possible, by dressing or other attentions. 
Post mortem examinations of such cases show but little engorgement of the lungs, and in some cases, none ; and if they sink in water, the two circumstances leave no room to doubt that air had not sufficiently entered the air-cells to maintain existence. 
It is too frequently the case, no doubt, that the ligature is applied to the umbilical cord as soon as the child is born. In such cases, therefore, of suspended respiration, the child has a very slender chance of existence. The division of the cord has separated it from all intra-uterine life before the extrauterine has become established. Prudence would, therefore, dictate that the cord should not be ligatured so long as there continues pulsation in it. 
When respiration has become established, the circulation in the cord will, from the necessity of the case, cease; so long, therefore, as the cord pulsates, there is no very great danger to be apprehended ; but should the pulsation in the cord have ceased, and a division of it is followed by a few drops of black blood, before the establishment of respiration, the case is one of danger, but not necessarily so hopeless as to forbid such efforts as have been recommended for its establishment. 
Genus II. —Congestion of the Lungs. 
Respiration, after birth, may be thoroughly established, and yet, infiltration and engorgement of the lungs may soon succeed. It is said to be occasioned by some disturbance to the circulation in the heart and large vessels. This may be very probable, but what is the character of this obstruction ? Cases 


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of this nature are not of unfrequent occurrence, and sometimes they continue for a long time, and may be the cause of very serious consequences. 
In pulmonary engorgement, the substance of the organ preserves its integrity, and it occurs more frequently in the right lung, than in the left, and in the posterior than in the anterior portions of it. It consists in an infiltration of blood or bloody serum into the substance of the lungs, and the quantity thus infiltrated is sometimes very great. The substance of the lungs crepitates less than when sound, under pressure; it is also more heavv than natural and less elastic, and is of a dark red color externally, and when cut it is red. It is sometimes the case, that the bronchise are red and covered with an exudation of bloody serum, in the body of the engorged portion. In hepatization of the lungs, there is no engorgement of the heart and large vessels, but in the engorgements of them, the contrary is the fact. 
The symptoms of pulmonary engorgement in infants, are enveloped in much obscurity, and therefore, during life, it is very difficult to determine, certainly, what the ailment is — they are simulated by those of other pulmonary forms of disease to such an extent as to render diagnosis very uncertain ; but, in the general, it may be said, that the face is purple ; the respiration labored; the thorax has not the appearance of being perfectly developed; the cries are short, painful, and obscure; a dull sound is produced by percussion, and a sanguineous plethora of all the organs is indicated by the general color of the skin. 
As pulmonary engorgement is frequently the precursor of pneumonia, we refer to it for the treatment of this form. 
Genus III. — Apoplexy of the Lungs. 
Between this form of disease in infants, and that of adults, there is a considerable difference, and it occurs more frequently in the former than in the latter. In adults, it is attended with hemorrhage, and very generally symptomatic of an incurable disease; in infants, it consists of a circumscribed effusion of blood in the body of the pulmonary or interlobular cellular tissue. 
The frequency of infantile engorgements, or congestions of 


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the lungs, accounts for the greater frequency of this affection. It may appear suddenly, or it may come on slowly, depending upon the urgency of the cause that determined the afflux. 
The most prominent symptom of this condition of the lungs, is a suffocating cry; percussion indicates the absence of air in the affected part; occasionally, bloody mucus is expelled from the lung. 
Under the influence of this malady, the pulmonary tissue becomes hard, and about its circumference apparently hepatized; yet in some cases, it has been found considerably softened. 
This disease always excites alarm, and very justly, but still, it is not always fatal. The effused portion of the lung may become encysted, and thus isolated, and finally, it may, possibly, be absorbed. 
In this affection, no time should be lost in producing a revulsion of blood from the lungs —at all events, an equalization of it. For the further treatment of this disease, we refer to that of pneumonia. 
ORDER III. 
NERVOUS FORMS OF DISEASE IN THE RESPIRATORY APPARATUS. 
Genus I.—Infantile Spasm of the Glottis — 
Crowing Disease — Thymic Asthma. 
So far as spasmodic action of the larynx and glottis is concerned, this affection resembles catarrhal croup, but here the similitude ends; the latter, as we have shown, is an inflammatory disease of structure, while the former is purely nervous— one of function; and one, too, which may mislead the student or young practitioner, without care—he may do, as others have, mistake it for catarrhal croup. 
It commences usually in the night, when the patient is asleep, and suddenly produces an inability to inhale the air; to which succeeds a struggle of all the muscles that can exert an influence in promoting or aiding the respiratory function ; just as we found it to be in a paroxysm of catarrhal croup, the head is inclined backward, the thorax is elevated, the 


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nostrils are spread, the mouth is open, the cervical veins are engorged, the face is flushed, swelled, and purplish, with a countenance distressed and anxious. 
In a short time, or not until the moment of threatened asphyxia supervenes, the spasm relaxes, and the air enters the lungs, producing an acute or young cock-crowing sound, and the child is again well, or its respiration may be a little short for a while. 
During the paroxysm, the extremities become singularly affected, sometimes, says Dr. West, " the thumb is drawn into the palm by the action of the abjiuctor muscles, while the fingers are unaffected; at other times, the fingers are closed more or less firmly, and the thumb is shut into the palm; or, coupled with this, the hand itself is forcibly flexed on the wrist. In the slightest degree of the affection, the great .toe is drawn a little way from the other toes; in some degrees of this affection, this abduction of the great toe is very considerable, and the whole foot is forcibly bent upon the ankle, and the sole directed a little inward. The affection of the hand generally precedes the affection of the foot, and may even exist without it, but I have never seen spasmodic condition of the foot when the hands were unaffected." 
For a short time, in the fore part of this disease, during the intervals between the paroxysms, the child appears as well as usual, but this exemption only seems to be a preparation for a more dangerous condition of the malady. 
The paroxysms become reproduced by such trivial causes that it is next to impossible to guard against their recurrence. A sudden change of temperature, the least exposure to a current of air, a slight mental disturbance, deglutition, or any pressure upon the larynx may provoke a paroxysm, more particularly at night. 
The general condition of the child is a departure from health —the bowels are frequently attended with an alternation of diarrhea and constipation — evident symptoms are sometimes present of dental irritation, as swelled gums and a hot condition of the mouth. In a long-continued paroxysm, death is sometimes produced by suffocation; at other times, the oft-repeated difficulty of breathing produces such a condition of the brain that the child dies convulsed, or in some 


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other mariner, equally indicating such a pathological condition of it as might be induced by imperfectly organized blood, or congestion from paroxysmal forces. If from these agencies, it should escape death, convalescence will be greatly protracted, because it cannot be protected against occasional returns of the disease. 
Causes. —The causes of this affection are as numerous as are the sources of disturbance to the general function of health. Whatever disturbs digestion, by improperly exciting the gastric branches of the pneumogastric or eighth pair of nerves, may produce it; also disturbances of the dental process, by acting upon the dental branches of the fifth pair. 
It may also be produced by derangements in the function of the intestinal canal, by which the spinal nerves become improperly excited, and, through them, the spinal marrow, the recurrent laryngeal, and those appropriated to the diaphragm and intercostal muscles. 
Dentition is thought to be the most frequent of the exciting causes of this nervous malady. We much prefer the idea, that as the disease occurs most generally during the period of dentition, a period of general development, and therefore of general irritation, that the muscles of the glottis and larynx are morbidly excited by a special display of the irritation peculiar to the dental age; because, in many cases, perhaps in a majority of them, though happening in the dental period, they were not occasioned by any morbid action in the dental process. 
Furthermore, this nervous malady has happened with infants at the age of eight or ten weeks, consequently, long before the period of dental irritation ; and it has happened long after the completion of this process —thus showing that there is no necessary connection between the two. 
The disease is sometimes produced by such local causes as enlarged cervical and bronchial glands pressing upon the recurrent and eighth pair of nerves. 
There cannot be a reasonable doubt, but that this and similar forms of disease are frequently occasioned by some peculiar pathological state of that portion of the encephalon which gives origin to the nerves which are distributed upon the spasmed part. 


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We Lave the skull of a boy, sixteen years of age, who died of the consequences, as stated upon the hospital register, of onanism. His respiration was in the highest degree asthmatic for some time previous to death. Post mortem examination of the cerebellum discovered a tubercle in one side, and a mass of encysted pus, of about the same size, in the other. He was affected, also, with paralysis of motion on one side, and of sensation in the other. 
If such results can be produced by such causes, then there cannot be a doubt but that a spasm of the glottis may result from local cerebral irritation. We are disposed to confine this variety of the disease, at least, to those children in whom the middle portion of each cerebellum is relatively small. We have never known a case of asthma or phthisis in which this part of the brain was not defectively developed. 
Upon the subject of this variety of spasm of the glottis, Prof. Meigs has given several interesting illustrations, and one of his paragraphs is so interesting, as to the purely nervous character of the malady, that we cannot refrain from extracting it: 
" I have witnessed very numerous specimens of quite young children affected with laryngismus or croupal respiration, occurring occasionally, and being repeated daily, and even many times a day for a month in succession, in whom no other sign of the least disorder could be discovered, and which finally ceased to appear. In such cases, the children have grown and prospered, as well as if not the least suspicion of doubtful health had arisen concerning them." 
To this cause he refers the " Parson's Cough," and the holding of the breath among children. 
As a further illustration of the subject, we have the skull of a man who became exceedingly angry, and while in his rage died instantly of suffocation, occasioned by a spasmodic closure of the glottis. 
As the disease generally obtains, it is one of little moment, and yet, its existence may well excite fearful apprehensions, inasmuch as an obstinate persistence of the spasm has produced asphyxia and death ; and even if this result be escaped, the frequent interruptions of the respiratory function, with the 


394 
NERVOUS FORMS OF DISEASE 
struggles that attend them, produce such a congestion of the brain, as may end in convulsions and death. 
Treatment. —When treating a child during a paroxysm of laryngismus stridulus, it should be immediately raised to a sitting posture, and gently fanned, and the Compound Tincture of Lobelia and Capsicum should be given by mouth or enema, to overcome the spasm; after which, the Compound Tincture of Lobelia should be administered in doses sufficiently large to produce emesis—though it must be borne in mind that, in this form of disease, emetics are attended with some danger. 
The throat, neck, and chest should be bathed freely with the Compound Tincture of Lobelia and Capsicum, or with Oil of Lobelia, and, after each bathing, a fomentation of Hops and Lobelia, of each equal parts, boiled in water, should be applied around the neck as hot as the patient can bear; these local applications should be continued as well during the paroxysms as in the intervals between them. 
The liniment composed of the Oils of Stillingia, Lobelia, and Alcohol, recommended in croup, may, if preferred, be used as a local application, instead of the above. There are no agents so useful in this affection, to overcome spasmodic action of the glottis, as the preparations of Lobelia. 
If the child be teething, and there is the least heat or swelling over the advancing teeth, the gums should be freely and deeply lanced, once or twice daily. 
Should gastric or intestinal irritation be present, or constipation, especial attention should be bestowed upon the diet, selecting that which is light, nourishing, easily digestible, and not disposed to cause acidity of the stomach; at the same time, laxatives may be given, as Rhubarb and Bicarbonate of Potassa, to which, in some instances, a small portion of Podophyllin may be added, and these laxatives may be repeated every day or two. 
If there is diarrhea, the Compound Powder of Rhubarb, or Syrup of Rhubarb and Potassa, will be found fully sufficient to overcome the difficulty in the majority of cases, and when it fails, Geranin may be administered in doses proportioned to the child's age, in connection with the powder or syrup above. 


m THE RESPIRATORY APPARATUS. 
395 
Dysuria occasionally accompanies the affection, for which an infusion of Marsh Mallows may be given, with the addition of Spirits of Nitr. Dulcis, and one or two drops of Tincture of Stramonium. 
If the fauces are swollen, a weak solution of the Nitrate of Silver should be applied to them by means of a camel's hair pencil. 
In the intervals between the spasms, agents must be used to prevent their return, for which purpose, either the Compound Tincture of Cramp-bark, Compound Pill of Black Cohosh, or Compound Pill of "Valerian, may be used — the bowels kept regular, and all species of excitement, either mental or physical, should be carefully avoided. 
If the case be very intractable, in addition to the preceding, pustulation should be produced over the seat of the disease, by rubbing on Croton Oil. 
As the child improves, tonics, as Quinine and Iron, may be employed, but the diet should remain the same. 
In all cases, where it can be accomplished, a removal to the pure, mild air of the country will be found to facilitate the cure. 
Genus II.—Nervous Cough. 
This form of disease, taking society at large, is not unfrequent, but its occurrence among children is only occasional, more especially with the very young. 
So far as has been observed, it exists exclusively in a cough, which, although having several modifications, is unlike any other, more especially when associated circumstances are taken into consideration—independent of these, it occasionally has some resemblance to that of catarrh, and even, to some extent, simulates hooping-cough, but with these there are other indications of disease. It has not been detected in the chest, and, except when most obviously a symptom, it seems to exist independently of disease, for the patient, though much annoyed with it, has no other indication of ill health; consequently, it is thought to be purely a nervous affection. 
A variety of it frequently exists as a symptom of gastric irritation, through the instrumentality of the per vagum; but when it is of this character, it is easily detected by every physician, and therefore, it does not, in this place, demand our 


396 
NERVOUS FORMS OF DISEASE 
attention. Furthermore, it does not closely simulate the idio pathic nervous cough which at present alone engages our attention. 
This cough presents no discoverable indications of being symptomatic, and it is usually dry and short, unless rendered otherwise by a severe and lengthened paroxysm of it, whereby the respiratory apparatus, in general, is excited by it, and then a little mucus may be thrown up. Its sound, however, is sometimes more full, lengthened and liquid. 
With some children, it will occur at irregular intervals throughout the year, without reference to season, and without reference to time, as to day and night; with others, it occurs only during the cold season, and with some it occurs only during the night. 
It sometimes presents such a hollowness and loudness of sound, as to arrest the attention of all observers. The paroxysm may consist of only two or three coughs, or it may consist of a single cough at frequent and irregular intervals, or it may be almost continuous through both day and night—allowing the patient but little unbroken rest; or it may occur in paroxysms of such severity as to excite perspiration, a secretion of mucus in the respiratory passages, and a full and flushed condition of the face. 
When hearing the cough, we cannot realize that the chest is either deep or capacious enough to produce it—in this respect, and even sometimes in the sound of the cough, we have thought it to simulate the sound made by some frogs. The listener is, furthermore, astonished, to find such a cough to attend the appearance of so much health. 
The most notable instance of this kind, which we have seen, is that of a very healthy girl, about fourteen years of age. She has been exempt from it during the three preceding summers, but it has troubled her very much during the succeeding winters. In all other respects she has excellent health. 
There is, in her case, an organic circumstance which deserves notice —her fauces and pharynx are exceedingly developed and appear entirely healthy. If all such patients have so large a pharyngeal chamber, all the peculiarities of the cough may be accounted for. 


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397 
This patient, furthermore, is very plumply developed, flesh firm, neck rather short, complexion fair, the chest large, but not flexible, the nose is small, and the nares are contracted— contra-indicative of a vigorous pulmonary function. In her case, the nutritive and cutaneous functions are well performed, and, from the lively character of the skin, we would infer that her kidneys do not perform as much duty, as they generally do. 
As this is the only well-marked case we have seen, since the formation of our present physiological views, we are unable to determine how far her peculiar organic conditions are involved in the production of the cough; but this much we are willing to venture: if this cough is always associated with such an organization, more or less, then the cough is but an indication of an imperfect pulmonary system, and consequently of a deficient renal one. 
This conclusion finds some support in an observation made by Prof. Wood; in speaking of the cause of this affection, he says: " I have seen it associated with tenderness of the spine between the scapulae. I have also seen it, apparently, the result of gouty and rheumatic irritation." 
Treatment.—Dr. Wood states that he has found nothing so effectual as Asafoetida. We have tried this, and know that it will give almost immediate relief, but it will not effect a cure—the cough will return. Based upon our pathological suspicions, we would suggest, for the purpose of trial, much exercise, the use of light clothing, azotized food, and diuretics. 
In this disease, much benefit may be derived from the use of the following compound: 
Podophyllin, gr. j, Cyanuret of Iron, grs. t, S. Morphia, gr. ss, White Sugar, 3j. Mix. 
Divide into twelve powders; give one powder three times a day, to a child about three years of age, or in proportion. In connection with this: 
Iodate of Potassium, grs. iij, Tinct of Belladonna, gtt. xx, 
Distilled Water, 3vi. Mix, and give a tablespoonful every half hour. 


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A strong infusion of Peach Leaves, or Wild Cherry Bark, may be used as a drink through the day, which will be found to have a sedative influence upon the cough. 
Genus III. — Hooping-Cough. 
When we reflect that this disease is almost peculiar to children—that it stands third in the order of fatality, and that it occasions, in the parental mind, much painful anxiety, it must be admitted to deserve particular attention; much more, we fear, than it receives from a large portion of the profession, because of the fact, that all grandmothers, and a large proportion of the mothers profess to understand and to treat it. 
But as physicians, this circumstance should not abridge our attention to it; on the contrary, we should as thoroughly as possible understand it, and then we should diffuse our knowledge of it to all the mothers in the land. This course is more imperative with this disease, than' with any other, because every child, as a general fact, must have it. 
A close attention to its peculiarities renders it of easy diagnosis—it consists of paroxysms of coughing, in which there is a lengthened and thorough inspiration, followed by a succession of short expirations or coughs, until no air continues or remains in the lungs. When the disease exhibits these two well-marked symptoms, there can be no doubt as to its individuality, whether hooping attends it or not. 
For the purpose of a more detailed definition of it, some advantage will be obtained by dividing it into three stages, the catarrhal, the spasmodic, and the declining; the first two are, generally, quite distinct, and the third is not of very difficult recognition. The catarrhal stage is of very indefinite duration ; Dr. West states, that the average of fifty-five cases was twelve days and seven-tenths, and that two extremes were, respectively, two, and thirty-five days. But, in six of the fifty-five cases, there was no formative, or so-called first stage, they were paroxysmal from the start. 
We may say then, as an approximation, that the forming or first stage continues two weeks, more or less, and is scarcely ever attended with any symptom that distinguishes it from catarrh. It begins with coryza, red and suffused eyes, sneezing, irritation of the fauces, dry cough, and sometimes febrile 


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399 
symptoms. More is to be determined from the prevailing presence or absence of the disease than from symptoms during this stage. If catarrh is prevalent at the same time, which is not usually the case, it has been observed to run the same course (save the spasmodic and hooping symptoms), as though it originated in the same cause.- 
The distinguishing symptom of the second stage, is spasm — the hooping sound of the inspiration may commence with the spasms, but frequently it does not supervene upon them, under several days, and occasionally not at all. 
In denning the disease, we stated that the paroxysm formed or commenced with a protracted inspiration — the hooping, when present, is occasioned by it, and that the coughing consists in the discharging or expiring the air of this inspiration, in broken, or interrupted, or spasmodic efforts, each of which constitutes a cough. A paroxysm may continue from thirty seconds to the fourth of-an hour. During a paroxysm, the face becomes flushed, then purplish or livid, the cervical veins distended, eyes prominent and probably suffused. 
It is thought that during the opening and closing of an epidemic of this disease, the cases which are marked by a protracted forming stage, are produced. This would seem to imply that the cause is less concentrated. 
It is further stated, that when the catarrhal stage is protracted, the spasmodic stage will be mild, or comparatively light; but on the other hand, it is not said to follow, that when this stage is short, that therefore the one of spasm will be more severe. The absence of the hoop, in the second stage, is regarded as an indication of intensity or violence. We do not remember to have seen it noted, that in those cases in which the violence of the spasm forces blood from the nose, mouth, and ears, and to extravasate the conjunctiva, were, or were not, attended by the hoop, yet so far as our own observation has extended, the hoop has always been present in these instances. 
In some cases, as we have remarked, the second stage begins the disease with high fever, dyspnoea, and other indications of bronchitis, but upon the subsidence of these acute symptoms, the real disease becomes developed. After the spasmodic character of this stage has become clearly defined, 


400 
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some days elapse before it reaches its maximum, and during this time, it is worse through the night than through the day. In milder cases, there is but little, if any, difference in the paroxysms between the day and the night, and it frequently happens, that when the patient is tolerably well all day and rests pretty well at night, it will have a severe paroxysm at going to bed and another upon rising in the morning. The first, probably, is caused by going into a cooler room for bed, and the second by the bronchial accumulations of mucus through the night. So long as a strong, loud hoop attends the disease, we can feel sure that the spasm does not close the glottis, and therefore the child is safe from suffocation for the present. 
When the disease has obtained its acme, it may continue with about the same intensity two or three weeks, when the third stage commences—the paroxysms become less frequent, the inspirations less protracted, and the broken expiration less spasmodic—in fine, the disease, again, takes on the catarrhal form, and the patient is comparatively well; but at other times, the termination is not so speedily favorable—it is sometimes marked with relapses, or it may assume the chronic form, and thus become protracted to months, and possibly to a year or two. 
When, however, the disease does not take a favorable turn, all the symptoms of the second stage continue to increase in violence, the hooping-pauses in the paroxysms cease to be heard; a short inspiration, however, is made and the coughing returns ; at length, as the paroxysm is going off, the hoop may again be heard, and though not so loud it will be more stridulous. The paroxysms become more frequent, and the intervals are measurably filled with dyspnoea—the inspiration is no longer announced, or but seldom, by the hoop, the cough changes, the larynx becomes closed, struggles ensue, the constriction at length yields, and the respiration is effected. These paroxysms so increase, that before one is completed anothei commences, and thus they recur, until one of them closes the scene. 
The greatest danger from this disease, however, results from its complications, which are numerous, as with convulsions, croup, diarrhea, inflammation of some portion of the intestinal 


IN THE RESPIRATORY APPARATUS. 
401 
canal, with tubercular predisposition, bronchitis, etc. Pertussis is admitted to be epidemical, and some contend that it is contagious. 
Prof. Bigelow says, that it is one of those diseases which cannot be shortened or mitigated to much extent. We admit that it cannot be materially shortened, but we feel pretty confident that it may be materially mitigated by such a course of medication as it naturally indicates—which is to equalize the circulation, remove constriction, establish depuration, and maintain a centrifugal action in the system. 
Treatment.—It is very seldom that the practitioner is called in the first or catarrhal stage of pertussis, unless the symptoms are very severe, in which case he will treat them upon the principles indicated under the head of Catarrh. 
Sometimes the first stage is wanting, and the disease then assumes its peculiar characters from the commencement; but, more usually, this stage is mild, and it rarely happens that the physician is consulted, except in the second stage, when the disease is properly manifested. 
As we cannot expect to curtail the duration of pertussis, our only course is to employ measures to moderate its violence and diminish the frequency and intensity of the paroxysms; for this purpose, during the earlier part of the second stage, should inflammatory symptoms be present, an emetic should be given, daily or every other day, according to the urgency of the case, and which should be followed by an expectorant. 
To fulfill both of these indications the Compound Tincture of Lobelia will be found the most effectual agent —and indeed, from its antispasmodic influence, it will prove, in many instances, an agent fully sufficient to accomplish all that can be desired, and that too, even after the inflammatory symptoms have subsided. 
In this affection, constipation should be overcome, and the bowels kept regular, not by active cathartics, but by mild, laxative agents. 
After the inflammatory symptoms have fully subsided, some of the specific remedies, so named, may be given — among which, however, we prefer the following, having used each of them with much advantage: 
26 


402 
NERVOUS FORMS OF DISEASE, ETC. 
St. Carbonate of Potassa, 9j, Pulv. Cochineal, 9 ss, "White Sugar, 3i, Distilled "Water, 3iv. Mix. 
Of this, a teaspoonful may be given three or four times a day to a child one year old, and in proportion. 
Alum, likewise, affords prompt relief in this disease, and may be given according to the following formula ; it does not constipate the bowels or produce any injurious effects, except its tendency to cause vomiting when given in large doses, and to induce diarrhea from too long an employment of it: 
Alum grs. xxv, 
Syrup Ginger, 3ij, "Water, 3iij. Mix. 
Of this, an ordinary sized teaspoonful may be given every six hours to a child a year old. 
In protracted, obstinate cases, a change of air will be found advantageous, often cutting short the disease at once. 
Infants sometimes have the paroxysms very violent, so much so as to cause an apprehension of suffocation or convulsions, to overcome which, Dr. Meigs recommends the application of compresses dipped in cold water to the sternum, or a piece of ice wrapped in linen and suddenly applied to the epigastrium. 
In those instances where, from spasmodic closure of the glottis during the paroxysm, there is a suspension of breathing for several seconds, greatly endangering life, the free use of the Compound Liniment of Stillingia and Lobelia, referred to under croup, may be freely applied to the throat, neck, and chest, for the purpose of preventing such closure in subsequent paroxysms. 
The clothing of the child laboring under pertussis, should be warm, with flannel worn next to the skin in cold or damp weather, and in such seasons, it should likewise be kept in the house; but in fine weather, during the second stage, the free, open air, in the middle of the day, will prove beneficial. The diet should be nutritious and of easy digestion. 


CLASS IV. 
MANIFESTATIONS OF DISEASE IN THE CIRCULATORY APPARATUS. 
ORDER I. 
NON-INFLAMMATORY FORMS OF DISEASE IN THE CIRCULATORY APPARATUS. 
Genus I.—Establishment of Independent Circulation. 
This subject has been so interestingly and ably developed by Mons. Billard, that we feel it to be our duty to present to our readers his investigations without modification or abridgement : 
" I have studied with the greatest care the changes which occur in the heart, ductus arteriosus, ductus venosus, and umbilical arteries, during the first days of extra-uterine life, and shall exhibit here the results of these researches. 
"I shall consider successively—1st. The period at which the fetal openings are obliterated; 2d. Their mode of obliteration ; 3d. I will exhibit the physiological and pathological consequences which naturally flow from these researches. 
"i. PERIOD OF THE OBLITERATION OF THE FETAL OPENINGS. 
"Infants of the age of one day. —In nineteen children, aged one day, there were fourteen in whom the foramen ovale was completely open; in two of them it had begun to be obliterated ; and in two it was entirely closed. Consequently no blood passed through it. 
"In the same children, the ductus arteriosus was free, and filled with blood in thirteen; its obliteration had commenced in four, and in the remainder it was completely obliterated. I also noticed that, in one of the last mentioned children, there 
403 


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NON-INFLAMMATORY FORMS OF DISEASE 
was a complete occlusion of the foramen ovale. In the other children, in the same state the ductus arteriosus was still open. 
"With respect to the umbilical arteries, they were still open near their junction with the iliac arteries, but their caliber was narrowed in consequence of a very remarkable thickening in their walls. In all these children, the umbilical vein and ductus venosus were free, and the latter was most generally gorged with blood. 
" From this examination, it appears that the foramen ovale and ductus arteriosus are still open on the first day of birth in most instances, although they may be obliterated at this period. 
" Infants of the age of two days. —In twenty-two children, aged two days, there were fifteen where the foramen ovale was perfectly open; in three of them it was almost obliterated, and in four entirely closed. In thirteen of these children, I found the ductus arteriosus still open; in six the obliteration had commenced, and in three was entirely obliterated. In all, the umbilical arteries were obliterated to a greater or less extent, but the umbilical vein and ductus venosus, although empty and flattened, would not allow of the passage of a moderate sized stylet. These facts are sufficient to demonstrate that, in most instances, the foramen ovale and ductus arteriosus are not obliterated on the second day after birth, although the child may enjoy independent life ; as to the umbilical arteries, having now become useless, they undergo the changes resulting from their default of action. 
" Infants of the age of three days. —I also subjected the bodies of twenty-two children, aged three days, to the same examination. In fourteen of these the foramen ovale was still open; in five the obliteration had already commenced, and was complete in the remaining three. 
" The ductus arteriosus was also open in fifteen ; the obliteration had commenced in five, and was complete in two. Both of these subjects also presented the closure of the foramen ovale. The umbilical vessels and the ductus venosus were empty and obliterated in all these subjects. Now, it is evident that these vessels are obliterated before the foramen ovale and ductus arteriosus have undergone any complete 


IN THE CIRCULATORY APPARATUS. 
405 
occlusion, and it can therefore be asserted, that at the third day the ductus arteriosus and foramen ovale are not generally closed. 
"Infants of the age of four days. — I found in twentyseven children, aged four days, the foramen ovale open in seventeen. In these seventeen cases, there were six where this opening was very large, and distended with a considerable quantity of blood, and in the remaining number it was slightly open. In the twenty-seven cases now under consideration, the closure of this opening had commenced in eight, and it was completely closed in two. 
" The ductus arteriosus was still open in seventeen children ; its obliteration had begun and it exhibited nothing more than a small hole in seven of these, and its closure was complete in three; the umbilical arteries, in almost all, were obliterated near the umbilicus, but still susceptible of dilatation near the junction with the iliac arteries. The umbilical vein and the venous canal were completely empty and considerably contracted. 
"Infants of the age of five days. —Twenty-nine children, aged five days, were subjected to the same examination as in the preceding instance; thirteen exhibited the foramen ovale still open ; but this opening did not exist in the same degree in all. It was largely dilated in four individuals, and in ten others its diameter was much smaller. 
"This passage was almost completely obliterated in ten individuals, and in six others sufficiently so as to leave no communication between the auricles. 
"I found, in these twenty-nine cases, the ductus arteriosus open in fifteen ; in these, there were ten where the duct was very large. The obliteration had made considerable progress in the remaining five, and was almost complete, or at least the caliber of the duct consisted of nothing more than a narrow hole, in seven, and in seven others the obliteration was complete. As to the umbilical vessels, their obliteration was complete in all. 
"We have seen, thus far, that the fetal openings remained free in a number of children five days after their birth. None of the children exhibited any peculiar symptoms which appeared to have their seat in the circulatory apparatus. We 


406 
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shall find the number diminish in subjects of more advanced age than those which have already been the object of our researches. 
" Infants of the age of eight days. —I have not observed any well-marked difference between children of six or seven days, and those which we have just described. This remark, however, is not applicable to those of eight days. Indeed, I have found but five where the foramen ovale was still open in twenty cases that I examined. It was partially closed in four individuals, and its occlusion was complete in eleven. 
" In these twenty children, there were but three in whom the ductus arteriosus was not yet obliterated; one of them presented an aneurism of the duct of the size of a hazelnut; interiorly, it was covered with a thick layer of a yellow color and fibrinous consistence, analogous in every respect to those fibrous layers which cover the interior of an aneurismal pouch. 
"In these twenty individuals, I found in six the ductus arteriosus almost entirely obliterated, and its obliteration was complete in eleven. The umbilical vessels were perfectly closed in almost all; I say almOoC all, because I observed neither the umbilical arteries nor vein in five of them. 
" From the last examination, it appears that the fetal openings are usually obliterated on the eighth day, but they may yet be found open even on that day ; I will also add, that even on the twelfth and fifteenth day, and in the third week, the foramen ovale or ductus arteriosus may still be open, without the child experiencing any particular symptom; for I will again observe, that I have chosen for these researches children who, for the most part, died from affections in which the respiratory apparatus did not participate. 
"From this exposition, it is evident that the fetal openings are not obliterated immediately after birth ; that the period at which this occurs is extremely variable, yet the foramen ovale and ductus arteriosus are usually closed on the eighth or tenth day. It results, also, from the examinations we have made, that the modifications which follow the cessation of fetal life, in the circulatory organs of a new-born child, occur in the following order: the umbilical arteries are first obliterated, then the vein, next the ductus arteriosus, and lastly, the 


IN THE CIRCULATORY APPARATUS. 
407 
foramen ovale. The persistence then of the fetal openings, for some days after birth, ought not to be considered as a disease, since it is not uncommon to meet with it without having given rise to any particular symptom. This irregularity or tardiness is attributable, as will be presently seen, to the mode of obliteration. 
"il. MODE OF OBLITERATION OF THE FETAL OPENINGS. 
" When the arrangement, which gradually occurs in the foramen ovale, from the earliest months of conception until the period of birth, is examined, it will be perceived that the form of this opening and the disposition of the surrounding parts, and particularly that of the eustachian valve, are such that the blood, which at first flows without any obstacle from one auricle to the other, by degrees experiences some difficulty in its passage. Sabatier especially has remarked this. Thus the first modification in the organization of the heart forces the blood to change its course; this fluid, in itself inert, is under the immediate dependence of the moving power which projects and directs it through the proper passage. If this be so, it must also follow, that in those parts which the blood leaves, an anatomical modification occurs, which changes the form and modifies the action of these organs, and produces in the blood which flows through them, a change of direction. Now, if the umbilical arteries and the arterial duct are examined, in proportion as they become obliterated, it will be seen that their walls gradually become thickened. The thickening of the umbilical arteries is more remarkable at the point of insertion at the umbilicns, at which point they exhibit a kind of swelling which materially affects the caliber of the artery, and this swelling appears to be the result of a species of rrypertrophy of the yellow, elastic, fibrous tissue; whence it follows, that the artery exercises, at this part, a contractile force superior to the dilating power of the blood propelled by the iliac arteries. It is very easy to prove the thickness of the warls of the artery, by cutting it in sections at this part; the thickness, it will be also perceived, diminishes in proportion as we approach the iliac arteries, and it is precisely in this direction that the progress of the obliteration is observed to occur after birth. Two conditions, therefore, cause the blood, 


408 
INFLAMMATORY FORMS OF DISEASE 
after birth to leave the course it had while in the uterus: 1st. the establishment of respiration and the pulmonary circulation ; 2d. the modification of texture occurring in the umbilical arteries. 
" The following phenomenon proves also that the contractility of the umbilical vessels is susceptible of suspending the course of the blood in them; if the umbilical cord be cut at some distance from the umbilicus at the time of birth, in a plethoric child, the blood will at first be seen to issue in a jet with considerable force, then becoming slower, and afterward stopping altogether; if another portion of the cord be cut, another jet of blood occurs, and soon stops. This hemorrhage may be renewed at each section of the cord. M. P. Dubois has informed me that he has seen this frequently occur. 
"Now, the course of the blood is in some degree arrested, because the umbilical arteries contract on it and force it to retrograde; if there exist near the umbilicus and within the abdomen a portion of the umbilical arteries more contractile from the existence of a greater quanty of elastic, fibrous tissue, it can easily be conceived that the course of the blood in the child, becoming less quick when the calm which occurs after birth begins to be established, these arteries may have power to resist from the first the progress of the blood ; in proportion as the child advances in age, the artery becomes more obliterated, and, undergoing a kind of traction from the progressive widening of the abdominal parietes, it loses altogether its vascular form, and is transformed into a true ligament. 
"What is observed in these arteries occurs also in the ductus arteriosus. In the embryo, it is as flexible as the other arteries, and is, therefore, as easily dilated by the column of blood which flows through it, which penetrates without any obstacle into the aorta; but at birth, and after this period, the walls of this duct become gradually thicker, and a sort of concentric hypertrophy is developed in them, w T hich, without diminishing in appearance the size of the vessels, nevertheless produces a contraction of its caliber, by which the blood driven from this duct passes through the pulmonary arteries. When the ductus arteriosus has undergone this hypertrophy and obliteration, I cannot describe it better than by comparing 


m THE CIRCULATORY APPARATUS. 
409 
it to a tube, the circumference of which is very thick and that presents in its centre nothing more than a small hole. 
"The obliteration of the vein and duct does not occur in the same manner. These vessels do not exhibit, as do the others, any remarkable thickening of their walls; the moment the umbilical cord is cut, the vein is no longer susceptible of receiving blood in its caliber, at least except by regurgitation from the vena cava. The sides collapse and approach each other; they thus come in contact, and the passage is at last obliterated, as is seen in all tubes of every character as soon as they no longer give passage to the fluid usually passing through them. Yet they still preserve for a long time a free passage, for they may easily be distended by introducing into them any ordinary-sized stylet, while this is not the case with the arteries. 
" In the arteries, there is, if I may be allowed the expression, an active obliteration; the blood has been forced to abandon them by a succession of organic modifications occurring in the texture of their walls, while, in regard to the umbilical vein and venous duct, there is a passive obliteration — that is to say, it follows the absence of the blood; and it is the result, and not the cause of the retropulsion of the sanguineous fluid. The difference, doubtless, depends on the difference of organization between the arterial and venous system. If it be necessary that the foramen ovale and ductus arteriosus should undergo organic changes for their obliteration, it will be easily understood, that nature, so fertile in anomalies, may prepare these modifications either prematurely or tardily; hence the cause of the obliteration of the fetal openings from the first, in some children, and the persistence of the foramen ovale and ductus arteriosus in others, to a period far removed from birth. Hence, also, the necessity of greater or less time in most cases for the completion of this obliteration. In this manner can be explained the irregularities of the period of the complete establishment of the independent circulation, without the necessity of considering them as the cause or effect of certain diseases of the heart or lungs. 
"The accomplishment of these phenomena of transition must doubtless be attended with an incomplete oxygenation of blood, since all this fluid w r hich the heart propels to the 


410 
INFLAMMATORY FORMS OF DISEASE 
different parts of the body has not passed through the lungs. But, after all, is it necessary that the blood of an infant just born should be oxygenated, equally with that which passes through the arteries of an adult % Would it not rather appear that the tender frame of a new-born child ought not to receive blood possessing too much stimulating properties, that the materials of nutrition should not be too suddenly charged with exciting principles, the action of which on the organs of an infant may be injurious to its health, and to the progressive establishment of independent life ? I am of this opinion, and do not think its correctness can be denied, flowing, as it does, from the anatomical examination of the circulatory organs of a young child. This assertion is supported by another remark: the lungs would be exposed to fatal congestions if the pulmonary arteries should suddenly throw into them all the blood which flows into the heart. The ductus arteriosus, by permitting the blood to pass through it, comes, as it were, to the aid of the respiratory organs, the congested state of which will not permit the air to arrive freely in the cells; the establishment of independent life is, therefore, actually promoted by the continuance of fetal life. Thus, then, there is a connection between the organization and disposition of parts, and the exercise of their functions, and they follow in a regular order, and by transitions prepared by nature, to the end that no sudden and unexpected change may interrupt the order and harmony of the phenomena of life." 
Genus II. — Ctanopathy — Cyanosis — 
Blue Disease of Infancy. 
We have placed this infantile affection here, rather than in the pulmonary division, because it appears to us as probable that it originates more frequently in some cardiac imperfection, than a pulmonary one; and yet, it maybe occasioned by some incompleteness of the respiratory apparatus. Though it may not depend upon the direct communication that exists between the right and left cavities of the heart, yet it is generally thought to be occasioned by some obstacle to the circulation in the right side of the heart. 
In this affection the integuments have a blue or violet-blue color, one that very much resembles that which is produced 


IN THE CIRCULATORY APPARATUS. 
411 
in adults by several species of asphyxia. So for as we can judge from appearances, the blood has not been properly oxygenated, and therefore, if the lungs should fail to perform their duty, the disease may become manifest without any cardiac malformation. Some think that it may be occasioned by a mixture of the two kinds of blood, but others do not believe that it can result in this way. 
We have cyanosis produced, in infants, by an engorgement or an inflammation of the lungs; whatever the remote cause may be, therefore, it seems pretty evident that the proximate one is an unoxygenated condition of the blood; and it will probabe the safest practice to assume it as being generally the fact, that it is produced by a sanguineous congestion of the heart or lungs—and, in practice, the best remedy consists in holding the child near to some source of heat, as a stove or even open fire, and to rub its head and body gently with hot cloths, and this should be persevered in, at the same time keeping the the child, when lying, constantly upon its right side. 
ORD.ER II. 
INFLAMMATORY FORMS OF DISEASE IN THE CIRCULATORY APPARATUS. 
Genus I. —Imperfect Cicatrization of the Umbilicus. 
The period at which the umbilicus separates, varies from two to fifteen days, but it is usually effected on the fourth or fifth. In a large proportion of cases, the cord is small and the desiccating process is soon completed, and generally without any unpleasant attendants; but in many cases the cord contains a large quantity of gelatinous matter, by which the process of desiccation is retarded ; and, in such cases, inflammation and suppuration may supervene —that is, the liability to these results in the latter is greater than in the former. 
These results are in nowise essential to the separtion of the cord, but are produced, sometimes, by causes of local irritation, and in some cases, no doubt, by some imperfection in the constitution of the cord, at all events, it is made necessary 


412 
NON-INFLAMMATORY FORMS OF DISEASE 
that we should interfere to prevent mischief, and to effect a perfect cicatrization. 
The cicatrization is usually complete in ten or twelve days. If the cord be small and the ring that forms around it be thin, the cicatrix is soon effected ; but, on the contrary, if the ring be large and much extended up the cord, the absorption will require time, and the cicatrization will be proportionally delayed. In some cases, after the usual period for the separation of the cord has passed, it will be found still attached by a filament which should be divided, because its existence is an impediment to cicatrization. This process is sometimes retarded by the formation of a sort of mucous membrane at the place of the separation of the cord, which produces a puriform discharge, while the cellular tissue at the same time produces pus. A soft tubercle, more or less red, consisting of the extremities of vessels reunited, forms in the center of the umbilicus, which, when its normal condition is maintained, is finally imbedded in the abdomen. This tubercle sometimes inflames, becomes fungous, and discharges a purulent matter and refuses to heal, but goes on to form an elevated and ulcerating surface, or it may take on the form of a pediculated button or one having a large base. 
Treatment. — Mayer's Ointment will generally effect a healthy cicatrization; but, in cases where stimulants are required, for the purpose of aiding the granulating process, the Sesquicarbonate of Potassa, or the Sulphate of Zinc, may be previously sprinkled lightly on the umbilicus; care should be taken not to apply too much of either of these agents, lest excessive inflammation should follow, and which must, whenever it occurs, be treated by poultices of Slippery-elm. 
Genus II. —Pericarditis — 
Inflammation of the Heart's Envelope. 
All the symptoms which usually attend this form of disease, in adults, are rarely sufficient to serve as a safe foundation for a diagnosis; if this be the case with adults, how much more obscure must be the symptoms in infants ? And, when we contemplate the causes of it, in adults, we are puzzled to surmise a cause for its occurrence in infants. 
In the presence of such obscurity, Billard states, "that 


IN THE CIRCULATORY APPARATUS. 
413 
when there exists a state of general restlessness, distress, and suffering, in young infants, there is almost always a gelatinous softening of the stomach, pericarditis, or acute pleurisy; and our judgment must be directed to a decision between these three different diseases." 
The pulse, which is a marked symptom in the adult, is worthy of no attention in infancy; the child may manifest the existence of pain by its cry, the face may be pinched, the breathing labored, and even suffocating, but these are not diagnostic symptoms. 
As the treatment of pericarditis is the same as that of pleurisy, of which we have treated, we dismiss this subject here; and also the further consideration of the diseased conditions of the circulatory apparatus, inasmuch as they offer nothing that is not common to adults except greater obscurity in their symptoms. 


CLASS V. 
MANIFESTATIONS OP DISEASE IN THE DERMA. 
INTRODUCTION. 
Before proceeding to the consideration of the special manifestations of disease in the dermoid system, we desire to indulge in some general remarks upon its structure, functions, and pathology, for the purpose of finding a suitable place to drop a few suggestions, which to us, appear to have a vital bearing on the subject. 
Upon the anatomical structure of the skin, anatomists and physiologists are considerably divided in opinion. Chaussir teaches that it consists of two parts, the derma, cutis vera, or true skin, and epidermis or scarf-skin; while Cruikshank maintains that it consists of six laminae; but the most prevalent opinion is, that it consists of three—the cutis vera, rete mucosum, and the cuticle or scarf-skin ; but as the rete mucosum has never been demonstrated to exist in the white race, so it is denied to it, by many, while others infer, and we think with just probability, that, inasmuch as it is demonstrated to exist in the negro and some other dark-colored races, it must exist also in the white. 
As the rete mucosum is the lamina that imparts the dark color of the dark-colored races, it may reasonably be presumed to be present in all human beings, except the albino. It is supposed that the rete mucosum is secreted by the corion or cutis vera. The scarf-skin or cuticle is a translucent inorganic membrane that invests all parts of the body. The cutis vera is supposed to consist almost entirely of a uniform network of minute vessels, some of which, from their exceeding delicacy, transmit only a colorless fluid. 
The secretions of the skin are essentially of two kinds—the 
(414; 


DISEASE IN THE DERMA. 
415 
sudoriparous or common perspirable matter, and sebiparous or sebaceous matter. The latter is confined to a small extent of surface, such as the point of the nose, the arm-pits, margins of the eye-lids, the pubis, and some other places. These secreted matters are produced by follicles which are about a quarter of an inch deep, and Dr. Willson, from his attention to this subject, concludes that there are in each square inch of surface, two thousand eight hundred of these pores, which, according to the length assigned them, would make a tube seven hundred inches in length. Now, supposing the surface of a man of medium size to be two thousand five hundred square inches, we would have, for the number of the pores, seven millions, and the length of tube one million seven hundred and fifty thousand inches, which is equal to twenty-eight miles. Supposing this calculation to approximate the truth, we can then entertain no doubt as to the importance of the skin as a secretory organ.* 
It is difficult to ascertain accurately the quantity of the secreted matter of the skin, but it may be assumed as an approximation of the average quantity that nine parts of solid matter are contained in every hundred secreted; and the greater portion of this consists of a compound of protein, and the balance of chlorides of sodium and potassium, muriate of ammonia, alkaline phosphates, free acetic and butyric acids, and occasionally other salts. To this may be added as an excreted product, the scarf-skin, which is constantly passing off from the surface: it consists of carbon, forty-eight, hydrogen, thirty-nine, nitrogen, seven, and oxygen, eighteen parts. In this extensive elimination of carbon, we perceive that the skin aids, considerably, the respiratory function. 
* An importance at least that should place under condemnation of perpetual exile from the profession the physician who would permit his patient to suffer and die, of any form of disease, and more especially of an inflammatory one, without giving the least attention to his cutaneous surface. We have known hearty and sound men to die of pneumonia, and other inflammatory forms of disease, whose skins had not been even moistened during the whole of their illness. Such patients would have recovered without their physicians,— although they belonged to that class of the profession which claims to possess all the medical skill of the age. We do not intend to intimate that they killed their patients, but we intimate that if they had shed no blood, and had administered no indigestible medicine, and had cleansed and relaxed the cutaneous Burface, they might have recovered. 


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MANIFESTATIONS OF DISEASE 
We have now treated of as many of the cutaneous functions, and as extensively too, as we deem essential to our present pathological purposes. 
All dermatologists admit that it is peculiarly difficult to arrive at the etiology of cutaneous disease; but all agree, however, that filthy habits have much to do in its production. Dr. Willan attributed the frequency of it, in England, to the want of public baths; and Dr. Worcester thinks that the same operates to a still greater extent in this country; indeed, he regards it as our most important cause. Now, we are not going to question the possibility, nor even the probability, that a want of cleanliness may produce it, but we deny the importance, in this relation, the preceding gentlemen appear to attach to it. 
We are sure that our slave population are less afflicted with this disease than are their more favored and cleanly masters; and if filth can produce it, then some of our Indian tribes should scarcely present an individual exception. They are eternally besmeared with grease, soot, ashes, and paint, and yet we never saw an Indian with a diseased skin. We have, furthermore, seen many negroes whose appearance indicated that they had a hydrophobic dread of water, and yet they had sound skins. 
When we find a dog with a diseased skin, he is one which has exercised but little and fed much—it is but rarely seen among the huntsman's dogs. Hogs, than which no animal is more filthy, have very rarely a diseased skin, and when they and dogs have such a disease, we cannot attribute it to filth. 
If we are to consider cutaneous inflammation as disease of the skin, as most medical writers have done, if we may infer their pathology from their use of the lancet and purgatives, then of course we would, as they have generally done, look for external causes of it. 
We do not wish to be understood as intimating that etiologists have overlooked other and more probable causes, such as indigestible and greasy food, but they have not dwelt upon such causes with the emphasis they merit. They do not appear to attribute as much importance to the pulmonary and digestive surfaces, in the production of cutaneous diseases, as they deserve. „ 


IN THE DERMA. 
417 
For the purpose of finding a solution to many of the difficulties that attend cutaneous disease, we must again refer to the results of our cerebellar investigations. 
In all persons of the first class (page 20), we find a native vigor and health in the skin—a skin in which disease is rarely seen, with the exception of the contagious and erysipelatous— in this class the digestive and pulmonary functions are ably performed, the energy of the former does not permit the production of cutaneous disease, from the ingesta of ordinarily indigestible food, nor does that of the latter allow such a result, from the use of the carbonaceous, such as fat, butter, sugar, etc. 
The second class is about as exempt from cutaneous disease as the first, in the absence of any interruption to the general health, because, whatever carbon is taken into the system over and above its demands is converted into fat. This is beautifully illustrated upon the sugar plantations of the south— almost every negro becomes fat during the sugar-making season. 
In the third class we have feeble digestive and respiratory functions, and, with them, we have troublesome and even fatal modifications of disease. In this class, indigestible food may not, generally, do anything worse than produce diarrhea, but carbonaceous food, when taken in quantity beyond the wants of the system, must do mischief of some kind—it must act as a foreign irritant. The respiratory powers cannot eliminate it, and those of nutrition cannot convert it into fat; but in the system it cannot remain — the vis conservatrix will find an outlet for it, if it have the power, and if it have not, then death ensues. 
It is in this class of children that we meet with difficult dentition and all of its associated forms of disease; it is in this class that the arresting of a cutaneous eruption is liable to result in convulsions, paralysis, encephalitis, acute or chronic hydrocephalus, or some other modification of disease; consequently it may ultimately become possible to divide the many forms of dermoid disease into three great classes, depending for their primary or organic causes, upon the three conditions, as set forth in the table above referred to; with the 
27 


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MANIFESTATIONS OF DISEASE 
exception of the contagious ones, and they may be divided into three modifications of character. 
These conclusions are so palpable that we feel that we have a right to infer that those cutaneous modifications of disease which do not depend upon a secreted poison, are referable, most generally, to the causes above assigned, more particularly with children, because of that over-feeding and cradle-inactivity in which most mothers indulge them. 
But, in this connection, there is another circumstance, connected with children, which is both interesting and important to observe: it is the highly vascular and turgid condition of the cutaneous and mucous systems, which, of themselves, admonish mothers to observe the most thorough temperance and care of their children. 
Before we conclude this introduction, a few general remarks upon the subject of diagnosis, treatment, and prognosis seem to be demanded. 
As cutaneous forms of disease are always exposed to an open, day-light investigation, it follows, therefore, if that attention which is usually devoted to the diagnosis of other forms, were given to these, a mistake could scarcely ever result, except perhaps in some instances of the complication of one form of disease with that of another, consequently diagnostic mistakes, in these, are less excusable than when they happen in other forms of disease. 
Some information can usually be had from those who have been in attendance, and as the introductory stage is usually passed before the physician is called, he may be able in many instances to ascertain whether the eruption commenced dry or moist; and as almost all forms of dermoid disease are successive in their progress, it is.generally possible to find an example of its elementary form, as vesicle, papule, or pustule, more particularly in the vicinity of the affected part. When, however, this cannot be done, it may be possible to detect the family of which it is a member, and learn of the attendant or the patient whether the vesicles appeared clear and limpid, or opake and yellow, and whether the eruptions were distinct or conglomerated, soft or hard, large or small, conical or flattened. 


IN THE DERMA. 
419 
By a proper observance of the foregoing means all the information that may be essential, may generally be had. 
Before venturing a few remarks upon the general indications of treatment of cutaneous disease, it becomes proper to observe, that we do not regard cutaneous eruptions, and the attendant fever, as disease, but as (firstly) indices of the existence in the system of a cause of pathological action, and (secondly) as manifestations of well-directed efforts to eliminate it from the system. 
Under these views, it is evidently improper to bleed or purge, because these means will reduce the cutaneous inflammation, and thereby cripple the effort the system is making to eradicate the disease. Nor can we, except under the extremest circumstances, reconcile ourselves to the introduction into the system of one poison, for the purpose of removing another. We are aware that Arsenic and the Bichloride of Mercury have much reputation in the cure of various forms of cutaneous disease, but we have been assured by some old and faithful observers, that while they effectually relieve the skin, in many instances, they invariably establish disease in some other part of the system. They are both poisons, and of that kind which cannot, by the power of nutrition, be appropriated to the development or repair of any tissue in the body, consequently, any portion of them which may escape elimination from the system must continue to act as a poison, at least as a foreign irritant, hence we cannot therefore recommend their use, until a more safe and consistent course shall have been thoroughly tried. 
The general treatment, then, should consist of alteratives and antispasmodics, with such adjuvants as shall be the best calculated to prevent local and constitutional irritation ; such as the mildest aperients, with soothing applications to the surface, which may consist of cataplasms, cleansing washes, and water dressings. These latter means will, in very many cases, alone prove sufficient. 
As a very large amount of cutaneous disease is, no doubt, produced by the ingesta of too much carbonaceous food, and whether it is or not, such food should be carefully avoided during the existence of the disease. 
Dr. Worcester says, that "Some articles of food, experience 


420 
MANIFESTATIONS OF DISEASE 
has proved, are particularly to he guarded against; as the nse of pork, of all salted meats, all articles of a fatty or oily nature, most articles containing the nutritious elements in a very concentrated form, etc., though to this last there are exceptions; in some cases a diet consisting of a large amount of sugar has been efficacious in correcting a depraved and cachectic state of the system. 
In regarding sugar as a nutritious article, the doctor is mistaken. Sugar must ever be contra-indicated, in deranged conditions of the derma, except in cases of marasmus, when the calorific function is being supported at the expense of the body. 
Cutaneous disease appears, sometimes, to have been established for vicarious purposes, and when we can have any suspicion of this, no attempt should be made to cure it, before the cause for which it was instituted shall have been removed. And when, further, such an eruption has existed so long as to have become naturalized to the system, which not unfrequently happens to youth, as well as old age, a similar precaution is to be observed. 
It will not be going too far to say, that the mass of physicians have but little acquaintance with the various forms of dermoid disease; their dermatological nomenclature consists of " tetter-worm, ring-work, nettle-rash, salt-rheum," and perhaps a few other equally vulgar names; and to about the same extent may we consider their knowledge of the subject. In harmony with their nosonomy are their therapeutics: Salts, Sarsaparilla, Sulphur, Arsenic, Corrosive Sublimate, and every variety of salve or ointment. But we doubt very much whether the most learned and highly-approved treatment of them is, really, much more commendable than the preceding. 
We are instructed, by Dr. Worcester, to be governed by the great principles that should guide us in the treatment of other forms of disease. This we approve of; and, therefore, it follows, he says, that inasmuch as most forms of cutaneous disease are inflammatory at first, " common sense would direct general depletion by bloodletting and cathartics;" and when this stage has passed off, a resort should be had to " tonics or even stimulants." Now, it so happens that our common sense is deeply penetrated with the conviction that there is no 


IN THE DERMA: 
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common sense in this plan of treatment. Our common sense dictates that we should so husband the resources of the patient as to have no occasion for the tonics or the stimulants. 
It is evident that he (his school) is aiming to remove or to break down a symptom, and in the accomplishment of it, and then only to a partial extent, he discovers that he has so broken down his patient as to endanger, more or less, his life, and then resorts to " tonics or even stimulants," to insure his safety. 
"We, on the contrary, at the outset discover that a pathological action is in progress to remove an agent that is unfriendly to health, and therefore we are satisfied to stand by, to remove impediments, and to render aid, as circumstances may require. 
A word or two on prognosis, and we close this introduction. When we contemplate the great importance of the cutaneous functions to a continuance of life, notwithstanding the extraordinary power of the system to adapt itself to very severe conditions, it necessarily follows, that when, by a long existence of the disease, great constitutional depravity, neglect, and possibly malpractice, it becomes very generally disorganized, death must ensue, notwithstanding the vicarious aid which is rendered by other parts of the system. When a disease of the skin has existed so long as to become important as a depurating organization, it frequently becomes a difficult question to decide whether any attempt should be made to cure it. When the disease is of a hereditary, or rather organic, character, and has come to perform an important function, it may be wise to decide in the negative, more especially if the patient be on the advanced side of life's meridian. When it performs, vicariously, an important function, as the catamenial, no attempt at a cure should be made, until the function has been restored to its proper organ. 


422 
MANIFESTATIONS OF DISEASE 
ORDER I. 
MALFORMATION AND DISEASE OF THE DERMA PRODUCED BEFORE OR AT BIRTH. 
Genus I.— Malformation of the Derma produced before 
Birth. 
Species 1. — Alterations of Color. 
Haller has reported cases of white children having been born of black parents, and black children of white parents. 
To account for the variety of color in the cutaneous structure of some infants which anatomists have observed, Billard supposes the blood to undergo changes in its composition when circulating toward the integuments. This supposition may, or it may not, be without merit, and the facts attempted to be explained are not of sufficient importance, generally, to justify us in mystifying them by any species of mere speculation. For the present, we must content ourselves with the bare statement of the fact that spots or discolorations are produced in some fetuses. 
Species II. — Excrescences. 
Children have been born covered with hair, and although the circumstance excites considerable astonishment in the minds of the unprofessional, and usually inflicts upon the parents a painful shock, yet the phenomenon is not one that should occasion much concern in anywise. About the middle of gestation the skin of the fetus becomes covered with hair, which, generally, falls off before birth, and at birth shows itself in the liquor amnios. 
Existing causes do occasionally produce an extraordinary development, and the action they establish is, in such instances, too energetic to allow of its disappearance before birth. In view of the facts, it amounts to nothing more than an unusually developed and greatly prolonged existence of a normal growth. As this pilous growth will spontaneously disappear, in due season, no remedy is demanded, while depilatory agents, if used, might irritate the skin and possibly do mischief. 


IN THE DERMA. 
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The excrescences produced during fetal life, may occur upon any part of the surface of the body, but are most generally met with on the face, hands, and feet, consisting most frequently of an elongation of the skin. It happens that they are so developed, in some instances, as to occasion a real deformity ; they should be removed as soon after birth as may be deemed safe and practicable, for the reason that the cicatrix will be more speedily and certainly obliterated. 
Species III. — Nmvi Materni — Mother's Mark. 
Professor Dewees, Billard, and others ridicule the idea that these productions are caused by impressions made upon the maternal mind during gestation, and yet Billard admits, as every one must, that their cause is "very obscure." Nevertheless, it does appear to us that those who maintain the negative of this question, are much more in the dark than those who occupy the affirmative, and, judging from the medical literature of the day, the advocates of the affirmative are rapidly increasing. If the cases we presented, when treating of this subject, be really facts, and some of them we know to be so, and as to the others we entertain no doubt, it appears to us absolutely impossible to resist an affirmative conclusion. 
These naevi materni may be divided into three classes: the first comprises those which merely indicate an alteration in the cutaneous pigment, representing clouded yellow, rose, red, livid, blue, brown, copper, or black colors; and, as they continue stationary after birth and through life, we are compelled to infer that there is in them no morbid action—no tendency to disorganization. They are neither more nor less than healthy peculiarities of the skin, and any attempt at their removal will generally do more injury than good, by leaving a cicatrix more disgusting than the nsevus. 
The second class embraces those which are pediculated— having a true erectile tissue, and having for their color some shade of red, with an apparent or real granulated surface. 
The third class contains those which are more deeply seated under the skin, irregular in their shape, broad in their bases, and appear to consist of aneurismatic vessels—sometimes called varicose wens, sanguineous fungi, and aneurisms of the small arteries. They differ from true aneurisms inasmuch as 


424 
MANIFESTATIONS OF DISEASE 
there is no communication between the arteries and the veins. 
The last two classes are both liable to enlargement, ulceration, and dangerous hemorrhages, consequently they should be removed as soon as possible, with safety to the child. But how should this be done? Some recommend pressure, some the ligature, some actual cautery, and others the knife; yet very few cases have ever been benefited by either of these means. 
Treatment.—No treatment is necessary in these disfigurations, unless they manifest a tendency to enlargement, ulceration, or hemorrhage, under which circumstances there is great danger of other and healthy parts becoming involved, which may take place to such an extent as to demand interference. 
For the removal of these difficulties, especially after hemorrhage or ulceration has ensued, we employ the pulverized Sulphate of Zinc, applying it over the whole of the affected part once a day; when the part has been covered with the zinc, it must be retained there by a piece of linen covered with paste or some soft, simple ointment. This course should be continued until the whole of the nsevus is killed, after which a poultice of Slippery-elm must be applied, and changed two or three times a day, until the cauterized portion sloughs off. Mayer's Ointment may then be used to heal the remaining ulcer. 
During the application of the zinc, it will often cause so much inflammation, as to render it necessary to discontinue its use for a few days, until the inflammation has subsided from the employment of an elm poultice. 
Sometimes it will happen that the ulcer will not heal after the first slight slough has passed off, in which cases it will be requisite to again apply the zinc, and proceed in the treatment as at first. 
With this plan of treatment, we have succeeded in curing many cases, even after the actual cautery had failed. From among them we select the following: 
A child of Mr. B., aged about ten months, had a mark on the orbital process, just above the nose, and immediately between the superciliary ridges. At birth, it was quite small and very red, and continued to increase in size until it became 


m THE DERMA. 
425 
nearly as large as a chestnut, presenting a malignant appearance, and involving the surrounding tissue, at which time it was considered necessary by the family pnysician to remove it, which he attempted to accomplish with ligatures introduced through the tumor by means of needles, and tying it in sections, after which he applied the actual cautery, and burned the tumor to a level with the ligatures. A few days were required for the sloughing to pass off, when it was discovered that the tumor grew more rapidly and assumed a more malignant condition than before—in consequence of which the case was pronounced incurable. Under these circumstances, the parents brought their child to this city to consult Drs. R. S. and O. E. Newton. After an examination, they considered the case, although very malignant, one that could be cured, and Dr. O. E. Newton, taking charge of the case, treated it according to the plan above given, and in a few weeks effected a permanent cure, with but very little disfiguration. 
This treatment, so far as we know, has never been pursued by any other practitioners, and we believe it is original with them. 
Genus II. — Disease of the Derma produced before or at Birth. 
Species I. — Absence of the Skin. 
It is sometimes the fact that infants, at birth, are destitute of a portion of the skin or common integument, at one or more points of the surface of the body. As to the cause of such injuries we may speculate, and this is, in reality, about as much as we can do. 
In the second Book, when treating of the psychological influence of the mother on the fetus (page 100), we introduced one case of lesion of the skin of the knees and muscles of the arms, and another of the skin of the knees which had commenced to cicatrize before birth. 
Impressions made upon the mind of the mother may, then, sometimes, be the cause of the absence of the fetal cutis, and of the parts below it. Billard states, that it is generally the case, when the skin is absent, so are the subjacent parts; and that in such cases the borders of the defective skin are red and hardened and considerably adherent to the subjacent parts. 


426 
MANIFESTATIONS OF DISEASE 
It is thought that the fetal skin may be destroyed at such points as may come in contact with uterine tumors, such, for instance, as polypi; and that it may also be effected by subcutaneous tumors of the child, causing, by their enlargement, an absorption of the cutis. 
Whatever may be the cause of such cutaneous disorganization, the treatment will consist of such means as will support the subjacent parts and favor cicatrization. 
Species II. — Tumor of the Scalp. 
Tumors of the scalp, when cedematous, consist of an infiltration of serum, which very rarely becomes of a cone shape, but appears, generally, as a repletion of the cranial integuments, and soon disappears ; but when they are sanguineous, they consist of an infiltration into the cellular tissue, or in a repletion of its minute vessels. 
Incisions made into the scalp readily give exit to darkcolored blood; in some instances the adipose substance appears to be mixed with drops of blood; sometimes the sanguineous effusion appears between the skin and pericranium, occasioned probably by a rupture of fine vessels. In these cases, the blood is dark and fluid, and so easily absorbed that all the contiguous parts are tinged with a violet color. 
Tumors of this kind present much difference as to the period of their duration—extending from one to three weeks. Capuron, says Billard, cautions us against confounding these tumors with encephalocele, as much mischief might result from such an error. 
Treatment. — The application of stimulants, as cold water, dilute Tincture of Camphor, etc., with slight compression, will generally be found sufficient. In cases of sanguineous infiltration, if extensive, a leech or two may be applied, after which a fomentation of the leaves of St. John's Wort (Hypericum Perforatum). 
Species III.— Petechial. 
This disease consists of few r or many small, round, violetcolored spots, which occur spontaneously in a scorbutic-looking skin. It happens under great prostration of strength; it may therefore be regarded as a debility of the capillary vessels, and 


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consequently the system is liable to hemdrrhages, both inside and out. 
The children in which this affection has been seen, were so feeble, appeared so starved and so cadaverous, as to be of no promise even if they had escaped the disease. 
In the milder forms of this disease, it may pass through its stages of development and terminate without any serious or troublesome symptoms ; but in other cases, very various symptoms supervene, such as hemorrhages from the gums, stomach, intestines, or bladder. 
In such cases, post mortem examinations have exhibited petechial spots upon the mucous lining of the stomach, small and large intestines, the surface of the heart, pericardium, pleura, bladder, and kidneys. Beside these marks of debility in the vascular system, extravasation and hemorrhage have been seen to attend almost every organ and tissue of the system. 
Treatment. —In these cases we have derived more benefit from the internal use of the Tincture of Muriate of Iron, than from any other course with which we are acquainted; it should be given in doses suitable to the age of the child, and well diluted with water. The body may be bathed every day or two with a solution of salt in water, and the addition of Capsicum if more stimulant action is required. 
Species IV. — Ecchymosis. 
Ecchymosis consists of a livid, black, or yellow spot, or spots produced by an effusion of blood into the areolar tissue, and, in infants, they are most generally produced by the straits of the pelvis during difficult and protracted labor; consequently the injury is most usually found upon the head, but it may occur to other portions of the body. 
But the scalp is liable to this affection from gravitation alone, when confined to the same position for a long time, and in some instances, both causes may conspire to produce it. 
Medical treatment is but seldom required in cases of this kind, as they spontaneously disappear by resolution; nevertheless, it would be judicious, as soon as possible after birth, 


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MOIST FORMS OF DISEASE 
to bathe the part with water, as hot as it can well be borne. If, after this washing, it should be attended with much swelling, resort may be had to topical remedies, such as the Chloride of Soda or Ammonia. 
ORDER II. 
MOIST FORMS OF DISEASE IN THE DERMA. 
Genus I.—VesicuLuE. 
The varieties of cutaneous inflammation comprised under this head, originally affect the exterior coat of the cutis vera— they are definite and circumscribed, and their eruptions consist of small elevations of the epidermis, filled at first with clear, transparent, and serous fluid, which presently becomes opake and sero-purulent, and, by desiccation, passes into scales or crusts, usually called scabs. "We shall notice but two of its species—Herpes and Scabies. 
Species I.— Herpes. 
In herpetic forms of disease, there is always a sensation of burning, itching, and tingling, which is sometimes light or comparatively trifling, and at others great suffering is produced. It shows itself in circumscribed patches, which, at first, are transparent, but soon become opake upon an inflamed surface of a more extensive area; and between the several inflamed surfaces and their vesiculated patches, there exists a healthy skin. It is a non-contagious affection —usually acute in its character, having its vesicles to vary in size from that of a pin's head to that of a pea. 
It is not necessarily preceded by, or attended with, a fever, but in all severe cases it is. The period of its duration varies from one to six weeks, but never terminates fatally, unless the constitution is so vicious that it could scarcely recover from disease however simple. 
The secretion of its vesicles—passing from limpidity into a milky opacity, forms into scabs which in due time fall off and 


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leave the skin red. Of this eruption there are several varieties, but the difference between them depends, principally, upon the location and the form of the vesicular patches. When it is most severe, it assumes, to a considerable extent, the appearance of erysipelas, but there attends it this one invariable diagnostic difference —the vesicular clusters are distinct or clearly defined, having the skin that surrounds them of a healthy and natural color. 
It more frequently attacks young people than adults, and among the former, those are the most liable who are the most sanguine, or those who are sanguine-lymphatic. Infants, however, are but rarely the subjects of any of its varieties. We shall notice particularly but three of them: Herpes Zoster, Herpes Circinatus, and Herpes Prseputialis. 
Variety I.— Herpes Zoster — Shingles. 
In this variety the cutaneous eruption always extends around one-half of the body, and it is affirmed by some that it has been known to spread itself entirely around it; but others maintain that it does not. Be the fact as it may, we deem the settlement of the question of no practical importance. 
It is, furthermore, affirmed, that it appears more frequently on the right than on the left side of the body—but this question, like the preceding, has been contra-affirmed, and like the other, its settlement can be of no great practical utility. All agree, however, that it never makes an assault without completing half the circuit of the body. 
It may commence on one side of the spine and extend itself directly or spirally to the linea-alba; or it may commence at the other extremity and travel in the contrary direction ; or it may commence at any intermediate point and extend itself in contrary directions ; and, lastly, it may commence at the two extreme points and meet in the middle. When the course of the eruption is spiral or oblique, though commencing on the body, it may begin too high or too low to conclude on the body at the linea-alba, therefore, in such instances, it will conclude on the arm or the thigh. 
Each patch or cluster consists of numerous small vesicles which gradually enlarge to two or three lines in diameter, and from their close proximity in the beginning, they not unfre- 


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MOIST FORMS OF DISEASE 
quently become confluent. The patches are always distinguished by irregularity of both form and size, but they are usually two or three inches broad, having the greater diameter in the direction of the belt. 
These clusters are marked by another irregularity—the vesicles of the several clusters do not appear simultaneously, but succeed each other —that is, some are on the decline before others are fully developed. The limpid contents of the vesicles, in three or four days, become opake, and in eight or ten days more they cast their scabs. This is only true of the individual vesicles, but not of the whole collectively, for, as they appeared successively, so they must decline, consequently, before the last scabs are cast, twenty or more days will have elapsed. 
Like many other cutaneous forms of disease, the eruption of this is generally preceded two or three days by febrile symptoms, as lassitude, general uneasiness, and loathing of food. These symptoms frequently disappear upon the occurrence of the vesicles, but in some they continue as long as the eruption produces constitutional irritation. 
Much care should be observed to keep the eruption from being scratched or rubbed off, because of the troublesome sores which are liable to result, more especially as the disease, normally, gives the patient much smarting pain in the skin, and frequently no little of a wandering and shooting character in the body. This affection is sometimes preceded, often attended, and generally followed by a neuralgia under the affected part, and not unfrequently continues for months after every other feature of the morbus has departed. 
Notwithstanding the fear that generally prevails as to the danger of this variety of herpes, it is in reality, most generally, mild and by no means dangerous. Some children are so liable to it as to have it almost every year; and yet it is sometimes indicative of remote danger. 
Variety II. — Herpes Circinatus — Ringworm. 
This eruption usually commences upon the face, neck, arms, or shoulders, in, apparently, a single vesicle, and then others appear around it, and thus it continues to enlarge until it becomes exhausted; but by the time the second or third 


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addition is fully developed the central vesicles have partially disappeared, and thus, as the outer circles appear, the inner ones disappear, so that in a few days the part occupied by the first vesicle and the circles that succeeded it, become well. In its progress, in consequence of this mode of development, nothing but a circle or ring of small, hard, round, and tense vesicles is seen. In three or four days, the vesicles break, and small scabs are formed, which in about a week are cast. But as they appear in succession, the eruption has an indefinite period to run, but it rarely exceeds a month. As it is but rarely, if ever attended with constitutional symptoms, the only trouble arising from it is the itching it produces. 
Variety III. — Herpes Prceputialis. 
This is the only other variety of this disease which we shall notice, and we do it only for the purpose of admonishing the student against mistaking it for an eruption of a syphilitic character. As this is a vesicular eruption, it is always distinguishable from a syphilitic one. The occurrence of herpes in clusters, the superficial character of its ulcers, should they supervene, and the absence of that yellowish-white, adhesive discharge, which is characteristic of chancre, will further aid to distinguish the one from the other. 
Herpes praeputialis may obtain upon the external or internal surface of the prepuce. The vesicles and clusters are very small, and usually run their course in ten days or two weeks. Because of the delicacy of the epithelium, the vesicles are very liable to break, when located on the inner surface, and therefore, without proper attention, they may run into superficial but troublesome ulcers. 
Causes.—Sudden exposure to cold in a state of perspiration and the direct action of irritants have been named as occasional causes. We admit that they may act as excitants, but as this form of dermoid disease occurs most frequently with those who have much cutaneous inactivity—feeble organs of animal sensibility and muscular motion—it may most generally be suspected of being symptomatic of some more deepseated form of disease. The existence of pulmonary irritation is sometimes thus manifested—and, though a very trifling form of disease in the abstract, yet it may indicate much danger. 


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MOIST FORMS OF DISEASE 
Diagnosis of Herpes in general. — As this eruption has been confounded with erysipelas, pemphigus, scabies, and eczema, it may happen again. In herpes, though the vesicles approach very close, yet they are never confluent, though at a glance they appear so, which, with the hard, globular vesicles, associated on an inflamed base, patches always distinct, with healthy intervening skin, should generally distinguish herpes from all other forms of skin disease. 
The rapid development, large size of the bullae of pemphigus, their scattered, distinct, and irregular character, with the further fact that their development requires but a day or two, should distinguish it from herpes. 
The more extensive inflammation, the rapid march, and more deeply-seated development of erysipelas, and the bulblike character of its blisters, should allow no observer to confound it with herpes. 
The locality of scabies, the sulcus of the acarus, its pruritus and contagious character, should distinguish it from herpes. 
From eczema, herpes is not so readily distinguished. In the former, however, the eruption arises suddenly, its vesicles are smaller, and at first make their full size, and continue only three or four days, while the disease, in the abstract, is continued indefinitely by elementary eruption, exudation, and excoriation. 
The different forms of herpes cannot very easily be confounded with each other, and the light, thin crusts which are characteristic of its varieties, will distinguish it from favus, the scabs of which are thick and friable. 
Prognosis.—In the young and comparatively healthy, under at least proper treatment, its termination must be regarded asfavorable. 
Treatment.—In most cases but little treatment is needed. In the young and vigorous, warm drinks and an absence from gross and indigestible food, will be all the constitutional treatment that will be necessary. Should the bowels become so constipated as to occasion irritation, an aperient should be administered. 
To allay the itching and smarting that usually attends these maladies, emollient poultices, water-dressings, antispasmodic, alkaline, and mucilaginous washes may be used. 


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We have a strong suspicion, that in most cutaneous affections there are some renal and pulmonary defects of function, consequently we would never neglect the kidneys—no mischief can attend this practice, even though we be mistaken. 
Species II. — Scabies — Psora — Itch. 
Almost every person, but more particularly those who belong to the lower or less provident classes of society, are practically acquainted with this disease. It locates itself on those parts of the hands, wrists, arms, etc., which are the most delicate, as between and about the roots of the fingers, the middle of the anterior portions of the wrists, and the flexor surface of the fore-arm, and thus it may take possession of all parts of the surface of the body where the cutis is fine and delicate. It is characterized by small, distinct, acuminated, and transparent vesicles, containing a viscous serum. 
This eruption is described by some as being at first papular, and then becoming vesicular and scattered, without any particular arrangement, over its selected surfaces. The face and head appear to be the only parts of the surface for which it has no affinity. 
This is, perhaps, the only cutaneous eruption that produces the unalloyed sensation of itching, and hence it is alone called the itch. The scratching it occasions produces an abrasion of its vesicles which is very apt to convert them into pustules that produce a yellow, viscid matter and much inflammation about their bases. When to that abrasion which attends scratching, is added intemperance, that variety of scabies is produced which is known as the purulent or pocky itch. The student who is not prepared to anticipate this change, under provoking circumstances, is greatly liable to unfortunate errors of diagnosis. 
It is difficult to determine why some individuals are not liable to contract the disease under any possible exposure to it. This is shown by the exemption of many hospital physicians and nurses, who resort to no precautionary means for the purpose of avoiding it. 
Stimulating food and potations greatly increase the irritation and itching, and although scratching augments the itching, yet it is said to constitute the greatest luxury that is 
28 


434 
MOIST FORMS OF DISEASE 
known to the catalogue of human enjoyments. The pruritus that attends it is peculiar and intense, and is usually more severe in the evening than in the morning—in young people than in old. 
Causes.—The infectious character of this disease has never been doubted, and Dr. Wood teaches that it is never produced otherwise. This may be true, but inasmuch as the first case that ever afflicted a human or any other being could not have been occasioned by infection, he is not, certainly, entitled to the conclusion that it cannot be produced by any other cause. The cause that first produced it may still act and occasionally introduce it into communities where infection has not been taken. To be positive, where a possibility to error may exist, is to close the door to further observation. 
So far as is now known, this eruption is occasioned by a parasitic insect, called acarus scabei, and the communication of the malady is produced by the transplantation of this insect—this has been experimentally proved. It has been asserted that a goat has communicated it to men. Upon those delicate portions of cutaneous surface affected with the disease, investigation will detect a short line or sort of handle appended to an occasional vesicle, in the further extremity of which the insect may be found and captured by the point of a needle. It is a small, white speck, visible to the unaided vision, having the shape of a turtle with eight legs. Its body is so bristled and bearded that it cannot make a retrograde movement when in its sinus under the cuticle. 
Improper nourishment, dissipation, and filth are thought to be predisposing causes to it. We have long thought that a proper mode of living would prove an effective prophylaxis. 
Diagnosis. — The sulcus, cuniculus, tail, or handle to the vesicle is found in no other disease, consequently, when this can be detected, a certain diagnosis is had—otherwise there is a possibility that it may sometimes be confounded with eczema, but a careful attention to the description of the two forms, respectively, will prevent such a mistake. 
As scabies is a moist and vesicular disease, while prurigo is dry and papular, there is but little danger of mistaking either of these for the other. But there are other diagnostics, prurigo is attended by a black scab, which is not the case 


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in scabies, and this is relieved by scratching, while prurigo is not. 
By a careless observer, it is possible that lichen might be confounded with scabies; this attacks the fine and delicate surfaces, but that, the extensor and the more indelicate ones — scabies is, furthermore, moist and vesicular, but lichen is dry and papular. But, in all cases where there is doubt, look carefully for the track of the sinus or sulcus of the acarus, which, if found, removes all doubt. 
Treatment.—For the cure of this eruption, Sulphur is universally known as an unfailing remedy; but we object to its use, and to all other external agents, until after the skin shall have been cleansed and relaxed, and secretion, in general, established. 
M. Helmerich has cured the disease effectually in two or three days, by the following course of treatment: The surface of the entire body, but more particularly of the affected parts, should be first washed well with a strong solution of soft-soap, the patient then placed for fifteen minutes in an alkaline bath, containing a pound of the Carbonate of Potash to twenty gallons of water, at the temperature of ninety-two degrees; the skin is then to be well dried and the following ointment thoroughly rubbed in: 
?r. Sulphur, gij, 
Carbonate of Potash, 3j, Lard, gviii. Mix. 
Of seven hundred persons treated at the Hospital St. Louis, in Paris, on a similar plan, but six were not cured, all the rest being cured on the third day. 
When great objection exists to the use of Sulphur, the body may be bathed as above, and then rubbed with an ointment composed of: 
Ijfc. Spirits of Turpentine, 3j, Oil of Bitter Almonds, 3j, 
Lard, Sviii. Mix; 
or the following wash may be applied: 
Sulphuret of Potash, 3j, 
Soft-Soap, 3ij, 
Rain Water, 3viii. Mix. 
We have found the use of the Compound Ointment of Zinc, 


MOIST FORMS OF DISEASE 
436 
used externally, with the internal use of Sulphur, fully sufficient to cure the most obstinate cases of itch. 
During the use of any of the above remedies, the patient should be carefully guarded against cold, damp air, sudden exposures, etc. 
Genus II.—Bullae. 
This division differs from the preceding, mostly in the vesicles being, in this case, from the size of a half pea to that of a half egg, and generally of a circular form. The fluid of the vesicles is serous, sero-purulent, or sero-sanguineous ; they usually terminate in the formation of a scab, which, among the species, varies much in thickness. We include in it three species—Pemphigus, Erysipelas, and Rupia, though doubting, in some measure the propriety of including the second. 
Species I. — Pemphigus. 
From the information we have been able to obtain concerning this disease, we conclude that it is usually associated with a feeble endowment of the cerebellum, as will be perceived before the conclusion of this history of it. It is characterized by blisters or blebs from the size of a split pea to that of an inch, and these may be disposed of separately or they may become confluent, and in the latter case a single vesicle may become to be two inches in diameter. These blebs contain a serous or sero-purulent fluid, which escapes by the rupture of the cuticle, and dries with it, and forms a thin scab or scale, which is succeeded by a slight ulceration or excoriation, and then gradually disappears. 
It appears most generally upon those who possess a delicate skin, and it may appear upon any part of the surface, but most frequently it is confined to the face, neck, and extremities, and apparently founded or located upon erythematic patches. 
When it is of a chronic character, in which form it most frequently appears, the blisters do not so readily heal, as above expressed, but continue to form a succession of scabs, which may cause a very considerable protraction of it, and yet, it is very rarely attended by any febrile symptoms. 
Its acute or apyrectic form is the most common to children at the breast, and it appears in erythematous patches, which 


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437 
in a few hours, and sometimes almost simultaneously, become covered with blisters. In some instances however, these erythematous patches will not, without some additional irritation, as the application of friction, become bullous ; at other times, the center only forms into a blister which can be extended by friction. The blisters, in nowise, differ in appearance from those which are produced by vesicating plasters. The skin that surrounds the blisters is healthy. 
The chronic form is the more liable to be attended with febrile symptoms, as fever, thirst, irregular chills, pain in the head and back, but they are usually too inconsiderable to be noticed. It is more painful and troublesome than the other, and is not unfrequently complicated with inflammation of the mucous lining of the bowels. 
When the face is assailed, the mouth but rarely escapes, and it is reported, in some rare cases, to have invaded the whole intestinal surface. It is never dangerous, except by its complications, and then it is governed by their character. 
Causes.—Bullae is not confined to either sex or to any age, but is more commonly met with in children and the aged. It is not decided as to which sex is the most liable to it. It is said to have been congenital. Those of a debilitated and broken-down constitution, among adults, and children shortly after vaccination are the most frequent subjects of it; but, as in many cases of cutaneous eruptions, it frequently obtains when no cause can be assigned for it. 
Diagnosis.—Being a moist eruption, it is readily distinguished from the squamous; from herpes, by its larger blebs and less grouped appearance, it is distinguished. Under the head of Rupia we will give the diagnosis between it and this. 
Prognosis. — In the acute form, the prognosis is always favorable; and in the chronic, its complications must determine, in the abstract; however it is always more or less important. If the patient have a feeble constitution, and is, at the same time, suffering with other maladies, the prognosis cannot be very favorable. 
Indications.— When inflammation is present, relieve the cutaneous spasm and irritation, promote secretion, and sustain nutrition. 
Treatment. —Some of our old school brethren inform us, 


438 
MOIST FORMS OF DISEASE 
that when highly inflammatory symptoms obtain, depletion is required by venesection and active purgatives. Why have they not recommended a similar practice in variola?—inflammation frequently runs as high in it as in pemphigus. 
When cutaneous constriction has been removed by the use of the warm lye-bath, with internal diaphoretics, our chief reliance then must be placed upon renal depuration, more particularly if the affection be connected with anasarca, which is not unfrequently the case. 
The bowels should not be disturbed, unless their contents are producing irritation, and even then purgatives are not required, but demulcent enemas will be found more beneficial. 
The blebs may be opened and their contents discharged, but much care will be required to save the inflamed surfaces from abrasion. 
As an absorbent, some desiccating powder may be sprinkled upon the blebs. For this purpose, dry, powdered Elm-bark, Flour, Chalk, powdered Hydrastis Canadensis, etc., may bo used. 
Dr. Willson teaches, that " When there is reason to believe that the eruption is an effort on the part of nature to determine to the surface a morbid disposition, I should strongly recommend the employment of Mustard-baths to the whole surface of the skin, or a stimulating liniment of some kind, such as that of Croton Oil, in the proportion of a drachm to an ounce of Olive Oil, to be well rubbed into the sound parts of the skin." 
We object seriously to his philosophy, but not to his practice—we approve of it; but we would like to know in which form it is, of eruptive disease, in which nature does not make an effort to determine to the surface ? So far as we have yet learned, this is her purpose in all forms of disease, and our duty is to aid her in effecting her object, and not to defeat her by bleeding and purging away that vital force by which alone we can hope for success. 
Species II.— Erysipelas. 
This disease usually makes its attack upon infants within a few days after birth, or at least within a month, and some have thought that it never occurred beyond this period, but 


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439 
others affirm that they have known it to appear as late as one year, but such cases must be exceedingly rare. 
The inferior portions of the body, as the nates, groins, and umbilicus, are the most usual points of attack, in infants, and it introduces itself in the form of a small, red blotch, from which it irregularly, but gradually, extends itself over the abdomen and along the back and inside of the thighs—wearing a diffused and inflammatory appearance, of a purplish hue, tumefied, resisting, and painful under pressure. It is common for large, but thinly-distributed vesicles to appear toward the close of the first day, with livid and inflamed bases, or they may not appear under several days, or in mild cases they may not appear at all. 
When the vesicles quickly succeed the inflammation, they usually become extended with much rapidity, and with equal speed, assume a dangerous appearance. The tendency to gangrene, in its violent forms, is so considerable that it should always be anticipated. 
When the invasion has been made upon the inferior extremities, the most probable termination will be ulcerative suppuration of the subcutaneous cellular tissue; but when made upon the abdomen, we are scarcely permitted to expect any other sequent than sphacelation. 
When the suppurative process assails the cellular tissue, its course, in infancy, is very much as it is in the adult —it will not be arrested so long as there is contiguous tissue to prey upon, if life shall be so long continued. 
Visitations of mild forms of this morbus are very rare, and in relation to the duration and violence of its other forms, but little can be said with certainty. In some instances, though not particularly violent, it is greatly procrastinated by its peregrinations. It will travel and invade almost every part of the surface, and in the rapidity of its movements, it frequently leaves every part sound, except its last and final abiding-place. Its travels and invasions, however, are not always, nor even generally, consecutive, but, like Bonaparte's campaigns — when it leaves a part, there is no predicting where it will next appear. 
In infancy, the splanchnic system usually betrays considerable derangement, as frequent alvine evacuations, with griping and 


440 
MOIST FORMS OF DISEASE 
a grass-green color. In other cases, a reversed condition of the bowels obtains, with colicky pains and acid ejections from the stomach. The urine has usually a bilious, and the skin a jaundiced, color. 
Causes.—These are acknowledged to be particularly obscure. Our observations induce us to believe, that, in adult patients, it depends upon a special organic liability, indicated by a thin and delicate skin, a large organ of animal sensibility, and of course a tolerably full habit of person. But the liability of erysipelas neonatorum to a sphacelous termination, induces us to suspect that the same organic conditions do not obtain, and yet they may, but modified by some peculiar infantile condition. 
The cause is sometimes attributed to a derangement of the chylopoetic viscera, and it is true that such derangement is manifested through the course of the disease, but whether it is a cause, or merely a sequent, is not certainly known. 
Meckel, by post mortem examination, discovered, in one case of an infant, the umbilical vein and a surrounding portion of the peritoneum to be much inflamed, and several similar cases have since been observed, and hence some have been disposed to attribute this disease in infants to this cause, supposing some injury to have been inflicted on the umbilical vein at birth. 
If those organic conditions obtain in infancy, which we hold to constitute a sine qua non in this disease in adults, then we are satisfied that a cause which is adequate to the production of coryza, is capable of developing erysipelas. 
Diagnosis.—A deep-seated inflammation of the skin, a disposition to spread, symptoms of dangerous fever, and tumefaction of the inflamed parts, may be regarded as the leading diagnostic features of erysipelas. In erythema, the inflammation is superficial, with a very trifling tumefaction. The partial location and uniform redness will distinguish it from the exanthematous. In erysipelas phlegmonodes there is no disposition to travel, the tumefaction is greater and all the local symptoms are more violent. 
Prognosis.—The prognosis in this affection may, in a great measure, be inferred from its history. In a mild form and a sound constitution, it is of little consequence; but, under a 


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contrary combination, it must be considered as particularly dangerous, from the great probability that it will occasion purulent deposits in the viscera, and establish inflammation in the lymphatic vessels and superficial veins. It is also dangerous from its metastatic tendency, and it is particularly dangerous when complicated with purging and vomiting. 
Indications. —Relax and cleanse the surface, maintain its centrifugal action —guard against repulsion, equalize the circulation, and sustain the vital tone of the system. 
Treatment. — To cleanse and relax the surface should be the first object of the practitioner in this disease, and afterward to maintain the relaxation and to effect and sustain a determination to the surface, by means of diaphoretics: for which purpose the Compound Powder of Opium and Ipecacuanha will be found very beneficial. 
The bowels should be maintained in an aperient condition, but active purgation should be as thoroughly guarded against as in the treatment of small-pox. The Compound Powder of Rhubarb and Potassa will be found the most useful aperient that can be given. 
To absorb the matter as discharged, powdered Starch should be sprinkled over the discharging surfaces; as, if the least danger is apprehended from mortification, a saturated solution of Sulphate of Zinc may be applied until the vesicated parts become white, after which apply an Elm poultice, and continue it until the inflammation subsides, and the white eschar sloughs off. 
In case of much tumefaction in any part, it should be poulticed with bread-and-milk, Slippery-Elm, or with what we regard as much better in this form of disease, a decoction of some vegetable astringent, as the White-Oak bark and corn meal; yet our principal reliance in the treatment of this disease is the internal use of the Tincture of Muriate of Iron, which may be given to a child two or three years old in doses of three or four drops well diluted with water, every three or four hours, and the affected parts bathed freely with the tincture. 
Should the patient become much prostrated, either because of its original debility (which is not usually probable), or 


442 
MOIST FORMS OF DISEASE 
because of the violence of the disease, tonics and stimulants should be prescribed; as, 
Pulv. Hydrastis Canadensis, 3iij, 
Port Wine, octj. 
Of this, a teaspoonful may be given three or four times a day to a child two or three years old, or in proportion. 
Authors very generally proscribe animal food under such circumstances as the present, but upon what just principle we cannot determine. We regard carbonaceous food, whether animal or vegetable, as objectionable, but we cannot come to the same conclusion with regard to animal muscle, in the abstract. It is already adapted to the nourishment of the human body, and for this purpose produces less irritation than almost any other kind of food. When the muscle cannot be taken, a tea of it can. If the stomach be in a secretory condition, fresh muscle will be the best generally, and if not, salted flesh will prove very palatable, and so will pickles. In this form of disease, the appetite of the patient may very generally be trusted. 
Species III. — Rupia. 
This affection, most generally, is found among the poor, the destitute, the ill-fed, and those possessing naturally a feeble vital system. It appears most frequently upon the loins, nates, and legs, and when of a mild character, it occurs, without inflammation, in blisters or bullae, from a line or two to an inch or more in diameter, which contain a transparent fluid that finally becomes opake, sero-purulent, purulent, or sanious, rarely appearing well concocted, often almost black, with a tendency to a rapid formation of scabs, w T hich are generally of a dark-brown or even black color, and more developed or thick at their centers than at their margins. When the scabs are detached, which is easily done, they exhibit ulcerated surfaces, which may cicatrize, or successively, for many times, form new scabs, depending very much upon the more or less depraved condition of the system; but finally, they heal, leaving the new skin of a livid redness, which continues frequently for a considerable time. 
That variety of rupia which most frequently assails infants, is of a more inveterate character — the blisters appear upot 


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previously-inflamed surfaces and contain a dark opake fluid. At first the bullae are small, but they gradually enlarge in breadth and depth, with inflamed borders, and finally eventuate in ulcers which produce an offensive, excoriating, sanious pus, accompanied with pain, fever, restlessness, and sleeplessness. 
In a majority of instances, where scabs become detached, they are successively reproduced, and thus the disease becomes protracted for two weeks or more, when it may or may not destroy its victim. 
Causes.—Beside those constitutional conditions with which we commenced this article, we may add, that in children it sometimes succeeds to the eruptive fevers, as scarlatina, rubeola, but more particularly variola. It has been contended that it is always a sequel of syphilis, but the unfounded character of this notion has been thoroughly shown. It is said to be frequently complicated with other forms of cutaneous disease, as scabies, pemphigus, and ecthyma. 
Diagnosis. — Rupia bears much resemblance to pemphigus and ecthyma. But the globular bullas and the thin, delicate, brown scab or crust of pemphigus, will distinguish it from the flattened bullae and the thick, rugose, oyster-like, conical scabs of rupia. 
The elementary form in ecthyma is pustular, while that of rupia is vesicular and bullous. Although the elements of these two forms of disease are very decidedly unlike, yet it is sometimes difficult to distinguish the one from the other. The very obstinate character of the ulcer, in rupia, may serve to aid the diagnosis. The best chance to arrive at a diagnosis is a close investigation of a new pustule or vesicle, as the case may be—one producing pus, and the other serum. 
Prognosis.—In giving the natural history of this affection, we said enough to authorize an inference as to the prognosis. When the constitution has a viable appearance, the disease is of a mild form, the conclusion may be favorable; but, under contrary conditions, unfavorable. 
Indications and Treatment.—The most important indication is to improve the general health; the next consists in removing all causes of irritation, particularly such as may 


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have had an agency in the production of the disease; and, lastly, to keep the surface and the eruption clean. 
The first indication may be answered by a generous and nourishing diet, and such tonic medicines as Hydrastin, Quinia, Iron, Ptelein, etc. 
The next indication will require a comfortable chamber, a pure atmosphere, and a proper attention to all the depurating apparatuses, especially the kidneys and skin, and which indication may be fulfilled by the use of diuretics and an alkaline bath two or three times a week. 
The bullae should be punctured early and dressed with dry lint and a bandage, or if the strength is sufficiently reactive, water dressings may be substituted. 
If the general condition of the system is too depraved to admit of improvement under the above treatment, such stimulating applications should be made as will excite the ulcers to a more healthy action, such as the Compound Ointment of Zinc. In the meantime the most perfect rest should be required. 
Genus III. — Pustule. 
Pustulous forms of disease are those which are attended with an elevation of the cuticle, upon an inflamed base, containing pus. Pustules are of various sizes, but the largest rarely exceed two lines. Pustulous disease, whatever may be its character in other respects, usually terminates either by absorption, by the formation of pus, by ulceration, or it may pass, by a process of degeneration, into a tubercular disease. Upon healing, it may or may not leave permanent cicatrices. 
In this genus, we include four species: Variola, Ecthyma, Impetigo, and Porigo. 
Species I. — Variola — Small-Pox. 
This form of disease is sporadic and epidemic, and consists in an acute inflammation of the cutaneous investment of the body, attended with fever and an eruption of red points, which pass, in rapid succession, from papules to vesicles, and then into pustules, which very generally attain their maturity between six and nine days, and then, by desiccation, pass into scabs, which lose their attachment between the fifteenth and 


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twenty-fifth day, from the commencement of the initial form, leaving upon the skin irregular pits and permanent cicatrices. It invades, very seriously, the mucous membranes, particularly that of the lungs, producing congestion of their surface, and not unfrequently pustules. 
The course of variola is divisible into five pretty distinctlymarked periods, which are those of incubation, invasion, eruption, suppuration, and desiccation. 
1st. The period of incubation comprises that time which elapses between the reception of the poison and the beginning of its consequent manifestation, which is usually between nine and twelve days, but sometimes it is procrastinated to twenty days, and in some instances even longer. 
2d. The period of invasion is attended with symptoms that indicate a serious constitutional invasion, such as languor, lassitude, pains in the bones, chilliness, headache, and finally fever. The last symptom, fever, is usually preceded or immediately succeeded by nausea and vomiting, in some instances it even happens that these symptoms constitute the first announcement of the morbid invasion. 
Attending these symptoms, there is usually thirst and more or less of obstinate constipation. In this condition of the system, there is generally some pain of a colicky character in the epigastric or umbilical regions, with much redness of the edges and point of the tongue. A characteristic symptom of this stage is pain in the loins, and it generally commences on the third day. 
It is not possible scarcely to ascertain the presence of chilliness or headache in children; but the fever, which varies greatly in degree, may always be ascertained by the dryness and heat of the skin. The existence of cerebral symptoms is indicated by restlessness and irritability, delirium, somnolence, and convulsions. 
The preceding symptoms are usually present from the commencement of the eruption, which is between the second and seventh day, but most generally about the third, and the more severe the disease is, the earlier it appears. The confluent form is more severe than the discreet—usually attended with more sickness and vomiting and a sense of exceeding prostration. At the close of the invasion, which most commonly 


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happens between the second and fourth day, the eruption appears, and with it may be expected an abatement of the febrile symptoms. It is proper to add, that throughout all the periods there is an exacerbation of the fever during the night. 
3d. The eruptive period is generally introduced by an exacerbation of all the constitutional symptoms, as languor, lassitude, nausea, oppression, and cough, but the moment the eruption appears they are all relieved — comfort is comparatively produced. The eruption usually appears first on the lips and forehead, thence upon the face, thence upon the neck and arms, and finally, it travels downward to an investment of the whole surface, and all this in the brief space of twentyfour hours. 
As we before remarked, the eruption begins in small, red points of a conical form, quite resisting, and disseminated in proportion to the pustules which are to be developed. In the simple or discreet variety, they are few and distinct; in that form known as the coherent, they are numerous and clustered together in patches; when the eruption is confluent, they are closely aggregated and so numerous as to occasion a general redness of the surface; they gradually increase in size and prominence for one, two, or three days, and as a general fact, the eruption on the second day passes into the vesicular form, and this change begins and follows the order of papular development. At first, the vesicles are smaller than the papules and acuminated in shape, but they grow larger, become flattened, sunken in the center, and so enlarged as to cover the whole papule and even exceed it in size. 
In the course of these changes, the vesicular fluid passes from transparency to opalescence, and finally the vesicles are converted into pustules, and this change introduces the fourth stage, which happens usually between the fourth and sixth day of the eruption. 
The vesicles are surrounded by small, inflamed areolae during the various changes, which differ in appearance in accordance with the greater or less approximation of the vesicles. In the distinct form, the areola? fade gradually into the natural color of the skin ; but when the pocks are close together, or apparently run into each other, the inter-pock spaces are more 


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or less of a bright color; and as the pocks approach to confluence, the areolae become imperfect. 
4th. The period of suppuration is introduced by an enlargement of the vesicles, and the conversion of their contents into pus. As they arrive at maturation, they gradually lose their umbilical shape and become convex on their surface. The same law is observed in the development of the pustules that obtained with the papules and vesicles, beginning on the face and progressing to the extremities. The areolae consequent upon the vesicular stage, continues through the early part of the pustular, but they assume a purple tint as they decline. 
Upon seeing a case in the papular stage, and then again in the pustular, no one.could realize the fact that there existed no more pustules, until he reflected that the papules were mere points, having much space between them, but that in their passage to pustules they had so much enlarged as to apparently cover the surface. The pocks are the most numerous on the face, and the number decreases, proportionally to the size of the space, as they descend ; so true is this, that when confluent on the face, they are distinct on the thorax and abdomen. 
Upon the mucous membranes, the disease becomes evident by a vivid redness, which is succeeded by papular elevations, but whether they are papular or vesicular has not been clearly determined; but they appear simultaneously with those of the skin, particularly in the mouth, nasal passages, fauces, eyelids, and sometimes the vulva. These papular elevations, if such they be, assume the appearance of small, whitish, rounded, pseudo-membranous points, which, commencing on the second or third day, continue about five days, and then become detached, leaving, most commonly, a little ulceration or erosion, which recovers without an apparent cicatrix. 
A true inflammation of the mucous membrane of the mouth and throat takes place in a short time after the appearance of the pustules; the gums become swelled, red, and spongy, and dotted over with white, pseudo-membranous and rounded points, when inflamed. 
The same white points, with redness and injection of the membrane, are sometimes present upon the velum pendulum 


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and the tongue, but with the latter they are much more rare. There is partial or general inflammation, in most cases, of the pharynx, and it is to be noted that it occurs subsequently to the formation of the variolous pustules, which is denoted by sore throat, more or less severe, and difficulty of swallowing, with tumefaction and soreness of the sub-maxillary glands. It often, perhaps generally, happens that there is pain in the larynx when assailed by the mucous eruption, and the voice becomes hoarse and whispering, with a hoarse, smothered, laryngeal cough. This pharyngo-laryngitis occurs usually between the third and sixth days of the eruption, and from the eighth to the thirteenth ceases. Sometimes it does not supervene, or if it do, it is very slight. 
The subcutaneous tissue becomes more or less inflamed during the variolous eruption, the intensity of which is determined by the extent of the eruption. The skin, more or less hot and painful, becomes red, tense, shining, and elastic in its resistance. Tumefaction supervenes on the fourth or fifth day of the eruption, and progresses for five or six, producing much pain, stiffness, and inconvenience. As desiccation progresses, the swelling subsides, and, in this feature of the disease, the face is always the most afflicted—the eyes becoming sometimes entirely closed by the facial tumefaction. 
"We have observed, in another place, that when the papules, are fully thrown out, the fever subsides, or disappears, and now, we add, the pulse falls, possibly from one hundred and forty beats to seventy-four, and that throughout the vesicular period the child is clear of fever; but about the fifth or sixth day of the eruption, when the process of maturation is nearly completed, a new fever, technically called secondary fever, announces its appearance by a pulse ranging from eighty-eight to one hundred and forty beats, strong, hard, full — and attended by a hot and dry skin. It continues to the ninth or eleventh day, or until the desiccating process is nearly completed on the face, having continued between four and six days. That condition of the system which obtains in the suppurative stage is evidently the cause of this fever. 
As, in a great measure characteristic of variola, the patient exhales a peculiar, fetid, disagreeable odor when the pustules begin to break and discharge their contents. 


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5th. The period of desiccation is indicated by a diminution of the tumefaction and a desiccation of the discharged pus and purulent matter, which had previously accumulated, by their conversion into scabs. This process, like all the preceding ones, takes place at first on the face, which happens usually on the eighth day of the eruption. The desiccating process is not the same in all cases; a dark point is formed in the center, in some instances, which gradually extends and forms the whole pustule into a hard crust; in other cases, the whole surface dries at the same time; and lastly, the pustule, in many instances, gives way, allowing its contents to escape, which then hardens into irregular yellow crusts, that become brown before detached. It is not uncommon on the arms and legs, for the pustular fluid to be absorbed, leaving the epidermis to be removed by desquamation. 
The falling of the crusts begins, usually, between the eleventh and sixteenth day, and terminates between the nineteenth and fortieth, but most generally before the twenty-fifth, of the eruption. 
Upon the detachment of the scabs, the derma presents, in different cases, very different appearances. In some, a true ulceration and loss of substance of the derma has been effected, and when desquamation occurs early in the disease, it presents all the indications of a suppurating ulcer. When desquamation obtains at an earlier period, the ulcer is discovered to be dry and cicatrized. In both instances, the cicatrices form little pits which continue during life. In other instances, the detachment of the scabs leaves the derma red and excoriated, without pits, which, upon drying, leaves reddish-brown blotches that continue for months, and finally pass off without leaving cicatrices. And finally, in other instances, the cicatrices are completed before the scabs become detached, and when they do fall nothing is observed but reddish spots, having a furfuraceous exfoliation of the cuticle; the whole process finally terminates without leaving cicatrices. 
With some general remarks, and we close our history of the variolous symptoms or manifestations. 
It should be constantly remembered, that constipation is almost as uniformly present in variola as are the pustules, and when we come to the treatment, it will be seen that it is 
29 


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indispensable to a successful development of the eruption. When diarrhea supervenes, therefore, it is to be dreaded—to be regarded as of bad import, more especially when severe. Abdominal distension is not a common symptom in this disease, and yet it does sometimes occur, to a moderate extent, and attended with some pain in the epigastrium, or in the umbilical or iliac regions; if, however, it should be seen, some unfavorable complication may be suspected. 
From the preceding history, it might be inferred that children would sink very much under an attack of variola, but such is not usually the case, except in dangerous cases, which are usually either confluent or irregular. From the great liability of children to cerebral disturbances, it might be supposed that the greatest danger should be looked for in that direction, but in regular variola this is not the case; yet such disturbances do occur, but they are usually light 
COMPLICATIONS OF VARIOLA. 
Under this head, we shall make a few extracts from Dr. Wilson, "On Diseases of the Skin:" 
"Hitherto the favorable course only of variola has been described, but the disease is not unfrequently attended with complications, which give it the character of a dangerous and often fatal disorder. These complications may occur during any one of the five periods into which the progress of the affection has been divided. 
" Instead of pursuing the mild " and uncomplicated course, "the period of invasion is occasionally marked by symptoms of excessive severity, the accompanying fever runs high, and the rigor which precedes it has been long and enduring, and the pains in the head, the chest, the praecordia, and the loins, are so violent as to lead to the suspicion of inflammation of the organs situated in those regions. There are sometimes delirium and coma, at other times convulsions, and death may occur before the eruptive stage is established. 
" The period of eruption, like the preceding, is liable to its accidents; serious congestions of one or more of the internal viscera may ensue. Sometimes the congestion is directed upon the brain and spinal cord, producing twitching of muscles, restlessness, convulsions, or coma ; sometimes on the 


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lungs, causing bronchitis, pneumonia, or pleurisy; sometimes on the mucous membrane of the alimentary canal, giving rise to diarrhea, dysentery, or hemorrhage; and sometimes upon other of the abdominal organs. In cachectic diathesis, passive hemorrhages and petechias may accompany this period; and under any of the complications, the case may prove fatal before the completion of the eruption. The variolous vesicles, instead of progressing, become stationary and flaccid, or distended with a sanguinolent or serous fluid. 
" The period of suppuration, as it is most severe in its symptoms, is also the most dangerous in its complications, and the most frequently fatal in its effects. Alarming symptoms sometimes appear with astonishing rapidity, and destroy life in a few hours, or even in a shorter period. Affections of the brain, of the larynx, and of the trachea, are most to be apprehended during this period. When these secondary affections are severe, the pustules remain stationary, or become flaccid, or are converted into sanguinolent bullae; sometimes they are accompanied by petechiae and passive hemorrhages, and in rare cases disappear by the absorption of their purulent contents. The latter occurrence is always fatal." 
The termination of variola is a period of much anxiety; for when the disorder has run favorably through its stages, and the danger of the disease has apparently passed away, the secondary affections are not uncommonly developed, as consequences of the variolous inflammation ; such are chronic inflammation of the various mucous membranes, producing deafness, ophthalmia, opacity of the cornea, staphyloma, oedema glottidis, hemoptysis, pulmonary tubercles, chronic diarrhea, chronic bronchitis, pneumonia, pleuritis-, empyema, glandular enlargements, caries of the bones of the face, subcutaneous abscesses, erysipelas, gangrene of the skin, disease of the joints, etc. 
Anatomy of the Variolous Pock. —A knowledge of the structure of variolous pock may not be of any great practical importance, but it must be considered as peculiarly interesting. 
A little limpid serum, of an alkaline quality, is found in the vesicle when opened shortly after its formation ; when removed the skin is found to be red, moist, and soft. A filiform 


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adhesion is discovered to exist between the center of the pock and the surface of the derma, which creates its umbilical peculiarity. When the pustule becomes globose, it is in consequence of a rupture of the filiform adhesion. Very soon after the vesicles become pustules, a false membrane is discoverable in the pock, of an opake and white color, soft and friable in its texture, and resting upon the derma in small and isolated points. These points enlarge, unite, and thus constitute a pseudo-membranous disc, after the lapse of a little time, which is of an uneven surface, and fills the pock, or is covered with serosity and finally with pus. In the progress of the pustule it forms an adhesion to the surface of the epidermis, and afterward becomes detached, and continues free in the pustule and enveloped in its contents. 
Diagnosis. —As this disease, when developed, can be mistaken for no other, the only diagnostic desire that can exist is the means of recognizing its character during its prodromic stage, which cannot certainly be done. But if the disease prevail as an epidemic, or if it be known that the patient has been exposed to its contagion, without having been previously vaccinated, then the concurrence of fever, constipation, bilious vomiting, and pains in the back, should be regarded as strongly indicative of its initial existence. 
Causes.—With the exception of a few individuals who are idiosyncratically insusceptible to its invasion, neither sex nor age is exempt from small-pox—not even the fetus. The profession are quite unanimous in the conviction that its cause is a specific animal poison—probably an elaboration of an abnormal secretory apparatus. It may occur sporadically and epidemically. Most generally one assault of the disease destroys the susceptibility to a second; but instances have been noted of some persons having had it six times. After the first attack, its invasions are comparatively mild, and yet to this rule strong and marked exceptions have been observed. The suppurative stage is regarded as being most capable of producing the contagion. When it is epidemic, the virus is transmitted by the prevailing winds. 
When we contemplate the variety of the variolous affections, and the fact, that one form is no preventive against another —even the most malignant is no protection against 


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the milder, we are induced to suspect that it may, primarily, originate in a purely atmospherical condition. 
Prognosis.—The simple or discreet small-pox may be regarded as never dangerous, and the same remark is applicable to the confluent variety, when uncomplicated. Rilliet and Barthez confirm this opinion; they state that all the cases they saw, recovered, when not complicated. The complication, then, of small-pox, must be attributed, in most cases, to some fault or infirmity of the constitution, or to injudicious treatment. 
When severe nervous symptoms occur during the first stage —a continuance of the fever after the eruption has appeared—an irregular appearance of the eruption—high sensorial irritation during the secondary fever, or any other departure from the general character of the disease, may be regarded as indicating some complication, and the variety and number of these we have elsewhere indicated. 
Indications. —Maintain the centrifugal action, reduce the spasm and irritation of the surface, remove all causes of irritation, and guard against repulsion. 
Treatment.—Dr. Gregory says that small-pox "is a fever which relieves itself by superficial eruption." If fever be the disease, how does it happen that it returns after the eruption is upon the surface % If the physician will regard the fever as indicating an effort of the system to cast the disease upon the surface which was produced by the poison, he will have a much more accurate idea of his 
He says, further, that " Heroic remedies are here wholly inapplicable, and the great object of art is simply to place the system under the most favorable circumstances for effecting what the old physicians called the concoction and elimination of the morbid humors." 
If he had made these remarks in his introduction, and had intended them for a universal rule, to be strictly observed in the treatment of all diseased manifestations, we would readily have conceded that he had a clear and intelligent view of his subject; but under existing circumstances he has thrown them out as expressive of a fact that is applicable to small-pox, and for reasons which he does not understand, as may be clearly 


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inferred from his remark, that "heroic remedies are here wholly inapplicable.''' 
If heroic disease indicates the use of heroic remedies, then they are as applicable to some modifications of small-pox as to pneumonia, bilious fever, broken bones, etc. The only difference is this: the consequences of his heroic remedies, in small-pox, are easily perceived, which is not the case with many other forms of disease. 
Dr. Wilson says, that " Meddling in variola is calculated to be as injurious as in other eruptive diseases depending for their origin on a specific poison ;" but why is " meddling in variola" more reprehensible than in other equally dangerous forms of disease ? 
He says, again: " It must be borne in mind, that any vascular determination to the surface, whether internal or external, will be followed by an increase in the number of pustules developed on the irritated spot;" but this increase of pustules can do no mischief, provided they are produced upon the external surface. 
He continues: "Thus an incautious purgative, at the outset of the fever, may induce so great a congestion of the mucous membrane of the alimentary canal, as may terminate very seriously." 
This remark is judicious, but it is empirical, because he does not explain why purgatives are demanded in fractured bones and guu-shot wounds, and not in small-pox. Inflammation is only inflammation, no matter where located—it is one and the same, and so are the general indications of treatment. 
Although Dr. Gregory has stated that small-pox is not the place for the use of heroic remedies, yet he teaches, that when the fever is violent in the initial stage, or even later in the disease, we should have recourse to general bleeding and the use of purgatives every day. Is not this heroic treatment ? During the period of pustulation, under indications of much debility, he advises the use of nutritious diet, wine, brandy, Carbonate of Ammonia, and Quinine. Now, is it not very probable that the exhausting practice, in the former stage, made the use of stimulants requisite in the latter ? Suppose 


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that the vital force, which was destroyed by bleeding and purging, was now present, is it not very probable that the stimulants would not have been indicated ? Would it not be far more wise and judicious to husband the vital force, in the early stages, to aid or sustain the system in the exhausting ? Does not such a practice indicate a most glaring inconsistency ? 
In the incipient or forming stage, the patient should be placed on a mattress bed in a room of comfortable temperature, by no means too warm, and then should be treated thoroughly with the alkaline wash and rather stimulating drinks and enemas of the same. We mean that this treatment shall be used at the time that pains in the back and head are complained of. This course should be persevered in until the eruption shall make its appearance on the surface. These drinks and enemata may consist of an infusion of Virginia Snakeroot and English Saffron. 
When the objects above specified shall have been obtained, the same course may be continued, but abated or diminished, as barely to keep the eruption upon the surface; or, in other words, to such an extent as may be found necessary to keep the pustules red and full at their bases. When these conditions of them are not maintained, the physician may feel assured that his patient is not doing well; hence his observation should be constantly directed to them. 
If, notwithstanding this vigilance, he should discover the pustules turn pale and more or less flattened, he should resort again to the previous treatment, taking care not to excite too much action upon the bowels—in this respect nothing more than an irritating constipation is to be avoided. In feeble constitutions a comparatively moderate catharsis may produce a fatal centripetal action. 
If the above treatment should fail, or even tardily reproduce the centrifugal action ; that is, return the pustules to the surface, an emetic, as the Acetous Emetic should be administered. The constitution must be too feeble to contend successfully with the disease when hot alkaline bathing, stimulating drinks, and emetics cannot reproduce the eruption upon the surface; should this be the case, however, warm, stimulating drinks may be given, as wine whey, gin sling, brandy 


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punch, or still better, the Compound Tincture of Virginia Snakeroot. 
The chamber should be kept thoroughly ventilated, the patient's linen and bed should be kept clean, he should be kept quiet, and prevented from scratching or picking the scabs, and his chamber should be frequently purified with the chloride of lime, or with alkaline or soap washings. 
During the filling and maturing of the pustules, the patient may drink water and thin gruel, and, as food, the least irritating and most nourishing is a tea made by boiling fresh beef, without any of the suet or fat, which may be seasoned to suit the appetite; this may be used, together with guava jelly, apple sauce, and juice of orange, which are generally preferred by the patients. 
Much has been said as to the best means of preventing the formation of pits by the desiccation of the pustules. We are acquainted w r ith an excellent practitioner who opens the pustules and cleanses them by alkaline washes, and then covers the face with a delicate oil-cloth. We have not witnessed the results of this practice, but he represents it as the best he has tried. This practice of cleansing the pustules, we believe, originated with the Persians, and we think favorably of it, as a probable means of lessening the secondary fever, by preventing the absorption of pus. 
It is recommended by others, to keep the face, as far as practicable, covered with some bland poultice, or even a wet cloth, for the purpose above-named, and to absorb the pus. Various means have been tried to effect an absorption of the pustules, and thereby prevent the production of the pits, and the least exceptionable of these is that of M. Briquet, which became suggested to him by the experiments of M. Serres; it is the emjplastrum de vigo. See Emplastrum Hydrargyri, U. S. Dispensatory. 
Dr. Oliffe recommends that the whole face should be covered with the above, except the mouth, nares, and eyes. When applied in the papular state of the eruption, it is said to produce a resolution of it. 
Dr. Picton, as late as 1832, is reported to have prevented the pitting after small-pox, by simply closing out the light 


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from the patient's chamber. M. Serres states that the best success he ever had in the treatment of this disease was in a very dark and poorly-ventilated cellar. 
Prof. J. King, who has had much experience in this disease, recommends the following course as having proved universally successful in his practice: 
" To prevent the pitting or disfiguration of the face resulting from small-pox, I have, for the last twelve years, pursued the course described below, by which, all who were attentive to the directions, have been cured without a single pit. Having suffered from a severe attack of the confluent form in my own person, I was led to investigate the subject; and so confident am I of its universal application, that I am willing to render all my services cheerfully and gratuitously to any patient, who, having followed my directions, finds himself at the termination of the disease, in the least degree marked or disfigured. 
"The body, in small-pox, is seldom pitted, because it is not exposed to the action of the light, and that of the atmosphere upon the pustules is greatly modified; whereas, on the contrary, the face, whatever other measures are adopted, is always marked, if exposed to the action of these agents, either singly or combined; we must then protect the face of the patient from the action of both the light and the air. And I am truly proud of the honor of having been the first individual to present this valuable mode to the public — having published it several years since. 
" To accomplish the above purpose, we must in the first place keep the room in which the patient lies, perfectly dark, but not closed so as to prevent a free circulation of air; and if this cannot be done, a piece of black oiled silk, well oiled, may be thrown over the face, having one or two apertures in it for the purpose of breathing. In the second place, the face must be kept constantly well oiled with Sweet Oil, which must be put on by gently touching, not rubbing, the face with a soft feather which has been dipped in the oil. Sweet Oil or Almond Oil will answer. The oil must by no means be allowed to dry on the face, and must be applied from the first appearance of the pustules, until they have disappeared or scaled off*. The patient must not be allowed to touch his face with his hands at all; and should he be delirious, the 


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hands must be secured; neither must the face be rubbed against the pillow or bed-coverings. 
"The room must be kept dark, using a lamp or candle only when a light is required for the physician or nurse to examine the patient. The eyes must be washed often with rose-water, or mucilage of Slippery-elm, which prevents them from being much injured by the disease; and the nostrils must be kept free by passing a camel's hair pencil, well oiled, into them several times a day. The treatment, in other respects, to be successful, must be strictly eclectic." 
In patients of the third class (page 20), or those of an unbalanced organization, there exists a constant liability to variolous complications, as assaults upon the brain, lungs, bowels, etc. In such cases, the additional treatment that may be required, will be found under the properly-indicated heads. 
In the secondary fever, we have only to equalize the circulation and to promote depuration, by the Compound Powder of Ipecacuanha and Opium; but, unless medicines are actually required in this stage, the less we interfere with it, the better it will be for the patient. 
When the scabs have all fallen, the surface of the patient should be thoroughly cleansed by the use of soap and warm water, and even his cutaneous follicles should be caused, by diaphoretics, to discharge their contents, and every vessel he has used, and also his chamber, should be fumigated by the use of Sulphuric Acid and common salt, or by the Chloride of Lime or Potash, and every article of the clothing of himself, bed, and chamber should be boiled and cleansed with soap. By these means all variolous contagion may be removed from the premises. 
In this disease, especially in the confluent form, there will often be found a closure of the nostrils from the matter secreted filling them and drying, and which very much interferes with the patient's breathing; this maybe obviated by removing the obstruction, and afterward passing a camel's hair pencil, moistened with Sweet Oil, up into the nostrils several times a day. When the matter enters the eyes, it should be removed by bathing them frequently through the day with distilled rose-water. 


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Variety I. — Varioloid — Spurious Small-Pox. 
This form of disease presents itself under so many modifications of character as to be of difficult description, which, indeed, we might have presupposed from the descriptions of various forms of variolous disease by early writers in the profession, under the names of swine-pox, sheep-pox, stone-pox, spurious pox, etc., which had been observed with those who had had the true small-pox, and with those who had not had it; and yet, no one seems to have doubted that all of these varieties, if indeed the nameB represent so many varieties, were referable in some mysterious manner to the variolous poison. 
It is now thought that these unclassifiable maladies have occurred more frequently since the introduction of inoculation and vaccination, than before ; but it is not our purpose to pursue such histories of disease as can have no practical bearing upon its pathology or treatment. 
At this time we shall treat only of that variety which occurs in those who have been vaccinated, or who have had variola in the natural or inoculated form. 
It appears from observation, that children who have been vaccinated are but little liable to varioloid, until after they shall have passed their fifteenth year, and this is attempted to be accounted for by supposing that the insusceptibility to variolous poison, occasioned by vaccination, becomes replaced by a susceptibility, resulting from the mutations of juvenile development. 
The symptoms of varioloid very much resemble those of variola, except that those of the former are more brief in their duration, and more mild in their character. Slight fever, headache, and languor usually introduce the disease to the consciousness of the patient. Constipation, most frequently, soon becomes apparent, and then, in two or three days, the eruption appears. The nervous symptoms, lumbar pains, vomiting, etc., which are constant attendants upon variola, are generally absent in varioloid, and when present they are generally very slight. The eruption that succeeds consists of small pustules, which in number may vary from one to twenty, and in the course of four or five days they may dry up ; the 


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duration of this stage, however, is very irregular, and therefore may terminate on the second day or continue to the fifth, from the commencement. 
In all cases, whether mild or severe, the prodromic fever and its associate symptoms completely subside upon the appearance of the eruption. 
A rash, resembling measles — a transient efflorescence, in many instances, precedes the eruption, which may first appear upon the extremities, or upon various parts of the surface, but the face is the most general locality of its appearance. In the beginning, it consists very generally of small, red, resisting, elevated papulae, which pursue very unlike courses—some of them dry up, without further change, and others progress to the vesicular form, and then assume a whitish, opaline appearance, become umbilicated, and change into pustules by the end of the second or third day. 
The secondary fever, characteristic of variola, very rarely occurs in this, and when it does it is very slight, exhibiting a slight acceleration of the pulse, and augmented temperature of the skin, which disappear entirely in one or two days. 
The pustules in this disease do not usually fill so well as they do in variola, and their contents are more sero-purulent than purulent. Like the other stages, the third or desquamating, occurs earlier and arrives at its completion with more rapidity than in proper small-pox, so that by the eighth day the scabs are falling off, and by the twelfth or fourteenth it is completed, leaving nothing but reddish spots or blotche-, which soon disappear without leaving cicatrices. The duration of this complaint is from ten to twenty days, but in a majority of instances, it may be considered as continuing from six to twelve. 
Causes. —For a long time the etiology of this disease continued to be a matter of doubt, but at this time it is generally considered to have its origin in variolous poison upon those who have had the natural or inoculated small-pox, or who have been vaccinated. But it is nevertheless confessed, that it does occur sometimes in those who have not been vaccinated, nor suffered from any variety of variolous poison. It is furthermore asserted, that it can be reproduced by inoculation, but under no circumstances does it become prophylactic 


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against small-pox. This occurrence renders its character particularly obscure, even under the admission that the poison may be atmospherically changed, or that its effects may be idiosyncratically or constitutionally modified. 
Diagnosis.—This presents a difficult feature of the subject, as it sometimes presents the characteristics of varicella; in other and severe cases, it is scarcely distinguishable from small-pox; and in some instances, it presents a striking resemblance to the pustule of vaccina. 
Professor Eberle reduces its diagnostic signs to the four following: 
1. "The eruption (in varioloid) comes forth in successive clusters, at uncertain periods, between the second and fifth days." 
2. "The eruption, rarely, if ever, enters into complete suppuration, as occurs in small-pox." 
3. "The eruption is unaccompanied by fever, except in very violent cases." 
4. " Desiccation or scabbing invariably occurs much earlier than in regular variola. It commences generally on the fifth or sixth day, and the scabs usually separate by the eighth or ninth day, leaving red discs or tuberculous elevations, instead of depressions." 
Prognosis.—The prognosis in this disease can never be unfavorable, except in very feeble constitutions, and then only in cases of complication with disease affecting peculiarly important parts. 
Treatment. — As varioloid differs from variola, so far as regards treatment, only in degree, being generally more mild in its character, the indications and treatment must be, too nearly the same in both, to admit of a well-defined difference; for the treatment of this form of disease, we therefore refer to that of variola. 
Variety II.— Vesicula Varicella — Chicken-Pox. 
As this affection but seldom, in either of its varieties, betrays a purely pustular character in either of its stages, but is vesicular, it should, if governed by this circumstance, be placed in the class Vesiculce but, as we are, in common with many others, disposed to regard it as a varioloid affection, we 


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think it best not to separate it from its varioloid associates. We do this simply through a bias of judgment, for the uncertainty that still invests it, is too great, to justify an expression of certainty with regard to it. 
Its period of incubation has not been determined, but from the circumstances that seem to attend its occurrence, we infer that it differs widely from that of variola. 
Its initial stage is usually introduced by loss of appetite, thirst, restlessness, acceleration of the pulse, increased heat of the surface, and pain in the epigastrium; and they may be attended by a slight inconvenience to the patient—and they may be attended by a severity equal to the worst cases of small-pox. When thus severely marked, it is attended with pain in the head, back, and extremities, and sometimes with soreness of the throat, a severe cough, and even convulsions. This stage continues from one to three days, when it is arrested by the appearance of the eruption, but in some instances, however, it continues even two or three days longer. 
The eruption, which is vesicular, is usually preceded, by a few hours, with a general erythematous rash, and attended with an itching and tingling of the skin. The vesicles appear, most generally, in succession during three or four days, consequently while some of them are just appearing, others are matured, others shriveling, and lastly, others have passed into scabs. It is usual for them to appear first on the breast and back, then on the face and scalp, and lastly upon the extremities. It is said that pustules are occasionally found mixed with the vesicles, but they are not considered as constituting a feature of the disease. 
Nosologists have divided varicella into three varieties, as, Varicella Lenticular, Varicella Conoidal, and Varicella Globate, or Swine-Pox. 
1. V. Lenticular or Chicken-Pox. —This variety appears early in the initial stage, and may be known by the eruption consisting of small, red, and rather oblong elevations, with a shining flat surface, and a very small and lucid vesicle in the centre. At the close of the second day, the vesicle is about one-tenth of an inch in diameter, and contains a whitish lymph, which by the third day has become of a straw color. In one day more, the vesicle is shriveled, and by the seventh 


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it has passed, by desiccation, into a brown crust, which by the ninth or tenth becomes detached, leaving its place red, but without depression. The desiccating process continues two or three days longer, on account of the successive appearance of the vesicles. 
2. V. Conoidal or Swine-Pox. —With a border somewhat inflamed, the vesicles, in this variety, appear suddenly; they are acuminated and filled with limpid serum on the first day; on the second, the surrounding inflammation and vesicle have enlarged, and the latter is filled with a pale, yellowish fluid; many of them are sunken on the third day, while others are full, considerably inflamed, and contain a purulent matter, which, upon healing, leave cicatrices; on the fourth day, the scabs commence forming into several varieties, as 'brown, yellow, and transparent. On the second and third days, fresh eruptions sometimes appear, which extend the stage of eruption to six days—and, therefore, the duration of the disease is continued to the eleventh day, possibly to the twelfth. 
3. V. Globate or Hives. —Large, globose, and irregularly circular vesicles, with an inflamed areola, distinguish this variety. Their fluid contents at first are transparent, w T hich, by the second day, has become turbid or whey-like, and by the third they begin to shrivel, and become yellowish, by the passage of lymph into a purulent matter, and by the fourth they pass into dark, thin, small scabs, w r hich by the fifth day become detached, and the surface, though red, does not become cicatrized. 
Causes.—Upon the causes of varicella, professional opinion is divided. By one party, it is maintained that it has a variolous origin—that in an epidemic of either variola or varicella, the other is directly or indirectly present — that they never exist separately — that the varicellous poison will produce variola, and vice versa. 
The other party maintain that small-pox epidemics often prevail without being attended by varicella, but the first deny that this is ever the case. 
We do not deem it necessary to enter into all the facts and arguments by which the two parties maintain their respective opinions; but we may add, that it appears to us, that if the two forms of disease can mutually produce each other, they 


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should he mutually prophylactic of each other; this, it seems, however, is not the fact. 
We will further add, that the various histories which have been presented of epidemics of both, have induced us to entertain but little doubt that the variolous poison is atmospherical to an extent sufficient to produce some variety of variola, which in turn may produce a more effective poison. 
Diagnosis.—There can be no difficulty in distinguishing varicella from variola, nor do we believe that a proper attention to the subject should permit the former to be confounded with varioloid. The initial fever in varioloid is, generally, more severe than in varicella, but the most distinguishing diagnostic consists in the fact that varicella is always essentially vesicular, while varioloid is as essentially pustular, except in the vesicular stage of it. 
Prognosis.—As in varioloid, the prognosis in this disease must be regarded as favorable, under even moderately favorable circumstances as to the previous health and stamina of the patient. 
Treatment. — As very little reaction, usually attends varicella, so very little energy is required in the treatment of it. A warm alkaline bath and some mild diaphoretic tea will generally fill the indications, but should the symptoms indicate greater energy some emetic should be administered, and then a stimulating enema. The diet should be simple and moderate. 
Variety III. — Variola Vaccina — Cow-Pox. 
This is the small-pox of cattle, a contagious inflammation of the skin, which is sometimes communicated to those human beings who attend them, as milk-maids, etc. It consists of multilocular and umbilicated vesicles, upon inflamed bases, which gradually become pustular, and elaborate, dark-brown scabs that leave upon their detachment deep and permanent cicatrices. The constitutional symptoms are mild through its initial and vesicular progress, but they increase, and sometimes become quite severe, particularly the secondary inflammation, as the pustular or suppurative stage advances to its full development. 
When the disease is contracted in this casual way, the 


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virus is communicated from the teats or udder of the cow to those who milk them, and from horses to those who groom them, consequently the eruption appears on the backs of the hands and between the fingers where the cuticle is thin, for it has been clearly shown that an abrasion of the surface or epidermis is not essential to the inoculation. 
It has also been discovered that when the virus is applied to an abraded or chapped surface, the consequence is apt to be subcutaneous abscesses, which are attended with much severity, producing, more particularly, inflammation of the lymphatic vessels and glands. 
Causes. —It will not perhaps be disputed by any one, that the inferior animals are liable to become diseased by all the causes that inflict disease upon the human race, but in consequence of organic differences, it would, a priori, be expected that the manifestations would be, in most animals, very greatly modified; therefore, it may be presumed that no one, at this time, would be surprised to learn that a disease analogous to small-pox occurs in both the cow and the horse; but in 1796, the effect upon the public mind was very different, when, for the first time, the fact was announced by the immortal Jenner. The fact is now well established that small-pox appears, not only epidemically but also epizootically, particularly with horses and cattle. Jenner was aware that the horse was sometimes afflicted with a disease, which, when communicated to the cow, produced a disease that could not be distinguished from true cow-pox. We can have no doubt, at this time, that the disease which then appeared in the horse was the genuine small-pox, which is now known to appear in the heels of that animal, and for a long time was confounded with the grease. As this work is intended for practical purposes, we cannot enter into the history of the many observations and experiments which have produced certainty, in many respects, with reference to this subject—we cannot do more than give a mary of the results. 
It is now pretty satisfactorily ascertained that when the small-pox prevails in human society, as an epidemic, the cowpox prevails among cattle —that when the small-pox contagion is transmitted to cattle, a true cow-pox is produced, and also when it is produced by inoculation. And it is, if possible-, 
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Btill better known, that when cow-pox is transmitted to the human subject, by inoculation, a pustule, precisely similar to cow-pox is produced. Touching these results, we will cite one experiment: 
Dr. Macmichael, in a paper which was read before the College of Physicians, in 1828, wrote thus: "Yaccine matter having failed in Egypt, medical gentlemen were led to institute certain experiments, by which it has been discovered that by inoculating the cow with small-pox, from the human body, a fine, active, vaccine virus is produced." 
Variety IY. — Inoculated Variola Vaccina — Vaccination. 
In the operation called vaccination, several plans have been practiced, but that which is generally preferred is the puncture or punctures, at the inferior extremity of the deltoid muscle, with the point of a lancet, previously imbued with the lymph or virus. In order that the papillary surface may be obtained without the effusion of blood, the punctures should be made obliquely through the epiderma. 
When the virus is of a proper quality, the patient in a proper condition, and the operation has been properly performed, there will succeed two or three days of incubation, and upon the third or fourth the papular stage will be introduced by some hardness of the skin and some elevation of its surface; on the fifth or sixth day, the vesicular stage will commence, indicated by a slight effusion of the liquor sanguinis beneath the epiderma, which passes into an oval and whitish vesicle of a pearly luster, which increases in size and fullness to the eighth or ninth, when it is umbilicated and perfect. Upon the eighth or ninth day it begins to become pustular, loses its umbilicated character, becomes flattened or even more convex at the center than at the periphery, and exhibits numerous small cells of lymph, and then becomes surrounded by an inflamed areola which is vividly red—presenting " the pearl upon the rose." By the tenth day, the areola enlarges from a few lines to one or two inches or more, attended by tumefaction, an increase of redness, some itching in the part, pain upon muscular movements of the arm, soreness of the axillary glands, and sometimes an erythematous blush appears in patches on various parts of the body. 


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The fluid contained in the vesicle becomes purulent by the eleventh day, and the areola begins to diminish, and desiccation begins at the center, and proceeds gradually toward the circumference. As the vesicle desiccates into a dark-brownish scab or crust of an irregular form, the areola disappears and the tumefaction subsides. The crust, after assuming a blackish hue, becomes detached at the close of seventeen days after vaccination, and the cicatrix that becomes thus exposed, presents in its bottom numerous little pits or foveolee, corresponding with the original cells of the vesicle. 
Corresponding with the inflammation of the areola, there is a febrile reaction, but it is generally slight, and in many instances scarcely perceptible, unless there should exist some adverse idiosyncrasy in the constitution, in which case the symptoms may be severe, and even lead to a fatal termination. 
For vaccination to produce a complete protection against the small-pox, it is indispensable that its course should be about as we have above described it. When its course is irregular or abnormal, it is no security against variola, nor should it be presumed to be, any more than any other inflammation that might succeed to a cause of local irritation. The most suitable period for vaccination, is between the third and seventh month, because of its greater absence from those forms of disease which are incidental to early youth. It is proper to add that the local affection, in infancy, is always more effectually marked than in adult age; nevertheless, the process should be deferred if there should exist a cutaneous disease, more particularly of the vesicular character. 
Deviations, in almost all possible respects, do sometimes attend the vaccinating process, and when they do the purpose for which it was instituted may be considered as defeated, consequently it becomes a matter of the first importance to observe its progress. 
In some instances, the whole course of the affection consumes but eight or nine days. In other instances, ten, fifteen, or twenty days elapse between the introduction of the virus and the formation of the pustule. In some cases, considerable inflammation and the development of the vesicle will appear by the second day after vaccination. In other instances, a true pustule appears, instead of a vesicle, and that too by the 


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first or second day after the vaccination. In other cases again, there maybe present a well-defined areola,surrounding a pustule which is elavated instead of being depressed or umbilicated. In other cases, the vesicle is perfect, but the areola is absent on the ninth or even the tenth day. Sometimes, again, the vesicle is too small, and beside, it may be flattened without a prominent margin. 
In all such cases as the preceding, doubts should be entertained as to the efficiency of the vaccination. It is not common for more than one pock to appear after vaccination, and yet, in some instances, several appear in the immediate vicinity of the original one, and in other instances they have been known to appear on various parts of the body. So far as is yet known, such manifestations of vaccination are valid. 
Vaccination ; what does it imply? Dr. "Wilson answers, in substance, as follows: 
By it we understand that the individual from whom the lymph or virus is taken, is of good, sound health — is not obese, gross, nor lymphatic. 
That it shall not have become deteriorated by neglect or age. 
That it shall have been taken from the vesicle between the fifth and eighth day, from one who had passed normally, or as we have described the affection, through the vaccine process. 
That the subject vaccinated shall have passed normally through the several stages of the process. 
That one vesicle at least shall have been permitted to progress to the spontaneous detachment of its scab or crust. 
That the cicatrix shall have all the marks that indicate a successful vaccination. 
Dr. Wilson regards vaccina and variola as absolutely one and the same, and that vaccination, as he understands it, and as we have defined it, to be as thorough a protection against small-pox, as the small-pox itself could be, for neither, nor both, constitute a certain protection to all persons. Some persons are insusceptible to the contagion of small-pox and to the virus of vaccina; and in others, no number of attacks of the small-pox appears to exhaust their susceptibility to its contagion. 
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have been proposed, but that recommended by Dr. Bryce, of Edinburgh, is the only one we shall name or recommend; and this is to re-vaccinate in a few days, three or four, after the first vaccination. If the first shall have properly impressed the system, the second will hurry through its stages, overtake the first, and terminate with it. 
Re-establishment of Vaccine Protection. —It is now, perhaps, universally believed, that when the animal organism has been thoroughly operated upon by contagion, that its susceptibility is destroyed to a second assault by a similar contagion ; and the opinion is as universally entertained that the impressions of the first contagious attack become gradually obliterated —that the original susceptibility becomes restored ; both conclusions are no doubt true, but in very different degrees in different individuals. 
Some persons, through a great portion of life, and others, possibly through life, are insusceptible to certain contagions; and it may be said, perhaps, with entire truth, that some are barely susceptible to one assault, while others are so susceptible as to be vulnerable, at short intervals, through life. Some have been rendered invulnerable through a long life by one vaccination or variolation, and yet constantly exposed, while others have had frequent attacks from the same or similar contagion. 
If these views are correct, and so we think them to be, no definite period can be fixed upon for re-vaccination as a requisite means of re-establishing the protective influence of vaccina. 
As no mischief, and but little inconvenience can result from re-vaccination, it would be prudent to have it done at periods of seven years. The most susceptible cannot be secure, w T e think, for a longer period ; but for the benefit of those who are disposed to risk a discretionary judgment on the subject, we would suggest, without experience in variolous forms of disease, however, but from our acquaintance with the human constitutions or temperaments, that the bilious and its lean and dense varieties are probably rendered secure by one invasion ; though this is our opinion, we do not advise them to risk it. The lymphatic combinations with the bilious would do well to re-vaccinnate at intervals of ten years, and also the 


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sanguine ; but the lymphatic combinations of the sanguine would act wisely to repeat the process at intervals of seven years. The lean varieties of the sanguine and the encephalic, if not secured by one impression, are not to be considered, at most, as being in much danger. 
If observations had been made during the preceding twenty years, with reference to the existing temperament, measurably all the questions involved in this subject, could now be answered. 
As shedding much light on the subject of vaccination, and as an illustration of its value, notwithstanding the errors and carelessness that may have attended its practice, we make a quotation from Dr. West, on infantile forms of disease. 
" But, although we should take a comparatively low estimate of the value of vaccination, and confess to the fullest extent the failure in its complete preservative virtue, we shall yet find, in the following modifying and mitigating influence which it exerts over small-pox, more than enough to make us value it as a priceless boon. Twenty years ago, small-pox raged epidemically at Marseilles, where it attacked almost exclusively persons under thirty years of age. M. Favart, who sent an account of this epidemic to the Academy of Medicine at Marseilles, estimated the number of the inhabitants of that city under thirty years of age at forty thousand. Of these, about three thousand had been vaccinated, two thousand had had the small-pox casually or by inoculation, and eight thousand had had neither variola nor cow-pox. Of this last class, four thousand, or one to two, were attacked by smallpox, and one hundred of thenj, or one in four, died. Of those who had had small-pox previously, only twenty, or one in one thousand, were again affected ; but four of these, or one in five, died ; while of the vaccinated, although two thousand, or one in fifteen, had it, yet it proved fatal only to twenty, or one per cent." 
According to these statistics, the mortality of vaccination and of no vaccination stand related to each other as one to three and three-fourths; this is a great saving, but it does not equal the desire of the medical philanthropist. 
Treatment. —In the inoculated form of vaccina, but little medication, in general, is demanded; the alkaline bath, warm 


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pediluvia, warm diaphoretic drinks, and slightly stimulating enemas, will usually prove sufficient. Much care, however, is required to prevent children from injuring the vesicle. 
Species II.— Ecthyma. 
The only profitable division that we can make of this disease, is into acute and chronic. To the former children are peculiarly subject; and it is very frequently preceded by constitutional symptoms, such as lassitude, pains in the limbs, loss of appetite, epigastric uneasiness, and irregularity of the bowels, and with these symptoms the patient is more or less troubled during the continuance of the disease. The eruption, most generally, appears upon the neck, breast, and shoulders, sometimes on the extremities, but rarely, if ever, upon the face and head. It appears in large pustules, elevated upon a hard, dry, and inflamed base, and covered with greenish-brown or yellow, with little or no inflamed areola surrounding them ; they are rarely grouped or confluent, but separated from each other. In the course of three or four days from the commencement, they exhibit pus at their summits and resemble small boils. In a short time they discharge their pus, which concretes into the scabs above-mentioned. In a week or tw T o from the beginning, these scabs fall ofY, leaving dark-red surfaces of half an inch or more in diameter. The extent of the attendant fever is such, sometimes, as to occasion a swelling of the lymphatic glands in their vicinage. 
The chronic form of ecthyma appears to hold a connection with chronic forms of disease of the digestive and respiratory organs, and becomes developed on those who have become emaciated by them. In this form, the eruption is renewed without ceasing, multiplies, spreads, and becomes confluent. Both forms are attended with constitutional symptoms —both produce a rapid emaciation of the system: but neither of them is contagious. 
Causes. —Most generally this disease, in all its forms, appears to be dependent upon some depravity of the system. Some substances are known to produce a disease of this character, and tartar emetic is one of them. Badly-nourished and greatly-neglected infants are particularly liable to it. Various internal irritations are said, also, to produce it. The general 


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causes are said to consist in a want of proper food, clothing, and cleanliness, but when it occurs in children, we suspect that it most generally results from a semi-viable condition of its organization—a feeble cerebellum. 
Diagnosis.—The only disease that may occur, in infancy, with which it could be confounded, is syphilitic, and with reference to this, the history of the case will generally be sufficient ; but, as a diagnostic, we may add, that there is not much irritation attending the syphilitic sores, and beside, they have a copper-colored areola, and will, more likely, be located on the forehead and commissure of the nose. 
Prognosis.—If the constitution is good—measurably sound, the prognosis is favorable; but under a contrary condition of the system, more particularly if complicated with any other form of disease, then it is unfavorable. 
Indications and Treatment. — Emollient applications to the local inflammation, remove all causes of irritation, correct the secretions, and sustain nutrition. 
The indications above-named will be sufficient for most cases, but in some there is much inflammation, and in others great debility, and therefore considerable extremes and variety of means will be demanded in the treatment. 
In the acute form, all the ordinary means to overcome spasm or constriction, and to promote depuration, will be required, for which purpose the Compound Powder of Ipecacuanha and Opium, or other diaphoretics, with diluents, should be given ; the bowels should be kept in a soluble condition by mild laxatives, but active purgation must be avoided. In connection with this, the warm bath (with the addition of Mucilage of Elm to it, in case of much local irritation), may be used daily, or every other day, as required. 
In the chronic form, generally, and at the close of the acute, in feeble children, tonics, as the bitter infusions, mineral acids, Iron, Quinine, etc., may become necessary, and as a local application, the Compound Ointment of Zinc, will be found productive of excellent effect. The patient should be allowed free access to the open air, if his condition will permit. The diet should be light, nutritious, and of easy digestion. 


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Species III. — Impetigo. 
Of this species, some six or seven varieties have been described, but only two of them are of such importance as to claim our attention, viz : Impetigo Larvalis (Porrigo Larvalis of Willan) and Impetigo Capitis. 
"Variety I.— Impetigo larvalis — Crusta Lactea. 
This disease consists of many small pustules of a whitish color, based upon a very red surface. They gradually change to yellow, and then to brown, and in a short time break and form a scab, from which issues an ichorous discharge attended with much itching. As the pustules extend, the scabby surface becomes enlarged, and also thickened, by the concretion of fresh matter upon its inferior surface. The eruption is very apt to begin upon the forehead or cheek, and, by the species of reinforcement above-described, it travels to various parts of the body, and sometimes to almost every part of it; nevertheless, the face, scalp, and neck are its most favorite positions; and, strictly speaking, a red spot, at the point of beginning, and not a whitish pustule, is the first indication of the disease. 
Like most other forms of cutaneous disease, it manifests considerable variety. It is sometimes confined to very limited areas, and the discharge is very mild ; at other times, even when not extensive, the discharge is so acid as to excoriate the adjoining surface; then again, it may be confined to a particular part of the face, as the chin, the cheek, or both of the lips. 
"When the crust is removed, the surface is found to be red, inflamed, and excoriated, and so abundant is the secretion sometimes that scabs cannot form. At other times, there is but little discharge, and the scabs are dry and adherent. It causes, sometimes, a considerable inflammation and enlargement of the glands of the neck, and it is liable sometimes to be complicated with inflammation of the eyes and auditory meatus. 
Its name is derived from the circumstance that its scales or crusts form a mask or larva, and, in keeping with its name, 


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the features are so covered with irregular, greenish, or yellowish crusts as not to he recognizable. 
It is sometimes quite acute, and yields readily to proper medication, but at other times it appears to be chronic and continues even for years, indicating, as a matter of course, a general and deeply-founded cause or special anaemia of the system, which is most probably pulmonic, as we shall now show. 
Causes. — Prof. Dewees thinks that it is invariably associated with dentition, and that it appears sooner or later, depending upon the retarded or advanced condition of this process. 
That the professor is in the general correct, we have no doubt, but not universally so, because it has been known to appear and disappear before the commencement of that process. 
Billard says, that there does appear to be some plausibility in the vulgar opinion that impetigo larvalis is a salutary depuration, because of the vigorous appearance which he had observed some children to possess after the disappearance of the disease. 
Worcester says, that, in a great majority of instances, no satisfactory cause can be assigned for impetigo. " Dentition (he says) seems to be the most common cause of crusta lactea." 
Dr. Wood says, that " the causes of impetigo are not always obvious. Dentition appears to dispose to it." 
As dentition is purely a physiological process, it cannot, therefore, be attended, necessarily, by any form of disease. At most, then, it can only become a source of general irritation — interfere with the physiological processes in general. But, if we admit that this process, when tardy, produces crusta lactea, we have made only a very insignificant advance toward an understanding of the subject. Admit this as a cause, and then the questions arise, what occasioned the difficult dentition? and how did it occasion impetigo larvalis? We may be mistaken, but we think that it will not be difficult to give a satisfactory answer to these questions. 
The children w r ho suffer from difficult dentition and impetigo 


m THE DERMA. 
475 
larvalis, are represented by the second and third classes of Table, page 20. 
In both of these classes there is a feeble pulmonary system ; but children who represent the first class, are those who rarely, or never, suffer from the development of any of the infantile physiological processes. Those of the second class become fat—look well, and yet their obesity is consequent upon their pulmonary incapacity —carbon, instead of being eliminated, is stored away in the form of adeps. Dentition interrupts the process of nutrition (and so may other causes of irritation, and hence impetigo larvalis is not always associated with the dental process), becomes interrupted, the lungs are incapable of sufficient depuration, the kidneys become so, and to aid in these processes another apparatus is established in the skin— impetigo larvalis. The child becomes lean and emaciated, but after a time the causes of irritation become removed—the nutritive process becomes re-established—the child becomes obese —regains its fine looks and meets with Dr. Billard, and he is induced to suspect that there is some plausibility in the vulgar opinion that impetigo larvalis is a salutary depuration. Our readers may question our reasoning, but the facts are as we have stated them. 
Those children who represent the third class are more liable to convulsions and cerebral congestions, than to impetigo larvalis ; nevertheless, when all the power of their systems is appropriated, before the period of dentition, to the nutritive process, and as they are apt through life to take more food than they can digest, we discover the source of their liability to this disease, and the reason why it continues so long with them. The lungs are incapable of performing their depurative duty, and nutrition is incapable of aiding them by the formation of adeps, and thus this disease becomes their companion, until exercise shall so increase as to render the lungs so capable of their function, as to promote renal depuration and relieve the skin. 
The table to which we have referred demonstrates the existence of certain organic relations, and death demonstrates the consequences — so far, there is no room for speculation, and when we contemplate these conditions and the results, in connection with what we have said of infantile disease, we 


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feel very confident that our conclusions, in the main, are correct. 
Diagnosis. — This affection is pustular, and eczema is vesicular, therefore, attention to these facts will distinguish one from the other. See diagnosis to the next species. 
Prognosis. — An arrest of this eruption is very apt to be attended by serious consequences; nevertheless, when children die in this complaint, it is generally from some coincident form of disease, which may even have been, remotely, the cause of it. 
Indications. — Cleanse the skin — by soluble applications, remove the scabs — promote secretion — sustain nutrition by nitrogenous food and plenty of exercise. 
Treatment.—It is thought to be best, by some, to let this disease alone, inasmuch as it is but rarely fatal, though sometimes very severe, and leaves no marks upon the skin. But, we inquire, is it not very troublesome ? Does not the discharge, which is characteristic of it, weaken, and even exhaust, the patient? Does not the continual itching it produces, through both day and night, defeat its rest, and therefore its nutrition ? 
If these interrogatories receive an affirmative answer, can it be either wise or humane to allow it to progress to its own exhaustion, without control or melioration ? 
It is contended by others, that this affection is only an indication of an effort on the part of the system to throw off a more troublesome or fatal malady, and that on this account, the best practice is to let it alone. This doctrine applies with as much force to every other form of disease, as it does to this. Are not small-pox, bilious fever, and Asiatic cholera, efforts of the system to cast off or expel disease ? Is not this absolutely true of all forms of disease ? If it be, then it must be best to let them all alone. 
According to our pathology, disease is a unit, and consequently impunity cannot be granted to one form any more than to another, so far as principle is concerned. And it should furthermore, be remembered, that each form of disease has, under circumstances, a prescribed course to run—and to arrest this course, prematurely, is to do mischief; hence it is true, that mischief will result from the drying up of this eruption. 


IN THE DERMA. 
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It must be cured —that is, the disease, of which it is a manifestation, must be removed, but in the meantime it can be meliorated. ? 
The cure, then, consists in carrying out the indications— keep the system in that condition which will dispense with eruption as soon as it should be. 
In the treatment of this disease, Prof. Dewees recommends a " diminution of nourishment of every kind," and particularly prohibits the use of any "in which animal food enters." "We cannot jndorse this doctrine, because we have no doubt but that this plan has rendered chronic many cases which otherwise would have terminated as an acute one. We have both tried and witnessed this plan of treatment in inflammations arising from wounds, and we hesitate not to assert that patients are sometimes confined to their beds six months by it, who, under a generous diet, would have been about in one. 
Before the child became sick, a given quantity of nourishment was requisite to develop the system and maintain the ordinary repairs ; now, to these demands for aid —for food, is added a wasting disease, and one too, which frequently continues for several months. Now, add to the wasting effects of the disease, partial starvation, and then say whether we should expect any other result than a chronic form of the disease, and such a debility of the system as to render it unable to cast off the disease) 
We do not advocate feeding to repletion, under circumstances, nor do we advocate starving under any. Under the circumstances of waste, the child can spare none of the real elements of nutrition, but it should be deprived of all others, because they produce irritation. Upon this principle, we should advise, if the patient be weaned, azotized food, as animal muscle, or a tea or broth made of it; and, if it be not weaned, the mother should thus live, for the good of the child. 
Carbonaceous food should be prohibited, unless demanded by the necessity of animal heat. By this course the child is simply nourished, and all causes of plethora and irritation are avoided. 
Finally, the treatment under the head of Herpes is equally applicable to Impetigo. 


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"Variety II. — Impetigo Capitis. 
This eruption does not differ in any essential element from the preceding, except that it attacks the scalp, instead of the face. The discharge, in drying, mats the hair, and both united form thick crusts or scabs, and being by the hair, firmly adherent to the head, produce great irritation and a constant discharge of cero-purulent, or purulent matter, and without great attention to cleanliness, the hair becomes felted into a disgusting mass—furnishing shelter and protection to immense numbers of vermin. 
It commences in a spot or spots which are red and of an oval or round shape, and upon which appear small, flattened, and grouped pustules of slight elevation, that burst, in three or four days, and discharge an abundant secretion of a viscid character, that spreads over the affected part and soon dries into thick, brittle, greenish, or yellow and semi-transparent crusts or scales. Sometimes the patches continue distinct, with healthy skin between them, and at other times they coalesce and form a very large one. 
The detachment of the scabs usually takes the hair with them, but it returns when the disease is cured. The scabs are brittle, and when comminuted, the fragments resemble old mortar in a similar condition. Inflammation sometimes runs high—abscesses form under the scalp—the cervical glands become sore and tumefied, and the general health greatly suffers. 
For its causes, consequences, and therapeutics, see Impetigo Larvalis. 
Species IV. — Porrigo or Favus. 
This species is thought to have its origin in a vegetable cryptogamic growth, and the opinion may be founded in truth. That some of the phenomena of these forms of disease may have a vegetable cryptogamic appearance, we are ready to admit, but until we have further light upon the subject, we can go no further. Authors notice two varieties, Porrigo Lupinoso and Porrigo Scutulata. 


IN THE DERMA, 
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Variety I. — Porrigo Zupinosa — Tinea Capitis — Scald- Ilead. 
This form of disease attacks infants, but it is not so common to them, as to children between five and ten years of age. It is most generally confined to the scalp, but it has been seen upon other parts of the body, to which it may have been transferred from the head by the nails or other means, as it is beyond doubt infectious. 
When the scabs are thoroughly formed, they present an appearance similar to a honey-comb, and hence the name of favus. It first appears in specks of a crusty character, and rising but little, if any, above the common level of the surrounding surface. They exhibit no method in their location, but are scattered over the surface without order; sometimes they continue quite distinct, but at other times they are crowded, and as the scabs, which succeed the pustules, enlarge, they mingle together, so as to cover continuously large portions of the surface. 
The pustules seem to form or appear about the roots of the hairs, and hence one hair will usually be found passing through the scab. When the inflammation has existed for some length of time, the bulbs of the hairs become so diseased that they fall or disappear, leaving the skin white and smooth. The cellular tissue surrounding these denuded patches, not unfrequently becomes the seat of chronic abscesses, which, extending their influence to the cervical glands, render them sore and painful. 
When the scabs have enlarged and mingled together, they form a great many cup-like hollows, which bear a considerable resemblance to the depressions in the fructification of some species of lichen. When these scabs are large, their edges often meet, and the scabious surface becomes a continuous incrustation. In this process, as the scabs are round or roundish, they acquire, in the force of crowding, a hexagonal shape, and thus, like the cells of a honeycomb, they fit into each other—each scab still retaining its cup or little central depression. 
When this incrustation is allowed to proceed undisturbed, it may continue for years, but in such an event it becomes 


480 
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drier, less cohesive, whitish, and disintegrates into particles which resemble the crumbs and dust of old mortar. In this process, the lichen-like condition of the incrustation is entirely destroyed. 
Pediculi are apt to feast and revel in neglected cases of this disease, and when they do, they very much increase the suffering of the patient, by the severe itching they occasion. 
Treatment. —In the first place, shave the head as closely as possible, and then apply an Elm poultice over the whole scalp, until the soreness and irritation which attend this affection are removed; then wash the head twice a day with strong soap-suds. Once a day wash the head with the Tincture of Phyl. Decandi. 
This plan of treatment, with the frequent shaving of the head, should be continued for three or four weeks; but if this should not be sufficient, the following ointment, which has, in many cases, been found to be very successful, may be adopted: 
Pix Liquida, ea., gij, Capsicum, gr. xxx, Pulv. Sulph. Zinc, gr., 1, Creosote, gtts., xx. 
This should be well mixed in a mortar and applied to the scalp night and morning. After having well washed the head, as above recommended, this ointment should be continued several days, but if the patient should experience much pain from the application, it should not be applied so frequently. It should be remembered, however, that in all cases the head should be shaved close before any treatment is adopted. 
If the above treatment should not be sufficient to remove the disease, in consequence of a hardened condition of the scalp, which frequently attends this disease, the Irritating Plaster should be applied over the whole scalp until free vesication is produced. This will soon be attended with copious, purulent discharges, which should be continued for ten or twelve days. 
When the parts become very much inflamed, the Compound Lead Ointment or Slippery-elm poultice may be applied until it subsides; and after the parts have healed, if there be any 


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portion of the scalp disposed to assume its former appearance, the Irritating Plaster may again be applied and treated as above. 
Constitutional treatment is very important, especially in individuals of a scrofulous habit. The alkaline bath should be applied, accompanied with active friction over the whole body, every day during the treatment. 
If there be any tendency to constipation of the bowels, it should be removed by mild laxatives, after which the Compound Syrup of Stillingia, in alterative doses, should be administered three times a day. 
Where the above plan of treatment has been adopted there has been little difficulty in curing all the cases. 
Variety II. — Porrigo Scutulata — Tinea Annularis. 
This eruption more rarely attacks infants than others, and it is more rarely confined to the scalp — appearing sometimes upon the forehead, face, neck, and other portions of the cutaneous surface. It differs also from the other, in being more obstinate; but the distinguishing difference between the two, consists in the annular arrangement of the eruptions in this. The scabs have that lichen appearance which is characteristic of the cryptogamic class. 
It begins by planting minute and thickly-crowded crusts upon a red spot or surface, and as they enlarge they exhibit the cup-shape upon their surfaces. They enlarge and progress precisely as in the preceding form, except that they group into circular clusters. The disease extends by the development of new patches upon the periphery of those that preceded; consequently, by the union of many clusters, thus formed, the entire scalp may become incrusted. 
Causes. —But little is certainly known of the causes of porrigo, as of other cutaneous eruptions. 
Dr. Worcester says: " While no doubt of its contagiousness exists, some are much more liable to contract it than others; children of a lymphatic* or scrofulous temperament, 
* So far as we have yet learned, the profession, practically at least, have made no distinction between fat and lymph, the latter only is constitutional. We think it probable the above reference was to the obese ; if so, it confirms our pathological views. 
31 


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MOIST FORMS OF DISEASE 
ill-fed and clad, living in low, damp, and confined situations, in filth and neglect, are the more frequent subjects of it; in such situations, occasionally, sporadic cases of disease occur without any exposure to infection." Of this we have no doubt. 
We have seen the disease under circumstances quite the opposite of all this, but we do not remember to have seen it unassociated with the fats. In the mountains of Arkansas, where we have seen it, the children usually live upon old, fat bacon through the summer, and upon fresh bear and hog fat through the winter. With such a life, there is filth, but we think that both the filth and the disease had their origin in the mode of life. Such children, furthermore, often live through the winter without shoes or other means of keeping the feet warm. 
We are candidly of the opinion, that if the profession will turn their attention to the relations we have exposed in the cerebellum, and the use of fats, they will succeed much better than they hitherto have done, in discovering the causes of cutaneous disease. 
Diagnosis.—There is no other disease, common to children, with w r hich this should be confounded, and yet it has been done with impetigo; but the cup-like scabs of the former will always distinguish it, to which we may add the hair that is usually to be found passing through the cup. The circular form of the patches, in tinea annularis, will serve to distinguish the two varieties, one from the other. 
Prognosis.—If we were to suppose the disease allowed to run its own course, our prognosis would be decidedly unfavorable, because spontaneous recoveries are rare, and even then it is at a heavy cost to the patient—as permanent baldness, enfeebled intellect, premature old age, and previous long suffering. Such is the depravity of some constitutions, which it attacks, as to render it incurable; but instances of this kind are exceedingly few. 
Indications. —Remove all local and general causes of irritation—excite the diseased parts to a healthy action —improve the general health, and maintain a depurating action of the kidneys. 
The first of these indications can be effected by cutting the hair from the diseased surface with a pair of scissors, and the 


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removal of the crusts. To effect the latter, cover the diseased surface with lint saturated with a solution of Subcarbonate of Soda or Potash, and then cover it with an oiled silk cap or one of caoutchouc. By keeping the crusts thus saturated for twelve or twenty-four hours, they may be easily removed; the part should then be thoroughly washed with soap-and-water, to remove all particles of crust and hair that may be upon the If heat or inflammation be present, evaporating lotions should be applied until it is reduced. 
The general causes of irritation may consist of diarrhea, constipation, or some other symptom of disease — in other words, all constitutional vices of the system should be removed. 
To excite in the part a healthy action, various stimulants have been recommended —the Tincture of Iodine may answer every purpose. It may be placed on the part by the use of a camel's hair brush after the morning ablutions. 
All possible exercise, avoiding fatigue, should be given to the patient, and, as far as possible, he should live on azotized food. 
ORDER II. 
DRY FORMS OF DISEASE IN THE DERMA. 
Genus I. — Exanthemata. 
Remarks.—This genus comprises those dermoid forms of disease which are distinguished by an inflammatory redness, that is so superficial as to disappear upon pressure. The whole surface may be covered with redness, or it may only appear in spots, with intervals of healthy skin. The spots have no particular size or shape. 
Species I.— Roseola — Rose Rash. 
This form of disease is exceedingly troublesome to the little patient, and apart from this circumstance, its importance consists, mainly, in so understanding its diagnosis as not to confound it with any other, particularly with those with which it is frequently associated. Children are more liable to it during dentition, and between the ages of six and twelve months, than at a more early period. 


484 
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It consists in a superficial inflammation of the skin, which is not as extensive as erythema, but is frequently mixed with symptoms of variola vaccina, which succeed inoculation. Summer is more adapted to its occurrence than any other season; but no matter at what season it occurs, it renders the little patient cross and restless. It occurs upon the body, neck, and arms, and consists, very frequently, of nothing more than small patches of a rosy-red color, smooth surface, and irregular form, and so changeable as to appear and disappear several times in the course of a day. A large majority of the cases are unattended by either fever or derangement of any of the digestive functions. 
If it should be associated with cerebral, alimentary, or respiratory irritation, it should not be passed over as a slight or unimportant concern, but combated with suitable remedies ; but in the absence of any such irritation, its medication will be simple. 
Causes. —These are acknowledged to be obscure, but it is a frequent attendant upon dentition, improper food—irritation of the mucous membrane of the lungs, stomach, and intestines. 
Diagnosis.—This is the most difficult feature of the disease, because it so much resembles rubeola, erythema, and scarlatina. Rubeola is attended by fever, cough, injected conjunctiva, and roseola is not. Its patches are smaller, more numerous, less permanent, and of a brighter rose color than those of erythema. Scarlatina is attended with violent fever, great heat, inflamed fauces, peculiar odor, and a deeper tint of color, than roseola. 
Prognosis.—It is attended with no danger, but renders the patient very restless. 
Treatment.—The treatment of roseola is very simple; the patient should be placed upon warm, diluent drinks, with low diet and confinement to his room, until the eruption appears, when a mild purgative may be given, which will usually be found sufficient. 
However, should there be a high fever, and the eruption but slowly manifests itself, the warm bath with warm diaphoretic drinks will be serviceable. 
If much heat or itching attends the eruption, it may be 


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allayed by an aqueous solution of Borax, or Borax dissolved in an infusion of Hydrastis. 
In chronic cases, and in weakly patients, vegetable tonics, as Hydrastis, Columbo, Gentian, etc., together with mineral acids, should be perseveringly employed, and the diet should be nutritious and digestible, avoiding all greasy articles. 
Species II. — Urticaria — Nettle-Rash. 
The appearances presented by the skin, in this disease, and the sensations which attend them, are so much like those produced by the stinging of nettles, as to suggest the name. It is not contagious, and no number of attacks will render the system invulnerable to it. It is not considered to be dangerous, but it is exceedingly tormenting. The eruption consists of roundish or oblong, solid, little elevations, either red or white, but usually both, with the latter color in the center. 
Appearances, very similar to those which distinguish this disease, may be produced on the skin by a blow with the lash of a whip, which are vulgarly called whelks, and the marks of this disease are sometimes called wheals, because of this resemblance, and it is probable that the former of these vulgarisms is only a corruption of the latter. 
Urticaria has been divided into some half a dozen varieties, but only one of them properly claims our attention, and that one is the variety which appears spontaneously and without fever, and which may appear and disappear several times in a day. It is a very mild disease with infants, producing no mischief, except crying and restlessness. 
Causes. —These are, most generally, in young children, intestinal irritation, indigestible food, stimulating food or drink, medicines, particularly of a poisonous or indigestible character. 
Diagnosis.—Urticaria may be distinguished from the rash of nettles by its history; from lichen urticatus, by the papules being more prominent, permanent, larger, rounder, and redder. 
Prognosis.—The tendency in urticaria to repeated returns, and its obstinacy, are its worst features. It is not dangerous, but requires perseverance in a judicious course of treatment. 
Treatment.—The first step, in the treatment, is to remove the cause, if discoverable; but whether discoverable or not, it 


486 
DRY FORMS OF DISEASE 
will be proper to allay the itching, and to remove such cutaneous constriction as may exist, by the use of the alkaline bath, which should be followed by a mild emetic, as the Acetous Emetic Tincture, or Compound Tincture of Lobelia, to remove such mucus and other offending matter as the stomach may contain. 
The large intestines should also be evacuated by enemas; and in full habits, with high fever, purgatives may be administered internally; the Compound Powder of Jalap, or, with infants, the Compound Tincture of Jalap will be found of great service. 
In cases of plethora, venesection is recommended, but the above remedies, energetically used, will be all-sufficient. 
Opiates are recommended to allay the itching and to secure rest, but these objects can be more judiciously obtained by the use of saline, acidulated, or alkaline baths—they will promote an equalization of the circulation and depuration, while Opium will only afford temporary relief by suspending all action. 
In the event that the eruption should be intermittent, recourse should be had to antiperiodics, such as S. Quinia, Tincture of Macrotys; and in chronic cases, S. Quinia and Ferrocyanuret of Iron. 
The diet should be such as we have hitherto recommended in cutaneous affections; and when the disease is present during dentition, proper attention should be paid to the condition of the gums. 
Species III.— Erythema. 
Some eight or nine varieties of this disease have been reported, but the distinctions are more scientific than practically useful. 
Erythema is characterized by a red, glabrous, tumid fullness of the integuments, attended by burning pain and terminating in cuticular scabs or vesicles. The inflammation is usually very superficial, and non-productive of any general derangement of the system. 
The scrotum and superior portions of the thighs, in children, are the most liable to this affection. 
When the affection is on the scrotum, and it assumes a redcopper color, and resists remedial efforts, more especially if 


IN THE DERMA. 
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there be much repletion of the cellular tissue, the physician may feel justified in suspecting it to be syphilitic, and equally so in seeking special information as to the health of the parents. 
Causes.—Mucous irritation and external irritants may be regarded as the general causes, and among the latter may be included the excrementitious matters of the child, a want of proper attention to cleanliness, and of the former, visceral disease in general. 
Diagnosis.—In children, it can only be confounded with lichen and psoriasis, and when the small, distinct, conical papule of lichen, and the flattened, scaly tubercle of psoriasis, are considered, such a mistake should not be made. 
Prognosis.—When the cause is removed, the disease disappears, except when located at the junction of the skin with a mucous membrane —then trouble maybe expected, and caution is demanded. 
Treatment. — If there be any derangement of the digestive organs, or of any other part or function of the general system, this should be more especially attended to, and removed by the appropriate means, after which the warm bath may be employed with advantage. 
The itching may be allayed by some mild application, as Cream, or fresh Olive Oil. The Compound Tincture of Lobelia will likewise allay itching, and prevent the disease from spreading. 
When scabs form, the following ointment may be applied: 
Simple Cerate, 3j, 
Compound Ointment of Zinc, 3ij, Glycerine, 3j.' Mix. 
In many cases, the Compound Tincture of Hydrastis, will be found preferable—it may be diluted with water, if required. 
When a syphilitic taint is suspected, the Compound Syrup of Stillingia should be given, the efficacy of which will be much improved by the addition of half an ounce of Iodide of Potassium to a pint of the syrup. 
In debilitated patients, tonics and nourishing diet, are indicated. 
Bathing with a solution of salt and water, two or three times daily, has often effected a rapid cure in this disease. 


488 
DRY FORMS OF DISEASE 
Species IV.— Rubeola — Measles. 
This eruption is very generally confined to children, but not entirely so—it sometimes attacks adults, and when it does, it is more critical in its character, leaving, too generally, as it were by replacement, some other form of disease that may prove very afflicting, if not finally fatal. 
In its febrile character, it does not perhaps attack the same individual twice. To the variety of measles under consideration, the Germans apply the term morbilli, and the term rubeola to a more mild variety of the same disease, or possibly of roseola — in common language, the Germans call it false measles, which has been designated rubeola sine catarrho, by Willan —the same, or analogous to what we call in this country, French measles. An attack of this kind does not secure the constitution against an attack of the other. 
It is asserted by some, that morbillous fever, i. e., the true rubeolous fever, may occur without being attended or followed by the exantheme eruption, but have the usual catarrhal symptoms, with a perfect immunity from the disease, as indicated by the dermoid eruption, during the subsequent rage of the epidemic. 
When we witness the different grades of violence that distinguish different epidemics, we cannot doubt that it is greatly influenced by atmospheric peculiarities; and we may add, almost as a matter of course, that much variety in its manifestation is produced by constitutional peculiarities; indeed, we could not, a priori, suppose it to be as severe—as fatal in those of a vigorous vital system, as in those of a contrary character. 
Its usual period of incubation is from five to seven days, but in some instances it may be less, and in others it may extend to three weeks, depending upon the impressibility of the system. When produced by inoculation, the eruptive stage very generally appears on the seventh day. 
Its usual introduction is that of a catarrhal fever, indicated by creeping chills, alternated with flushes of heat, some redness and soreness of the eyes, with an increased lachrymal secretion, cough, and coryza. It happens sometimes that there are two or three days of febrile excitement, before the 


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supervention of catarrhal symptoms, but they never fail to occur. 
In the beginning, the respiration is apt to be oppressed, the cough dry and harsh, with some soreness in the fauces. The stomach, sometimes, becomes quite irritable, on the second or third day, and may be attended with nausea and vomiting. It is not infrequent for the lymphatic glands of the neck and eyes to become swollen and tender, and when the febrile symptoms run high, delirium may be expected. The skin is hot and dry, and the pulse is quick, hard, and frequent. 
Causes. —Upon this subject the profession have not agreed, but at present the preponderating opinion is, that rubeola is contagious. In the estimation of those who occupy this position, the success of Home and Hust, in producing the disease by inoculation, seems conclusive. It is admitted by all, however, that it cannot be traced from house to house, nor from street to street, as can be done with small-pox and scarlatina. But is it the case with these ? 
It is furthermore admitted by all to be epidemic, and so it is with small-pox and scarlatina ; but we confess that we are unable to comprehend how a cause can be both contagious and epidemic. The admission of one seems to destroy the possibility of the other, unless it be admitted that all of the so-called contagious forms of disease may be atmospherically produced, and when so produced, have the power of reproducing themselves. 
It is a pretty thoroughly-ascertained fact, that small-pox epidemics are generally attended with chicken-pox, and the febrile rubeola by the infebrile varieties. Upon the idea of specific poisons, we cannot account for these facts — to admit that the cause of chicken-pox, if it be a secreted poison, may produce small-pox, is about equivalent to admitting that the cause of gonorrhea may produce syphilis. 
We do not, and never have doubted, but that all contagious forms of disease may be atmospherically produced, and we admit that all those that can be propagated by inoculation, are contagious. It has not yet been proved that small-pox, in every instance, resulted from contagion. 
Diagnosis.—Rubeola and scarlatina have not always been successfully diagnosticated: indeed, they were regarded as one 


490 
DRY FORMS OF DISEASE 
and the same a century since—at all events, a diagnosis had not been produced ; and still, we cannot see why they should ever be confounded. The catarrhal symptoms of the former, with its small, red spots, and their union into semilunar patches, with intermediate healthy skin, should always distinguish rubeola from the diffused and uniform blush of the latter, more especially when viewed in connection with its exantheme of innumerable, minute, red points, so united together as to resemble a boiled lobster. 
Prognosis.—When the patient has good general health, at the time of the attack, and also a strong vital system, the disease is not attended with danger, because the vital force moves on regularly to the elimination of the poison that produced it; but when the vital force is feeble, and more especially if the system be diseased at the time of the assault, the prognosis should be, at least, doubtful. 
When the vital force is incapable of maintaining, upon the surface, a febrile action, congestion is sure to happen to some other and possibly more indispensably vital part; hence, among the sequelae of this disease, we find pneumonia, bronchitis, croup, arachnitis, etc. It is apt, furthermore, to afflict the lymphatic system, more especially in those who possess a scrofulous liability; hence, we have from this cause scrofulous ophthalmia, porriginous eruptions on the head, and tumors about the neck. 
Indications. —Steadily maintain the centrifugal action of the system—guard against revulsion—relax and cleanse the surface—remove all causes of irritation, whether internal or external, and finally, restore nutrition. 
Treatment.—In a very large proportion of rubeolous cases a pediluvium, an alkaline washing of the skin, and some aromatic tea, as Ginger, Catnip, or Spear-mint, will prove sufficient ; but, if in the beginning of the complaint, the patient complains of being cold and having pains in his limbs, the pulse being small and feeble — indicative of congestion, beside the pediluvium and alkaline bath, stimulating teas, as of Virginia Snake-root, Saffron, and even the Compound Tincture of Virginia Snake-root, should be administered; and it would be more agreeable to give them in the aromatic teas first named. If the supervening fever should run high, the 


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Compound Powder of Ipecacuanha and Opium should be given in appropriate doses, with a free use of warm diluents, and the application of the warm lye-bath every hour or two. 
If by this course the oppression is not overcome — and the eruption does not appear, Mustard sinapisms must be applied to the wrists, ankles, and even over the whole abdomen, and allowed to remain until considerable redness of the skin has been produced. 
If the condition of the stomach, either because of mucous or other offending matter, or if mucus should clog the respiratory vessels, the Compound Tincture of Lobelia should be given in doses to produce vomiting, or the Acetous Emetic Tincture may be used for a like purpose. Too free emesis should be avoided, except when imperatively required. 
If the condition of the bowels be such as to occasion irritation, they should be operated upon by enemas, or some laxative medicine ; and under such circumstances it is always best to combine it with some diffusible stimulant, to prevent tenesmus, and to aid in forcing the eruption upon the surface, or if already out, to maintain it there. 
But it should always be remembered, that in all cases of inflammation, when the system is acting favorably, that more or less of constipation is established, and it is done as an initiatory step in the establishment of a centrifugal action ; consequently no effort should ever be made to move the bow r els, in this form of disease, until the eruption is out upon the surface, and even then a purgative action should be carefully avoided. 
We are fully satisfied that incomparably more mischief is done, in all branches of the profession, by the use of cathartics, than good. This practice is a remnant of the old humoral pathology. Constipation did not exist before the inception of the poison—when it obtained, it was for the restoration of the patient, and so long as it exists as mere constipation, it should not be disturbed, unless it be for the purpose of revulsion or counter-irritation, and then the good that is hoped to result, will very much depend upon the agent selected. 
If it be conceded that disease cannot be cured or removed, except by secretion or depuration, it follows, upon the principle that two supreme or major actions cannot be maintained in the system at the same time, that so long as the bowels are 


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active but little can be gained by depuration, through the skin or kidneys. Admit this, and the folly of bleeding and purging, to remove disease, becomes too apparent to be tolerated. Our old-school brethren admit that it is dangerous to give cathartics in small-pox—under this admission, how can they justify purgation in any form of inflammation ? 
The patient's condition, as to his bed, clothing, ventilation, food, and drink, should be such as that recommended in small-pox. 
Dr. Eberle says, that this eruption, " as in every other exanthematous affection, must be regarded as an effort of the system to relieve itself from the noxious influence of some internal irritation, by a critical or metastatic deposition on the surface." We regard this as sound doctrine—but observe his inconsistency, when he says, that " all that is usually requisite in such cases, is to keep the bowels in a soluble condition by the employment of mild laxatives." Is not this practice a direct counter-action of the organic law which he has admitted to be correct ? 
He says, in another place: " A high grade of fever undoubtedly indicates the propriety of moderate venesection." When this is properly interpreted, it means about this: the rubeolous poison has produced a powerful obstruction in the system, and its vital force is making a strong effort to determine it to the surface, or to expel it, and consequently success may be more certainly achieved by removing a part of the force. 
Eclectics entertain the opinion that it is best to equalize this vital force, and save it for the purpose of sustaining existence and the depuration of the disease; consequently, instead of bleeding, they make use of diaphoretics, bathing with lyewater, and rubefacients, which answer all purposes, as a general rule, in the treatment of this disease. 
Dr. Eberle informs us that Dr. Armstrong advocated the "cautious abstraction of blood in congestive measles;" but he thinks a more prudent method would be to " impart warmth and vigor to the system, and to recall the circulation to the extreme vessels of the surface;" he therefore recommends : " Stimulating frictions to the skin, with Tincture of Capsicum, or flannels wrung out of hot brandy, sinapisms to 


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the epigastrium, and bottles filled with hot water applied to different parts of the body and extremities, are the means best calculated to procure these ends. Measures of this kind expose the peculiar advantage of exciting the energies of the system {much better than bleeding) without diminishing its resources, at the same time that they most efficiently tend to equalize the circulation and remove the congestion. In addition to the above means, we should not neglect the use of warm and gently-stimulating drinks." 
In the preceding paragraph, the doctor has written as becomes a medical professor — but how badly it contrasts with his preceding teaching. His treatment, as a whole, clearly shows that he was guided by no rule of action or governing principle ; and as the allopathists very generally, perhaps uniformly, teach the same, we are forced to conclude that their practice is nothing else, and nothing less nor more, than learned inconsistency—empiricism—quackerj^. 
A retrocession of the eruption is quite liable to take place with those who have been reduced, in an earlier stage of the disease, by bleeding, purging, etc., and also with those who are naturally feeble—such patients have not the requisite vital force to maintain a centrifugal action in the system. When this event supervenes, tonics and stimulants are required, as Wine, Capsicum, Porter, with Quinia, Hydrastin, and in nervous conditions, Camphor and external friction. 
Measles, in those of an unbalanced constitution, are very liable to induce or complicate with other inflammatory forms of disease, the treatment of which will be found under their appropriate heads; but we may add, by way of prophylaxis, rubeolous patients should be particularly careful to avoid, during convalescence, improper exposures of the surface— indeed, prudence in all respects is highly imperative. 
Species V.— Scarlatina — Scarlet Fever. 
This is a disease of the skin which is seated in the cuticular surface, and is manifested by a diffusing or spreading inflammation. 
If we may be allowed to form an opinion from the evidence that has been furnished us by the profession, it would be, that scarlatina is produced by an atmospherical poison, and that 


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DRY FORMS OF DISEASE 
when produced, it furnishes a poison that will reproduce it; that while the cause of it differs from that of measles, it is mainly governed by the same law. 
The period of its most poisonous activity is thought to be that of desquamation, which happens from three to six days after the first impression. Like measles and small-pox, one attack generally destroys the susceptibility of the system to a second assault; we say generally, because some assert that it does sometimes assail, successfully, a second time, while others positively deny it; indeed, it has been maintained by some that they have known it to make a third attack. 
Some persons are insusceptible to its impression, as some are to that of small-pox and measles. It has been discovered that those who are, in age, intermediate between that of old age and infancy, are the most liable to it. This may be a general fact, nevertheless it is well known that some epidemics assail children almost exclusively. It observes no particular choice as to season, but is most apt to appear in warm and humid weather, and in such seasons it is most apt to be severe. 
Like other epidemics, it betrays considerable variety — sometimes it is very mild; at others, greatly fatal; sometimes it will rage with violence for a time, and then almost disappear, and then return with equal violence in its assaults. 
Because of the differences which have been observed in the intensity and character of the disease, it has been divided by nosologists into three varieties: S. Simplex, S. Anginosa, and S. Maligna. 
This division has been founded upon the observed facts in the history of the disease, but, as to why or how they exist, has not been explained; therefore we may be allowed to hazard a few suggestions. 
With regard to all forms of epidemic disease, some visitations are comparatively mild, while others are as signally fatal. This difference may be referred to a less or a greater elaboration of the poison, or to a difference in the prevailing atmosphere, respectively; but, no matter how mild may be the general character of an epidemic, some cases occur of such malignancy as to destroy life. . This difference we must refer to differences of human constitution. 


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Further, there are some constitutions that possess a vital force capable of successful contention with all causes of disease for a hundred years or more; such persons may have scarlatina simplex, only, and that too, in the rage of the most fatal epidemics. There is a third class which possesses an average constitution, and are, therefore, liable to scarlatina anginosa; and there is a fourth and large class, which manifests, in all the relations of life, a feeble vital force, and they are the subjects of scarlatina maligna. 
We were led into this train of thought by the complete fitness that exists between a feeble vital force and the phenomena of scarlatina maligna—a fitness that thoroughly penetrates us with the conviction that these three forms of the disease are founded in the three constitutions above defined; with the exception of those cases, wmerein the too general antiphlogistic treatment of a milder form of the disease, has produced a more malignant one, by exhausting the vital force. 
Variety I.— Scarlatina Simplex. 
Symptoms. — Between the premonitory manifestations of febrile irritation and the onset of the eruptive fever, there is usually an interval of three or four days. This period is characterized, by an alternation of momentary flushes of heat and slight chills, with nausea, pain in the loins, head, inferior extremities, and a feeling of general depression. The skin is hot and dry, and the pulse is quick and frequent. After a continuance of febrile symptoms for about forty-eight hours, the eruption appears, first upon the face, and then descends, covering the trunk and extremities, and finally working its w r ay into the nostrils and over the buccal surface and fauces, showing itself by a coalescing of innumerable red points that produce a diffused blush upon the cutaneous surface. 
There is frequently an enlargement of the papillae and miliary glands of the skin to such an extent as to give a feeling of roughness to the touch; in other instances, there appears upon the whole surface a scarlet efflorescence. 
With or about the beginning of the fever, the patient manifests some difficulty in deglutition, and complains of some soreness of the fauces, with a voice considerably diminished in sonorousness. The extremity and edges of the tongue are 


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usually red, while a white fur, with the scarlet-colored and enlarged papillae appearing through it, occupy the balance of it. Considerable restlessness and sometimes delirium attend the evening exacerbations, but they generally disappear before morning. The face is usually somewhat swollen during the presence of the fever, and the pulse, instead of being quick and frequent, is sometimes tense and vigorous. These symptoms continue, with more or less modification, until about the fifth day, when they begin to decline—the eruption, and of course, the fever, diminish, pari passu, until they have entirely disappeared, which happens usually about the seventh day. 
As the disease subsides, there is one peculiar symptom—a copious and reddish sediment in the urine, and frequently some diarrhea. The process of desquamation, which usually begins on the eighth day, is attended with much itching, and is followed by an equal sensibility of the whole surface. 
Authors inform us that there is a considerable abatement of the febrile symptoms upon the appearance of the eruption. To those who regard fever as a disease, this may be information, but to those who regard the eruption as the aim and necessary sequence of successful fever, it would be anticipated. Sometimes the fever is remarkably light, as might be expected in a highly physiological condition of the system, but in other instances, and under a contrary condition of the system, it runs high, thus indicating a pretty strongly-founded condition of the disease. 
Variety II. — Scarlatina Anginosa. 
This variety is more severe in its whole character, more particularly in its anginose affection, than the preceding. It is usually attended with considerable praecordial oppression, nausea, headache, muscular prostration, and occasional vomiting during the introductory stage. The febrile action is developed with much rapidity, the pulse becoming very quick and frequent, but has less tension, vigor, and fullness, than the preceding variety. Deglutition becomes painful, a feeling of esophagal stricture is experienced in respiration; the fauces, palate, tonsils, and uvula become red and slightly tumid; and a sense of stiffness, with a dull pain, seizes the cervical 


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muscles and those under the ears and about the angles of the jaws; the skin is said to be more intensely hot than in any other febrile affection, and is attended by a corresponding degree of thirst. The whole course of the disease is marked by unusual languor, restlessness, and prostration ; the tongue is dry, its edges are florid and projecting, and highly-inflamed papillae cover its surface. 
In this variety the vital force is less effective than in the former, and consequently the eruption does not usually appear before the third day of the fever; and when it does appear, it is neither so regular nor so generally diffused, showing itself on different parts of the body, particularly about the elbows. The rash sometimes disappears, and probably the day after its appearance, and by the next day returns, but this mutation is governed by no regularity—it shows only that the system is struggling to effect a permanent reaction. 
If the disease manifests a declension by the fourth or fifth day, the inflammation of the fauces usually passes off by resolution ; but when the symptoms are violent and are protracted beyond the time above specified, ulcers are formed about the tonsils and palate, which rapidly pass into ash-colored superficial sloughs; at the same time mucus may be secreted in the fauces and concrete into flakes, which, without care, may be mistaken for sloughs. 
As the fever subsides, which happens about the eighth day, the sloughs separate, leaving ulcerated surfaces that readily, cicatrize, unless the separation is procrastinated beyond the eighth day, in which event it is common for them to enlarge, become of a brown color, and throw out an acrid and sanious fluid, attended by a hard, painful, and swollen condition of the cervical glands, diarrhea, and possibly tenesmus. 
Variety III.— Scarlatina Maligna. 
Between the most inflammatory and unmanageable form of scarlatina anginosa, and that of which we are about to treat, the differences may be considered to exist in degree rather than in kind. In malignant scarlatina, the febrile manifestation very early in its history assumes a typhoid character: in scarlatina anginosa, there is a pretty general equality between, the constitutional symptoms and the local mischief; but in 
32 


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DRY FORMS OF DISEASE 
this, the speedy death that supervenes cannot be explained by the extent of the local lesions. 
Its introduction may resemble scarlatina anginosa, but the mask is soon removed by the dangerous character of the symptoms that supervene. No certain periods are observed for the appearance of the eruption, but it usually appears between the second and fourth day. No definite period can be assigned for its duration ; when it appears it may continue a few hours, and then appear after two or three days, but upon different parts of the body. By the second day, the pulse passes from activity to smallness and feebleness; the skin does not become particularly hot — delirium appears early in the disease, and with occasional intermissions and exacerbations continues throughout the disease. 
In the most aggravated cases, a livid flush covers the cheeks, and the eyes appear dull and inflamed —the breath is fetid, and the tongue is dry and covered with a dark-brown fur—gray-colored sloughs appear on the soft palate, in the fauces, and tonsils, which soon become of a dark color; but before the arrival of these symptoms, death frequently relieves the patient by the infliction of some cerebral outrage. 
It but rarely happens, that when the fever is not protracted beyond the fourth day, that the ulcers become fetid, black, and ill-conditioned sloughs. 
If the disease has shown itself to be particularly malignant, about the middle of the second week, collapse, manifested by a great prostration of the vital force, as a frequent and feeble pulse, a low condition of the cutaneous caloric, exhausting hemorrhages, or diarrheas, dark-brown or black tongue, and the appearance of petechias, may be expected. In some instances, the vital force proves entirely insufficient to force the eruption upon the surface during the existence of the disease. 
Dr. Armstrong has divided scarlatina maligna into three sub-varieties, the inflammatory, congestive, and mixed. The first is indicated by a full, hard, and vigorous pulse, early delirium, and very hot skin. In this stage it differs nothing from scarlatina anginosa, but runs speedily into collapse, the eruption appears early and vividly red, but in a short time it acquires a dark purple hue—the vital force is soon expended, and petechia?, colliquative diarrhea, and passive hemorrhage 


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ensue. This form of the disease is better known by the name of "putrid sore-throat." 
A complete overwhelming or overpowering of the vital force, by congestion, indicates the second or congestive variety. The patient feels oppressed, disposed to syncope, complains of giddiness, weight in the head, nausea, oppression in the praecordia, and deep-seated pain, if of any at all, and a pale skin. Diarrhea, petechiae, gangrenous spots, and exhausting hemorrhages from the nose, mouth, or bowels, precede dissolution, which is but rarely procrastinated beyond two or three days. 
The third variety can readily be inferred from the two preceding, and therefore no description of it is necessary. 
Sequelae. — Anasarca is, probably, the most frequent sequelae of this disease —it generally appears in eight or ten days after the termination of the disease, and continues two or three weeks; but sometimes, it is said, invades the chest and even the brain and thus proves fatal. 
Occasionally it causes gutta serena, rheumatism, eruptions of the derma, neuralgia, hysteria, asthma, chorea, inflammation of the testicles, tonsillar abscesses, tumefaction of the parotids, deafness, ophthalmia, otitis, excoriations about the nates, suppuration of the cervical glands, cough, hectic fever, inflammation of the mucous lining of the bowels, etc. 
Causes.—All, and perhaps more than we know of this disease, is embraced in our leading remarks. 
Diagnosis.—When treating of rubeola, we gave the diagnostic differences between it and scarlatina, and the only other eruption with which it can be confounded is miliary fever, and this can only happen with superficial observers. The miliary eruption is generally attended with considerable perspiration, which is not the case with scarlatina. The eruption of miliary fever seems to be seated on a skin which preserves its natural color. 
Prognosis.— This disease is divisible, as we have shown, into three pretty strongly-marked varieties, and each of these is attended with several modifications, consequently, the prognosis must be attended with as many qualifications. This is not all, the general character of the prevailing epidemic must be taken into consideration. 


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We may say, however, with reference to scarlatina simplex, that, under judicious treatment, its prognosis may be considered as generally favorable; as regards scarlatina anginosa, where the contending forces are pretty nearly balanced, that a judicious treatment may be expected to produce a favorable preponderance, and consequently the fatality which has generally attended it, is not justified by its pathological conditions. In the third variety, there is no equality in the forces—those of an inimical character greatly preponderate— it is pregnant with the most obvious indications of an inherent deficiency of the vital force, and hence no treatment should be expected to achieve more than a mitigation of its violence, and a brief procrastination of the necessarily fatal termination that attends a large majority of its assaults. 
Indications. —The indications in scarlatina are the same as in measles, particularly in its milder forms; but its more malignant peculiarities demand more energetic treatment — to effect and maintain a centrifugal action must be the leading principle. 
Treatment. —There is no fitness or proper relation between the symptoms of this disease and the mortality that attends the general practice. If in this opinion we are correct, then the practice must consist too much in a war upon the vital force—upon the fever and inflammation instead of the disease. The accuracy of our opinion is sustained, if we mistake not, by the success of the homoeopathic treatment, which, in our judgment, is about equivalent to none at all. None at all, then, is better than that which generally prevails. 
Prof. Wood says, that" in the vast majority of cases, scarlet fever would end favorably without treatment; hence the reputation acquired by homoeopathy in this disease.-" 
Under this view of the subject, what should we think of the practice of those physicians who lose a " vast majority " of their scarlet fever patients ? We know a few who are thus unfortunate, and yet they have the presumption to call a more fortunate class " quacks." We are very much mistaken if Prof. Wood, himself, would not have greater success if he would practice the bread-pill system, which is less than homoeopathy, than the one he recommends. If our unfortunate physicians make him their guide, we are not surprised 


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at the fatality of their practice. He teaches, that in all cases, except those of "great mildness, it will be proper, in children, to follow the emetic with a purgative dose of Calomel, which, if it do not operate thoroughly in six or seven hours, should in its turn be followed by Castor Oil, Magnesia, or one of the saline laxatives. Afterward, the bowels should be kept open, if necessary, by cathartics, which should be accommodated to the circumstances of the case; those of a depletory character, such as Sulphate of Magnesia, being given if there is much excitement with considerable energy of the system." In another place, he states, that " the practitioner should always be on his guard for symptoms of debility." Are we to infer that he prescribes Calomel purges as a means of guarding against debility ? 
For the practice of Eberle, Watson, and Armstrong, our opinion is about that which we have above expressed concerning that of Prof. Wood. As these four writers measurably lead the profession, we have no occasion of surprise at the fatality that attends this form of disease. 
Among the local remedies, is that of inunction, upon which we desire to offer some comment. It consists in greasing the whole surface, with the exception of the face and scalp, with a piece of fat bacon every morning and evening. Of this practice, Dr. Schneeman, of Hanover, speaks in flattering terms. We have never tried it, and from the ill-success of those whom we know to use it, we think it much inferior to homoeopathy. As a means of counter-irritation in visceral inflammation we think favorably of it, but when applied to an inflamed surface, we are disposed, a priori, to think as badly of it, as of blisters to the scalp in encephalitis. 
We have stated that the leading and principal indication is the maintenance of a steady and constant determination to the surface; and, if this principle be correct, purgation of any kind must be, in the highest degree, incompatible. Nothing, except the most clearly-manifested alvine irritation, can justify the use of the simplest laxative. Under a highly vital manifestation of the disease, simple enemas may be used, if required by indications of alvine irritation, and under depression of the vital energies stimulating ones may be used to 


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DRY FORMS OF DISEASE 
evacuate the large intestines, and to promote revulsion or a centrifugal action. 
The treatment we have laid down for measles, is all that is required for scarlatina simplex. 
In the anginose form, prompt efforts should be made to reduce the fever, by equalizing the circulation and the promotion of secretion, which may be effected by the administration of a mild vegetable emetic, that should be repeated daily for two or three days in succession ; the Acetous Emetic Tincture will be found useful for this purpose. 
After the action of the emetic, the body should be bathed with a weak, warm lye-water, followed by the spirit vaporbath, in adults, and the free use of the infusion of some of the simple vegetable diaphoretics, as Catnip, Balm, Sage, etc. 
In using the lye-bath, its temperature must be regulated by that of the body; if this be not above the natural temperature, the bath must be merely blood warm. The more severe or malignant the disease, the oftener must the bathing be repeated, even to every hour. 
Our next duty will be to induce the deep-seated inflammation of the neck to the surface, for which purpose the throat and neck should be bathed with the Camphorated Soap Liniment, or the Compound Stillingia Liniment; this should be repeated three or four times daily, applying after each bathing a warm fomentation of Hops and Wormwood, or a Slipperyelm poultice. 
The fever being so far reduced as to admit of secretion, our attention should, in an especial manner, be directed to the kidney —depuration through them is, perhaps, indispensable to the cure of this form of disease. An infusion of equal parts of the root of Althaea Officinalis and Apium Petroselinum may be drank freely, and will prove as effectual in fulfilling this indication as any other diuretic we can employ. 
Scarlatina maligna is but scarlatina in a constitution highly feeble and vitiated. The anginose form, we have no doubt, is very frequently forced into the malignant by allopathic purgation. By such a practice the vital force is so reduced that it cannot contend successfully with the disease, and death takes place through mortification—not inflammation. 


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The pains and sensations of heaviness—the anxious expression of the countenance, and withal, the alternate chills and heats, indicate a congested condition of the system ; the vital force is inadequate to a successful revulsion, and the morbus settles upon the throat, and that too without much delay. The inside of the throat becomes florid or crimson-colored —spread- rapidly, it soon becomes covered with whitish spots that mark the beginning of the ulcers. 
In the malignant form of scarlatina, the treatment abovenamed must be energetically persevered in. For the ulcerations of the throat, a wash or gargle must be employed, and used several times a day, composed of: 
Black Pepper, 3i, 
Salt, 3j, 
Boiling decoction of Hydrastis Can., fgiv. 
Mix, and allow it to stand fifteen minutes ; then add, 
Vinegar, fgiv. 
"With this, the mouth and throat must frequently be washed with a swab, or gargled, and a child two years old may swallow a teaspoonful of it several times a day, or in proportion to its age. 
When the low typhoid symptoms appear, as frequent and small pulse, dry and cracked tongue, sordes upon the teeth, jactitation, muttering delirium, etc., stimulants and tonics must be resorted to, with generous, nourishing, and easilydigested food. For tonics and stimulants the agents may be employed which have been heretofore advised for a similar purpose in the treatment for laryngitis. 
The room of the patient must be kept well ventilated, and his clothing should be changed often. 
Genus II. —Papulae. 
This genus consists of eruptions which are marked by small, hard, resisting, acuminated, and unsecreting elevations of the cuticle, attended with a more intense itching than any other genus, and terminates usually in scurf. Dermatologists describe three species: Strophulus, Lichen, and Prurigo—neither of which is contagious. 


504 
DRY FORMS OF DISEASE 
Species I.— Strophulus. 
This is a disease of infancy, and it consists of pimples, which are usually red, but they are occasionally whiter than the healthy skin—they may occur on a part, or they may appear over the entire surface of the body. They rarely give rise to any constitutional symptoms, but they exceedingly annoy the little patient by the itching they produce, with some increase of cutaneous temperature. Their termination is by resolution and desquamation. It consists of five varieties: Strophulus Intertinctus, S. Confertus, S. Yolaticus, S. Albidus, and S. Candidus. 
Variety I. — Strophulus Intertinctus, or Red- Gum. 
This eruption consists of prominent and pimples, dispersed generally over the body, or only over several portions of it, in erythematous patches, and covered with small, red points. It more frequently attacks the backs of the hands, the forearms, and cheeks. Its introduction is sometimes preceded by nausea and vomiting, or possibly by diarrhea. 
Prof. Dewees says, that " most nurses are very fond of it, so much so, indeed, and so invaluable and useful do they consider its presence, that should indisposition befall the child, and this eruption not have possession of the skin, it is at once attributed to the absence of the gum." They then resort to means to produce it, such as warm clothing, heating teas, etc. 
It is no doubt true, that so long as the infant is in possession of this disease, it will be little liable to any other, but the same argument is as applicable to any other disease; the possession of one usually precludes every other. But this fact can furnish no argument favorable to its retention or introduction. It is most probably symptomatic and vicarious in its purpose. 
Variety II.— Strophulus Confertus, or Tooth-Rash. 
This eruption usually appears upon infants about the fourth or fifth month, but it may occur at any time during dentition. The pimples are of smaller size and more numerous than in the preceding variety, and also more aggregated into patches, 


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which are sometimes confluent. It most generally attacks the cheeks and side of the nose, or it may appear on the arms and forehead, and, if more than ordinarily violent, it may possess the entire surface. 
When of such violence, it is attended with much pain and itching, and sometimes excoriation, more particularly when it is seated upon the thighs or inferior portion of the body. It is less vividly red, more painful, and more lasting than the previous variety. In two weeks it usually attains its height and then declines with a copious furfuraceous desquamation of the epiderma. 
On its decline, it is frequently succeeded by another eruption, which Willan describes as attacking infants of seven or eight months. It appears in one or several large, irregular patches of pimples upon the arm, leg or some other part of the body and extends upward and downward. 
The intermediate skin, as well as the patches, is of a deepred color, and after the epidermal exfoliation, in which they result, the skin is left of a dull, dark-red color, dry and harsh. 
When it visits the legs, it generally becomes painful and most obstinately forces its way to the thighs, and in many instances to the loins and abdomen. The epiderma is apt to crack and separate in large flakes, leaving the derma rough and inflamed. It is frequently continued for several months, and even to the close of the first year, and attended all the time by much heat and irritation. 
Variety III.— Strophulus Volaticus. 
This variety usually betrays itself upon the arms or cheeks, in small, circular, bright-red patches or clusters, varying in number from three to a dozen papulae in each. Sometimes these patches appear in succession upon different parts of the body; and in some instances they have been observed to disappear, and then to be quickly replaced, at a little distance, with another, and in this wise to spread over the entire surface. 
The patches and thin interstices have a highly-inflammatory color, and are attended by an increased temperature, a quick pulse, a white tongue, and an irritable disposition. 
In most instances, the inflammatory condition subsides in a 


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DRY FORMS OF DISEASE 
few days—the papulce become of a brownish tint, in a desquamation of the epidermis. 
Variety IV. — Strophulus Albidus. 
This cutaneous affection, consisting of a pale or whitish eruption, is very mild in its character — very rarely attended with any constitutional symptoms, and hence, as seldom requiring medical attention. 
It is readily distinguished from the other varieties by the hardness, smallness, and dryness of the papulae, which are but slightly elevated, and cast, as it were, upon a mild-red ground, and in great numbers upon the face, neck and breast. It continues for a considerable time, and though very mild, its repulsion produces sometimes dangerous symptoms. 
Variety V.— Strophulus Candidus. 
This eruption is said to appear about the close of dentition with children, and to be also a consequent upon convalescence from fevers, and also inflammations of the intestines and lungs. 
Its papulae are of larger size and broader than in the preceding forms ; they are but sparsely scattered over the loins, arms, and shoulders ; they are hard and smooth, but attended with so little inflammation that, in consequence of their smoothness and brightness, they appear to be less colored than the adjacent skin. They usually continue hard, tense, and elevated for six or seven days, and then disappear. 
Causes. — This species, and all of its varieties, are considered to depend upon, or originate in, the deciduous dentition, and are therefore called tooth rashes. 
Upon this subject, Professor Dewees says, that "nothing declares the intimate connection, or play of sympathies between the gums and skin, during dentition, more than the number of eruptions to which it becomes liable at that period." 
Against such an opinion as this, we have much to say, if time and place permitted — it is a part, a fragment of that doctrine that inculcates the plurality of disease —a fragment of that doctrine which leads, in practice, to a contention with symptoms, instead of the disease which they indicate. 


IN THE DERMA. 
507 
The dental process is just as normal — as physiological, as the cerebral, muscular, or osseous; and its period of development is that of all, and if all the others progressed physiologically, we would have nothing to fear from it. The difference is, that it becomes the organ of complaint for that defective nutrition and consequent development or feeble condition of the vital force, which is characteristic of all such cases. The sympathy, then, is not between the gums and the skin, but between the latter and the system of nutrition. 
In treating of strophulus intertinctus, he makes its cause to be entirely independent of any condition of the teeth or gums. He says: "This derangement may proceed (1st.) from the meconium not having been well purged off, or its being of an unusually acrid quality; (2d.) it may proceed from an acrid state of the stomach, owing to feeding the child with improper food, or to its being made to receive too great a quantity of it; to some ill quality in the mother's milk, or a constitutional feebleness of the stomach," etc. 
If these remarks be true, and we are ready to admit that they are, he has thoroughly sustained our conclusion. There is too much similitude between the several varieties of strophulus to make them symptomatic of entirely different forms of disease. Such a pathology as would attribute one member of this family to such causes as we have above specified, and at a period, too, long antecedent to the existence of any dental irritation, can never lead to anything else than empirical practice. 
If we consider the remote cause of these eruptions to be the disease—an inability of the nutritive system to discharge its duties, physiologically, all the members of this family are accounted for by differences of age and other attending circumstances. 
Dr. Wilson says, that " Strophulus is generally due to gastric and intestinal irritation, and is frequently associated with the constitutional disturbance induced by dentition." Dentition induces none—that which is in the system is only manifested through it. 
Diagnosis.—The period of life in which this family appears is generally sufficient to distinguish them from all others. If lichen occurred at so early a period, it would be difficult, if 


508 
DRY FORMS OF DISEASE 
not impossible, at least in many instances, to diagnosticate them. 
Prognosis.—If we speak of these eruptions as so many forms of disease, then the prognosis is favorable—for, instead of being attended with danger, they rarely present features of severity; but of that constitutional weakness, of which we regard them as symptomatic, very many children die. 
Indications.—Remove all causes of irritation, and promote cutaneous and renal depuration. 
Treatment.— Cleanse the surface with the alkaline wash, and if the child possess a respectable share of vital force, a simple enema and mild aromatic teas will usually be sufficient, aided by decoctions or infusions of some of the vegetable diuretics. 
But if it be feeble, and re-action effected with difficulty, the enemas and drinks should be stimulating; and alteratives and tonics may be given with benefit; the Compound Syrup of Yellow Dock will be found to fulfill both indications. 
In some instances it will be judicious to administer mild emetics, especially when much mucus appears to abound in the stomach ; and the bowels should always be kept open by mild aperients. 
The diet should be nutritious and easy of digestion. 
Species II.— Lichen. 
This eruption consists of elevated, acuminated papulae or pimples, which are small, hard, and solid, and grouped together upon particular portions of the cutaneous surface, or distributed over4he whole body, and attended with a troublesome sense of tingling, itching, and pricking. It is common to children of eight or nine years of age and to adults. It is not necessarily attended with constitutional symptoms. 
Of this species there are three varieties which interest us: Lichen Simplex, L. Agrius, and L. Urticatus. 
Variety I. — Lichen Simplex. 
This form of disease appears usually on the face and arms, but may extend to the neck and breast, and indeed to nearly all parts of the body. It appears in small, red, distinct, conical, and hard pimples, or papules, more or less grouped, with 


IN THE DERMA. 
509 
an inflamed base, and attended with various degrees of heat, itching, and tingling; its duration is from one to several weeks, or even months, but such an extension of it is occa sioned by successive crops of the eruption. 
After the attack, it appears to continue stationary for several days, and then declination begins and terminates in one or two weeks in a slight scurf, when the disease is of a simple or mild form. 
"When the erupted parts have been exposed to abrading forces, the papillse will frequently be found wearing bloody scabs on their surfaces. 
In chronic cases, the skin has, to the eye, quite a normal appearance, but the passage of the finger over the part will detect the eruption. This form is usually attended with more desquamation than the acute, and the skin, also, becomes thicker and less pliant. 
In the heat of summer, this disease is called prickly heat, by the unlearned, and by the learned, lichen tropicus. In tropical latitudes, it is much more severe than in the temperate ; but in any latitude it is a harassing disease—producing an uncontrollable disposition to scratch. 
In numerous instances, it is attended by no constitutional symptoms, and yet, in some, it is preceded by fever, and other evidences of internal disorder. 
Yariety II. — Lichen Agrius. 
This variety attacks, preferably, the outside of the limbs, and in this wise differs from eczema, to which, in some respects, it bears a resemblance. It commences with fever, which, upon the appearance of the eruption, generally, but not uniformly, subsides. To the tingling and itching sensation, common to lichen, is added, in this form, burning and smarting, which are greatly augmented by heat and by everything else that can excite or irritate the skin. 
The eruption consists of numerous small, red, inflamed papillae, which are clustered upon large areas, and surrounded, often to a considerable extent, by an erythematous redness of the skin. Sometimes small vesicles are intermingled with the papules; their occurrence, however, is a mere circumstance, as they soon disappear. 


DRY FORMS OF DISEASE 
510 
This form of disease is usually marked by remissions in the morning and exacerbations in the evening. After the existence of the pimples for some days, an excoriation or ulceration commences, which throws out a sero-purulent fluid that forms into scabs. 
This circumstance is a considerable violation of the definition of lichen—a proof that all classification is more or less arbitrary. To the scabs, however, succeed minute furfuraceous scales, which may terminate the disease. 
Two weeks, or a little less, is the usual period of the disease, but sometimes, after the disappearance of the scabs, the surface continues moist, and the departed scales are replaced by others, or the eruption may entirely disappear, and yet, in a short time, re-appear — in this wise the disease may be protracted for several weeks. The passage of the disease through these several modifications leaves the skin chapped, thickened, and tender. 
Yariety III.— Lichen Urticatus 
In this variety of lichen the papulae possess more magnitude than is common to the other varieties. The papules are clustered, and they are either white or surrounded by a faintred areola; sometimes they are prominent and considerably inflamed, and at first bear considerable resemblance to flea bites. The suddenness with which they appear and disappear constitutes a remarkable peculiarity in this disease. Yery frequently, they are attended with a burning heat and pungent itching, and when scratched, they bleed and form black crusts upon their summits. It is peculiarly obstinate, being maintained indefinitely by succeeding crops of the papules — thus desquamation and reproduction may, pari passu, progress for months. 
Causes. — Children of sanguine and sanguine-lymphatic constitutions are the most liable to these eruptions, and they are more liable to occur in spring and summer than in winter, but the latter season is by no means exempt from them. 
We have no doubt but that they are produced by too much feeding, or food of improper qualities, and deficient exercise. The last variety has been excited into development in children by mental emotion—as a little ill-humor. When that consti- 


IN THE DERMA. 
511 
tutional condition exists, which seeks relief by these eruptions, they are easily produced, as slight friction, rough clothing, stimulating drinks or food, etc. 
Diagnosis.—Lichen is distinguishable from scabies by the dryness and hardness of its eruption, and by a difference of locality—being found generally upon the thick skin, and not upon the thin, as in scabies. 
It is distinguishable from herpes, by the dryness of the former and the moist and vesicular character of the latter; furthermore, the skin, in the former, is thicker and more harsh. 
From prurigo, it is not so easy to distinguish it; both are sometimes found upon the same individual, and that too, at the same time; and further, they are species of the same genus, and it is even thought by some that prurigo sometimes degenerates into lichen. 
In general, however, the larger and flatter papules of the former, especially as they are of the common color of the skin, will distinguish it from the smaller and more acuminated papules of lichen, especially as they have more color, and are more grouped into clusters. 
From urticaria, or nettle-rash, lichen is distinguishable by its more permanent or chronic character; —but in confounding them no mischief can result. 
Prognosis.—Lichen cannot be charged with being dangerous, but it is obstinate and tormenting, and the longer it exists the more these traits of its character increase. It has sometimes proved entirely intractable. 
Indications. —Regulate the secretions and restore the digestive functions. 
Treatment. — When the habit of body is full, the diet should be simple and unstimulating. The large intestines should be maintained in a normal condition by the use of enemas —simply cold water will be best, if sufficient. 
The skin should be maintained, as far as practicable, in a depurating condition by the frequent use of alkaline washings. These washings, furthermore, may be sufficient to allay the pruritus, which is peculiarly tormenting in this malady ; but in the event they fail or are insufficient, Acetic Acid and water 


512 
DRY FORMS OF DISEASE 
may be tried. This eruption is one in which a proper diuresis should not be neglected. 
When the disease has become chronic, although the skin may be inflamed, Dr. Wilson recommends an ointment to be rubbed upon the skin, containing half a drachm of Croton Oil to two ounces of Ceratum Cetacei, and then, after three, four, or five days, to relieve the irritation occasioned by the Croton Oil, he prescribes an oleaginous cerate containing Liquor Plumbi, and then, at the termination of another similar period, he prescribes a lotion of Tannin of the strength of two drachms to a pint. The constitutional treatment, at the same time, consisted in taking four pills daily, containing twelve grains of Tannin, with Extractum Rhei and Extractum Hyoscyami. 
Under circumstances of anemia, he relies much, in the treatment of this affection, upon the mineral acids and the bitter infusions. 
Species III.— Prurigo — Pruritus — Old Man's Itch. 
This species is made, by dermatologists, to embrace some half a dozen varieties, but that which is known as prurigo infantilis, is the only one that interests us. All the varieties so closely resemble lichen, that it is generally difficult to make out a satisfactory diagnosis. 
The seats of the disease are generally the neck, shoulders, back, and extensor surfaces of the extremities. It is more confined to one spot, and more disposed to attack several spots simultaneously than lichen. It may be local or general, simple or complicated with affections of the skin, but more particularly with lichen and psora. Its complication with psora is rather an unexplainable circumstance. 
The papulae are so generally colorless, or so nearly so, as not to be generally observed, the only external appearance that exists to call attention to them are the black scabs or concretions of blood which were drawn by scratching, to which the sufferer is impelled by the sensation of extreme itching; to which, in severe cases, is added a feeling of formication and painful pricking. 
These sensations are almost constant and always increased 


IN THE DERMA. 
513 
by heat or exposures to cold. Like lichen, it is not contagious. 
For its causes, diagnosis, prognosis, and treatment, we may refer to the preceding species, as we can add nothing of moment here. We may add, however, a few remarks from Billard. 
In the treatment of one case, which was cured, he says, the u child was immersed in a decoction of Marsh Mallows, and the limbs and body anointed with Oil of Sweet Almonds, carefully covering up the hands and arms. Rice-water, sweetened with the Syrup of Marsh Mallows, was administered internally, and milk-and-water was given for nourishment." 
In the way of general instruction, he further remarks: "In general prurigo, emollient, saponaceous, or sulphurous baths, demulcent or slightly-acidulated drinks, constitute the treatment. In local prurigo, it will be necessary to apply emollient, sulphurous, or alkaline lotions alternately to the diseased parts. Gelatino-sulphurous douches have been employed with success. The greatest care should be used to accomplish the early removal of the prurigo that is developed around the vulva or anus in children advanced in age, because the excessive itching of these parts, compelling the child to scratch them constantly, they may thereby continue in a state of erythism, and of irritation, extremely prejudicial to their health." 
Dr. Wilson says that the Milk of Sulphur in moderate doses, night and morning, for two or three weeks, is sometimes useful with children. He has also presented us with a number of formulae, from the French dermatologists, for ointments. 
For local prurigo: 
Muriate of Ammonia, 3i, Powder of White Hellebore, 3ss, 
Lard, giij. Mix. 
Vc. Hydrate of Lime, 3ji, 
Subcarbonate of Soda, 
Laudanum, aa 3ss. s Lard, 3j. 
33 


514 
DRY FORMS OF DISEASE 
B\ Laudanum, 
Sublimed Sulphur, aa 3ss, 
Oxide of Zinc, 3j, Oil of Almonds, 3j, 
Lard, 3iij. M. 
Genus III. — Squamae. 
The eruptions included in this genus are characterized by the formation of scabs, without having been preceded by other elementary forms, common to cutaneous eruptions, such as vesicle and pustule. An abnormal and highly-increased production of the epidermis produces the scabs which distinguish this genus. 
There may or may not be an elevation of the cutis in their formation. "When elevations occur and the scabs are removed, the skin is discovered to be red and inflamed. 
Some authors include in this genus four species, Pityriasis, Psoriasis, Ichthyosis, and Lepra. As the last is a stranger in this country, we shall pass it by. 
Species I. — Pityriasis. 
Dermatologists have divided this species into some dozen varieties, but as the differences between them are but slight, there is nothing to be gained, therapeutically, by a separate consideration of them. 
This affection is sometimes quite generally distributed over the surface, and the patches are frequently successive in their appearance; at other times, it is confined to some particular spot, as the head, where it may remain without any disposition to spread. Neither sex nor age is exempt from it. The squamae appear in patches of very irregular shape and size, slightly inflamed, and attended with a constant exfoliation of the epidermis in the form of semi-transparent scales or whitish scurf. 
When this affection is located upon the head, it is called pityriasis capitis, and occasions a copious production of dandruff. It is attended with frequent and troublesome itching, and when the scabs are removed, the skin is seen to be of a slight redness. On the scalp the scales are large, thick, 


IN THE DERMA. 
515 
and flat, but they are quite light on the temples, chin, and forehead. 
When it occurs at the junction of the skin and mucous membranes, it is always more troublesome than when otherwise located. In most instances, as it usually occurs, the skin is slightly elevated, and of a light rose-red color. When it attacks the palms of the hands and the feet, between the toes, it is peculiarly troublesome. 
Causes. —These are regarded as being peculiarly obscure. We are disposed to believe that it is frequently caused, remotely, by an imperfect or feeble pulmonary function. We have, in another place, shown that obesity depends upon this cause; and having seen this disease confined to those who were organically disposed to be obese, and to those who were phthisically liable, and from the great amount of carbon contained in epidermoid matter, we have been induced to make the above suggestion. 
Strong mental emotions are said to have produced it in adults. This fact, if such it be, is favorable to our suggestion, because the full chested are those who suffer, most generally, from strong mental emotions. The liability of old people to this disease, is another strong circumstance favorable to our opinion. 
Diagnosis.—The vesicular and pustular diseases are all moist, this is dry; its fine scales and slightly-elevated surface distinguish it from psoriasis, with its large, shining scales, inflamed and elevated base. 
Prognosis.—As regards life, it is never dangerous, but with the aged it can never be cured —with the young it may be, by a proper attention to food and exercise. 
Treatment. —In pityriasis, we would recommend the bathing of the surface of the body with fresh Olive Oil, two or three times a day, for several days in succession, to be followed by a spirit vapor-bath, in adults, or a warm alkaline bath, in children—and this treatment should be persevered in for several weeks after an apparent cure has been effected. 
Internally, the use of the Compound Syrup of Yellow Dock, with Iodide of Potassium, four drachms to a pint of the syrup, must be prescribed, together with an attention to diet, avoiding all vegetable acids, fats, liquors, stimulants, and indigestible 


516 
DRY FORMS OF DISEASE 
substances. The bowels must be held in a regular condition, and exercise be taken daily, adapted to the ability of the patient 
Species II.— Psoriasis. 
This affection is marked by scaly patches, which are irregularly circular, of a red color, and at first small and projecting. The papulous elevations are frequently not larger than a pin's head, and have their summits speedily covered with a slight scab. They enlarge and rise, but their borders are never prominent, nor their centers depressed. They multiply promptly, many of them breaking out at the same time, and often become confounded with one another. They appear on different parts of the body, but more particularly on the face, trunk, and head. 
When they are divested of their scales, either spontaneously or mechanically, as by scratching, they present a red and slightly-elevated surface. In this condition, they are quite painful, but this does not continue long, for they are speedily re-covered with scales. The spaces which separate the patches are of various extent and surrounded by an inflamed border. 
When the patches are considerably elongated and have a spiral direction, they are called psoriasis gyrata; when the patches spread and coalesce, they are called psoriasis diffusa; and when the disease has continued for many months or for years, it is then denominated psoriasis inveterata. 
In this form of the disease, the skin is said to resemble the bark of trees covered with lichens. When it occurs in infants, it is called psoriasis infantilis, which does not differ from psoriasis diffusa, except that it is more acute and rapid in its course, with a liability, it is said, of causing deep fissures in the diseased skin, which occasion much suffering. 
Beside the preceding, many other varieties are enumerated, which have not sufficient importance to claim our attention. 
Causes.—That condition of the system, of which pityriasis is symptomatic, we suppose to be, also, the cause of psoriasis, under modifying influences. It is said to be more common to females, than males, and it is often " evidently hereditary." 
Diagnosis.—It is distinguishable from all other cutaneous affections, by the dryness of its eruptions, its salient patches, 


IN THE DERMA. 
517 
thickened and inflamed skin, the elevated centers of the patches, their inflamed shape and size, and their covering of scales. 
Treatment.—In this affection, the warm bath must be used daily, and the following ointment applied locally: 
Benzoic Acid, 3ij, Spirits of Turpentine, gtts. xx, 
Camphor, grs. x, Lard, gj. Mix; 
or, if symptoms of irritation or inflammation are present, the Compound Ointment oi»Zinc will be found highly serviceable. 
The internal treatment should consist of alteratives and diuretics, as the Compound Syrup of Yellow Dock and Iodide of Potassium, as heretofore named—the bowels kept regular, with a strict attention to diet and regimen — the same as referred to in the treatment of pityriasis. 
Species III.— Ichthyosis. 
The supposed incurability of this disease gives it a greater physiological than pathological importance, but darkness still envelops it in both respects, and should it ever be found, we predict that it will be to serve a vicarious purpose — the elimination of carbon from the system. 
Its appearance in infancy, and that of adult age, presents a great difference, and yet it is one of degree, rather than one of kind. In infancy, it is liable to be mistaken for that epidermic exfoliation which is natural to infancy, a few days after birth. It is considered to be, most generally, a congenital and hereditary disease, which may, and usually does, continue for life. 
It is essentially a disease of the epidermis, and appears in patches of a dirty-gray color, and separated from each other by lines which are superficial and irregular. When detached, the epidermis beneath is discovered to be thickened, and to impart to the touch a harsh feeling. The health does not appear to be affected by it, and the skin does not appear to be inflamed when the scales are removed. 
The thickened condition of the epidermis, its continual reproduction, the form and appearance of the patches, and the obstinacy of the malady, will distinguish it from that epidermic 


518 
DRY FORMS OF DISEASE IN" THE DERMA. 
exfoliation which is common to infancy, and also from all other cutaneous affections, which American physicians will probably see. 
No particular or specific remedy has yet been discovered for this malady — so far as is now known, its treatment must consist in observing a proper course of diet, exercise, and tepid baths. Willan recommended the use of tar and pitch water, and as no better remedy has been discovered, this still continues to be in use. Alkaline baths soften the scales so that they can be readily removed, and then stimulant applications are said to have cured recent cases. 


CLASS VI. 
MANIFESTATIONS OP DISEASE IN THE CELLULAR TISSUE. 
INTRODUCTION, 
A mere perception of the non-inflammatory affections of the cellular tissue appears to be attended by a momentary impression of incomprehensibility, which results from the fact, that we do not witness an obvious and —a visible cause. When we see destruction succeeding, in point of time, inflammatory action, the momentary impression is that the latter is the cause. But further examination and reflection find in the pre-existing state of the system, in the first instance, ample cause for the phenomena, without a visibly-active agent; and in the second, we discover that what appeared to be the cause, is only a manifestation of a restorative effort of the system. 
Prof. Caldwell used to contend, and with much ingenuity, that Prussic Acid destroyed life by over excitement; but, where is the proof of it ? where is the time for such an action ? All that we can know in the premises is, the existence and the order of two events: the administration of the drug, and the instantaneous death. In the investigation of oedema and gangrene of infants, we shall find it as difficult to show that they are results of inflammation, as that Prussic Acid causes over-excitement. We think that it will be discovered that the inflammation appears, in these forms of disease, as a secondary event, and for the purpose of separating the dead from the living parts. 
519 


520 
NON-INFLAMMATORY FORMS OF DISEASE 
ORDER I. 
NON-INFLAMMATORY FORMS OF DISEASE IN THE CELLULAR TISSUE. 
Genus I. — (Edema— 
Induration of the Cellular Tissue. 
The above caption is well calculated to produce a confused idea in the mind of the student; from the first word, he would not infer a serous repletion of the cellular tissue, but he would conclude that the tissue, in the abstract, was indurated, hardened, compacted, or consolidated. 
Now, the fact in the premises is, the cellular tissue is not in the least at fault—it retains its entire integrity, but, in consideration of its extraordinary serous repletion, it offers to the sense of touch such a resistance as to produce the idea of hardness or induration. 
The serous and adipose tissues present two varieties of hardness or induration — the former is attended with an increase of the size of the limbs or parts affected, and also with a violet color of the integuments, and the other, indications of a sanguineous congestion — such as difficult respiration and irregular pulse —unequivocal signs of enlargement of the heart and lungs. Adipose induration may, or may not, exist with the serous—it shows itself usually in the calves of the legs, nates, and cheeks. "When merely adipose, it will not be attended by the difficulties in the respiratory and circulatory functions, above-named. 
This variety is most generally exhibited in the moment of dissolution, but may be developed after death. To the touch, it produces such a sensation as would be experienced by touching the fat of dead animals. By an inordinate reduction of the animal heat, this hardness may take place before as well as after death, and it is not difficult to conceive of such a possibility, in parts so remotely connected with the centers of circulation, more especially in such patients Ss are usually the subjects of this form of disease, for they are so feeble as to be barely able to manifest the presence of life. 
The light which has been shed upon this subject, goes to show that the so-called induration of the cellular tissue is 


IN THE CELLULAR TISSUE. 
521 
nothing more than such an oedema as may and does occur with adults. This we conclude to be the fact, however differently produced. 
When we contemplate the exceeding debility with which such patients are born—the great amount of venous blood in the tissues, particularly in the cellular —and the dry state of the skin, it does not, to us, appear difficult to arrive at a probable conclusion. 
The facts above-stated show that no process was in action for the production of animal heat—that the cellular repletion was very probably produced passively or mechanically, and that the condition which might thus result, must continue because of the non-cutaneous transpiration. 
(Edema is very frequently complicated with other forms of disease, but, of itself, it should not be regarded as necessarily fatal. In so tender an age, we can do but little except through the skin, and, fortunately, through it alone we can frequently effect a cure. 
The practice must consist of irritating frictions, woolen garments, and warm covering. In this wise, cutaneous transpiration is easily excited. Tepid baths have been tried, and have, pretty uniformly, been found mischievous ; and for the obvious reason that the vital force is incapable of contending against the external pressure; and the vapor-bath has not been more favorably received, but why, we cannot tell. 
Genus II.—Gangkene of Infants. 
We have always observed that it is exceedingly difficult for men to adopt a false position and maintain consistency in its discussion. We shall find this fact to be strikingly illustrated by Wood and Billard, in the investigation of this subject. 
The latter informs us, that he understands this disease to be a "variety of gangrenous inflammation,"* and that it occurs " in those infante in whom the respiratory and circulatory functions are imperfectly executed, producing a very evident sanguineous congestion of the extremities, which become purple and cold, and soon shrink, dry, decompose, and sphacelate, until an inflammatory circle forming, bounds the 
* A singular inflammation ! a composition of vitality and death I 


522 
NON-INFLAMMATORY FORMS OF DISEASE 
ravages of the gangrene, analogous to the gangrene of old people—or until death terminates this disorganization of the integuments." 
We do not remember ever to have seen, in one paragraph, more inconsistency than the preceding contains. What is inflammation ? Is it not an accumulation of vitality to remove disease or overcome obstruction, and is it not characterized by redness, heat, and tumefaction ? Are these phenomena witnessed in the gangrenous part in any stage of the process? 
In this form of disease, the extremities become cold and purple, and soon' shrink and dry, and what stops this process ? Simply the absence of death —the gangrene progresses until it reaches a part which has sufficient vitality to make an effort to cast off the dead part —and this effort is evinced by the inflammation—by an inflammatory circle which divides the living from the dead parts. The inflammation then, was a sequent and not an antecedent—death takes possession of the part before there appears a single inflammatory indication. 
Prof. Wood thinks it very probable, that many cases of spontaneous gangrene may have their origin in an inflammation of the arteries. Although we would not dispute this position with him, yet we have a right to infer from it, that the disease under consideration may also be sometimes occasioned in this way, more especially as he has not treated of gangrene as independent of inflammation. To such an inference, we object, because the circumstances under which infantile gangrene takes place, preclude all idea of inflammation as a cause. 
It occurs in those whose circulatory and respiratory functions are imperfectly executed. They stand closely allied to the cedematous. They have inherently in them, an absolute inability to discharge the essential functions of life. The same condition becomes true in extreme old age. 
We can perceive no difference between an extremity frozen to death, and one that dies for want of nourishment, especially when it is denied through a positive inability of the constitution to provide it. If the gangrene of an extremity frozen to death, is one of gangrenous inflammation, then the terms defy definition, and can serve no other purpose than that of a 


IN THE CELLULAR TISSUE. 
523 
cloak to conceal ignorance, and we feel better under an open confession of ours, than in maintaining a false position. 
This form of disease, ordinarily shows itself upon the toes and fingers, but sometimes upon the arms and legs, and, instead of the skin shrinking and wrinkling, as before remarked, it may become covered with small blisters, which contain a sanguineous fluid. The integuments become emphysematous and yield the well-known gangrenous odor. The blisters break and are replaced by a livid excoriation. The abdomen becomes distended with flatus and the body cedematou —the senses become dead, the respiration is barely perceptible, and thus the patient gradually sinks. 
The only treatment that can be adopted with any probability of success, is to promote capillary circulation, by bathing and frictions applied to the whole surface of the body, together with tonics and diuretics internally, as Quinia, Hydrastin, Xanthoxylin, etc., for tonics, and the roots of Eupatorium Purpureum and Daucus Carota, or Epigea Repens and Pyrola Maculata, as diuretics. When the gangrene is formed, a solution of Sulphate of Zinc should be applied to the ulcers, over which an Elm poultice, must be placed, both for the purpose of allaying undue action from the zinc solution, and to facilitate the removal of the slough. However, but little can be expected from any treatment. 


CLASS VII. 
MANIFESTATIONS OF DISEASE IN THE ORGANS OF THE EXTERNAL SENSES. 
ORDER I. 
INFLAMMATORY FORMS OF DISEASE IN THE ORGANS OF THE EXTERNAL SENSES. 
Genus I. — Ophthalmia Purulenta — 
Inflammation of the Eyes. 
Of all the sources of human blindness, this is perhaps the most fruitful, sometimes through neglect, at other times through mal-practice, and sometimes, probably, through its own inherent violence. It sometimes happens that mothers and nurses neglect it frequently in the beginning, under the impression that the infant has taken a little cold in the eyes, and that probably it will subside or leave the child in a few days. In the meantime, the only remedy that has been used was the washing of the eyes with breast-milk—not so "insignificant" a remedy as some have thought it to be—far better than the profession has sometimes prescribed; but, nevertheless, inadequate to the demands of the case, as many physicians can testify, who upon being called, have found the eyelids swollen and glued together, and upon obtaining a view of what is going on beneath them, finds sometimes only inflammation and suppuration, but at other times he finds one or both eyes destroyed—irreparably ruined—the cornea is opake or it has sloughed, or possibly some variety of staphyloma has been produced. 
It usually attacks the infant between the third and eighth day, but sometimes at a later day, though probably never after the second week from birth. The first manifested sign of its approach, is the gluing together of the eyelids during 
524 


DISEASE IN THE EXTERNAL SENSES. 
525 
the night, but shortly after, they become swollen, which is most apparent in the early part of the day, and quickly following, the globes of the eyes are found participating in the inflammation, and the infant keeping its eyelids closed —shun- the smallest and most diffused ray of light. 
After the third or fourth day of the attack, there is usually a copious secretion of pus, the inspissation of which between the eyelids, pretty firmly glues them together during the night, and the balance being retained between the lids and globes, gives the appearance of much swelling of the eyes, in the morning. 
When the lids are separated, which is readily done by the use of warm water, considerable pus escapes, and upon separating the lids, the balls seem to be floating in pus; no part of the iris can be seen, and when the pus is removed the lining membrane of the lids is found to be of a bright red or scarlet color, indicating a severe inflammation. 
Causes.— Prof. Dewees is of opinion that this form of disease is occasioned by the presence, with the mother, of ieucorrhea or gonorrhea; and that it is acquired by the infant in transitu. The reason he Assigns for this opinion, which has the most influence upon us, is, that in many instances of this affection which came to his notice, he learned, upon inquiry, that the mother was the subject of one or the other of the above forms of disease. In confirmation of this conclusion, or rather one of the facts that induced it, is its appearance in about the proper time for such a cause to have produced it. 
There is another circumstance which he names, in this connection, that is entitled to some weight, and that is, the severity of the inflammation ; but Dr. Watson states that it sometimes occurs "in infants of mothers who seem to be healthy, and who deny that they have any unnatural discharge." 
Dr. Watson thinks it probable that it may be induced by other causes, as bad management of the nurse, cold air, a hot and bright fire, soap, ardent spirits, etc. Without any intention of denying the existence of such probability, we would remark, that it seems to us quite reasonable to suppose, that if other than the causes assigned by Prof. Dewees, can produce the disease, that it would not be confined to so early a period of life. 


526 
INFLAMMATORY FORMS OF DISEASE 
Prognosis. — This form of disease, in adults, says Dr. Wat son, is much more controllable than it is in infants, so much so, that when the physician finds the cornea, in the case of the latter, to be sound, he may confidently assure the parents that the eyes of the infant are safe; if opacity has seized upon the cornea, the chance of saving the eyes is doubtful, but not hopeless; and if the cornea cannot be seen, the prognosis is unfavorable, and this should be the statement to the parents, " for such is the ignorance of the vulgar, (and I include both rich and poor under this phrase), that if they are not forewarned of the danger, they are very apt to attribute the blindness that ensues to your stuff, as they call it." 
Treatment.—The first indication is to relieve the inflammation, should it exist, and this may be accomplished by the application of cold water to the eyes, applied by means of a light compress, and the eyes should be frequently bathed with a decoction of Marsh Mallows or with Rosewater. 
As soon as the inflammation has been subdued, the eyes should be bathed several times a day with a decoction of Hydrastis Canadensis, and, in obstinate cases, the Compound Myrrh Collyriura, or the Compound Collyrium of Golden Seal. 
The bowels must be kept regular by enemas ; active cathartics by the mouth must be avoided, as well as the action of excessive light upon the eyes for several days, both during the treatment and after a cure has been effected. 
Genus II.—Scrofulous Ophthalmia. 
We are not prepared to believe that there is such a specific form of disease, but we admit that common ophthalmia, induced in a scrofulous constitution, may be so modified as to deserve a special consideration, more especially as it has this specific feature, namely: infants are the most general subjects of it—in them, it appears, apparently, as the first indication of the existence of a scrofulous constitution. 
When it first invades the conjunctiva, its character is that of simple ophthalmia, and so it continues through the truly inflammatory stage, and therefore, it is not until a somewhat chronic character has been assumed that the scrofulous symptoms appear, to impede recovery. It is seen that the conjunctiva 


IN THE EXTERNAL SENSES. 
527 
does not return to its normal color and condition ; that the light ha3 become painful; that the tears flow copiously ; that the purulent discharge has become reduced; that the glands of the tarsi produce a muco-purulent secretion that agglutinates the eyelids during sleep; and in many instances, we find delicately-small vesicles scattered over the cornea and conjunctiva of the sclerotic coat. These vesicles may run on to the formation of ulcers, and they progress and so penetrate the cornea as to communicate with the anterior chamber of the eye, and thus give egress to the aqueous humor. A considerable remission of the symptoms frequently, if not generally, takes place in the evening or after sunset, 
Treatment. —In the treatment of this affection, the first indication is to correct the depraved condition of the constitution, and this can be best effected by placing the patient in a pure and healthy atmosphere; to apply warm and comfortable clothing; to supply a nutritious diet: beyond these, to effect a general purpose, we must rely upon tonics, salt-water, and alkaline baths; very little local treatment is required. 
In the early stages, except in cases where the constitutional treatment has been neglected, cold water and Slippery-elm poultices and confinement to a dark room, will, in most cases, prevent any further development of the disease; but, in cases where this is not sufficiently active to arrest the inflammation, the leaves of the Scrofula Marylandica may be powdered and mixed with Slippery-elm. This, in many cases, will remove the inflammation in a very short time, but, in more obstinate cases, a strong decoction of Hydrastis Canadensis should be applied to the eyes constantly during the day. 
The Alcoholic vapor-bath, with the Sudorific Tincture, should, in all cases, be used when the skin is dry. 
As soon as free perspiration has commenced, it should be kept up by the aid of diaphoretic teas or by the internal use of cold water, after which cold water may be frequently applied to the eyes. 
If constipation of the bowels be present, the Compound Powder of Jalap and Cream of Tartar should be used until free catharsis is produced. 
If ulceration of the cornea should occur after the active 


528 
INFLAMMATORY FORMS OF DISEASE 
stages have subsided, the following prescription may be used: 
Tinct. Hydrastis, % 
Tinct. Capsicum, Olive Oil, aa 3i. Mix 
From two to five drops should be applied to the eye twice a day. This will produce pain when first applied, but it will continue only a few minutes. After having used this for several days, as above described, and no improvement of the ulcer or opacity takes place, a mild solution of the Sesquicarbonate of Potassa may be applied. 
In all cases, the free use of the Alterative Syrup, or the Compound Syrup of Stillingia should be made, given in as large doses as the patient will bear, without being attended with nausea. 
When the disease resists all of the above treatment, as it may in some cases, the Irritating Plaster may be applied and kept upon the back of the neck, until suppuration is induced, and this, as a general thing, should be kept up by the reapplication of the plaster until the disease has disappeared, which may require from three to five months. 
Genus III. — Otitis— 
Inflammation of the Mucous Membrane of the Ear. 
This form of disease, with those who are old enough to make known their condition, produces excruciating pain and intolerable humming in the ear, and therefore, we cannot doubt that the same is true of its existence in the infant. 
Otitis is divided into external and internal, according as it affects the meatus auditorius, or the cavity of the tympanum or internal ear. 
Its occurrence in the internal ear, not unfrequently appears before the completion of the first dentition, producing great suffering, of which the patient is unable to give any particular information: we must be guided to the seat of the disease by its instinctive manifestations. Before the violent stage of the attack, the child is peevish and fretful, from a few hours to a day or so. During this time, it manifests no disposition to play, all sounds are unpleasant to it, and if tossed about, it 


IN THE EXTERNAL SENSES. 
529 
will cry ; it seems but little disposed to take the breast, but will take food from a spoon. It desires to rest the affected side of its head upon its mother's bosom, and if on the bed, it turns its head from side to side on the pillow, and finally comes to repose upon its face. After crying, it sleeps, but the repose is short, because of some sudden infliction of pain. It may sometimes cry for hours in defiance of all means to quiet it. If old enough, it will frequently apply its hand to the affected ear. 
The greatest intensity of the pain does not continue long, before it is relieved by a discharge of pus, which may prove a final terminus of the disease, or merely an abatement of it, but in young infants it very rarely puts on the chronic form. 
When the disease becomes chronic, it is accompanied by a purulent discharge from the meattis auditorius, and usually proves so incurable that it progresses to an invasion of the internal ear, and after a complete destruction of the organ, it becomes well, in most cases, but, occasionally, it invades the brain and terminates fatally. 
Diagnosis.—There is some little danger of mistaking the acute form of this disease for hydrocephalus; but if proper attention be given to a few circumstances such a blunder may be avoided. In hydrocephalus, there is costiveness, vomiting, and febrile indications, which are absent in otitis — pressure upon the cartilages of the affected ear will produce indications of suffering, which the well one will not, and the constant disposition of the patient to rest the head on the same side, and the placing the hand to the same side, furnish an ample diagnosis. 
Treatment.—In this affection, we have found the greatest use by applying sinapisms of Garlics, bruised, to the feet, and behind the ears, with the use of Saffron infusion, or other agents which will equalize the circulation by a cutaneous determination, together with the application of a mixture composed of two to four drops of Oil of Sweet Almonds and one of Laudanum, a drop of which, warmed, may be allowed to fall into the affected ear, or may be pressed gently into the ear on some lint, and repeated as often as required. 
The bowels should likewise be kept free by mild laxatives, brisk purgation being unnecessary. 
34 


530 
DISEASE IN THE EXTERNAL SENSES. 
When a discharge takes place from the ear, and manifests 
a disposition to become chronic, the abscesses not healing readily, the parts should be kept clean, by frequently syringing out the canal of the ear with Castile Soap and water, or a solution of Chloride of Sodium; after which, to prevent, if possible, any mischief from an extension of the disease, the ear should be syringed with a weak solution of Sulphate of Zinc, or Sesquicarbonate of Potash. 


CLASS VIII. 
MANIFESTATIONS OF DISEASE IN THE GENITAL APPARATUS. 
ORDER I. 
DISEASE OF THE GENITAL APPARATUS. Genus I. — Adhesion of the Labia Pcdendi. 
This event may sometimes be congenite, but it does not generally occur before the child is six or seven months old, and perhaps it as rarely occurs after the age of twelve months. There is too much solicitude felt about the normal condition of the genital parts to admit of a supposition that it should escape an examination within the first day or two of independent existence; we must, therefore, conclude, that when the discovery is made between the sixth and twelfth month, that it resulted from neglect. 
The genital parts of infants should be as regularly cleansed as the child is washed, and this duty should be positively enforced upon nurses. When we consider the extreme delicacy and vascularity of the lining membrane of the labia, we should not be surprised that such a result should follow neglect. The uterine and vaginal secretions may, by continuing too long upon a surface unadapted to them, produce irritation, and when aided by the salts of the urine, may produce inflammation and consequent adhesion. 
Billard says, that in infants, the labia are veiy prominent, and become infiltrated, tumefied, and inflamed with the greatest facility, when constantly covered with the excretions. 
An event of this kind has, very unfortunately, sometimes escaped detection during infancy, and if detected in after years by the female herself, it has been neglected to a moment the most embarrassing in her history—and then a ,surgeon is sent for to effect their separation. 
531 


532 
MANIFESTATIONS OF DISEASE 
The labia readily separate when in their normal condition, and therefore, when they refuse to separate by a very slight effort, we may suspect that adhesion has taken place, and when it has, it is found to exist through their whole length, as far as the meatus urinarius. Through this opening, the urine is discharged, and so is the menstrual secretion in after years, should the adhesion continue. 
The profession has but one remedy for this accident, which is the knife. The division or separation may be easily performed by passing a probe-pointed bistoury into the unclosed part and cutting down to the junction of the labia. They may be then kept separate by the introduction between them of a little oiled lint. 
This separation is, however, sometimes spontaneously effected ; the adhesive inflammation that closed them may pass into suppuration and separate them. Medical history records several instances of this kind, but such an event is never to be hoped for, because it is never so well done as with the bistoury. In two or three days after the operation, the parts are well. 
Genus II. —Discharges from the Infantile Yagina. 
In infant females, the vagina is very much developed, and its mucous lining secretes a large quantity of white, adherent mucosity. It is, furthermore, not uncommon to observe a red, blood-like fluid to flow continually from the vulva for some days or weeks after birth—it has much resemblance to the catamenia in adult females. It is not known to produce any inconvenience, and after a time ceases of itself. These physiological facts indicate a necessity for great cleanliness during the first weeks of female infancy, a neglect of which occasions, no doubt, those unhealthy discharges of which we are about to treat. 
Discharges of a purulent character, from the vagina, show themselves, sometimes, in females of about the age of five years, which may continue indefinitely. In reference to such a condition, mothers should keep over their daughters a vigilant care. Upon the indulgence of such conditions, is founded those troublesome cases of fluor albns, which do so much to impair and enfeeble the general health in future life. 


IN THE GENITAL APPARATUS. * 
533 
This form of disease cannot be cured without the most strict regard to cleanliness, and hence the treatment should commence with it. Let the vagina and the interior surfaces of the labia be washed with warm water four or five times' a day, and after each washing, apply the warm Borax Lotion with Morphia. If excoriation of any part exists, let it be coated with fresh Lard, or covered with flour of Slippery-elm bark. The bowels should be maintained in a normal condition, and the diet should be nourishing — fats, sugars, butter, and old or rancid meats should be avoided. If such a course of medication does not remove the discharge, then alteratives must be conjoined with the treatment, as the Compound Syrup of Yellow Dock, or the Compound Syrup of Stillingia, with or without the addition of the Iodide of Potassium, as the case may require. 
Genus III. — Hydrocele, or Dropsy of the Scrotum. 
We understand, generally, by this term, a collection of serous fluid in the areolar texture or in some of the coatings, either of the testicle or spermatic cord. When the fluid is in the spermatic cord, it is known as encysted or diffused hydrocele of the spermatic cord, as the case may happen to be. Hydrocele of the tunica vaginalis occurs when the collection of fluid is confined to the envelope; and it is regarded as congenital when the interior of the membrane possesses a free communication with the cavity of the abdomen. 
Although the affection may be congenital, it very rarely becomes noticed under several days. As all affections of the genital organs, in consequence of their great importance, excite alarm, it may be readily supposed that this forms no exception, and it is fortunate that such is the case, because a neglect of this might occasion an indifference to another affection, which it resembles, namely, a rupture, which is really of more importance, as it involves the life of the patient. 
The tumor is sometimes as large as an egg, and it is occasionally confined to one side of the scrotum; it gives the patient no inconvenience, and though it generally occurs in infancy, yet, in some instances, it is delayed several months. Diagnosis.—It is important that a clear diagnosis should be had between hydrocele and rupture. The former presents a 


534 
DISEASE IN THE GENITAL APPARATUS. 
considerable transparency; the scrotum is more equably distended ; the tumor is not increased by crying; the handling of it gives no pain, and pressure does not remove it. 
Treatment. — Cold water poured upon the parts twice a day, from a height of some two or three feet, will usually overcome the difficulty; about half a gallon may be used at a time, allowing it to run through the spout of a tea-kettle. 
Should the case not readily yield to this, the parts may be kept constantly moistened, in the interim, with a solution of Muriate of Ammonia in vinegar, which may be applied on cotton or lint, and gentle pressure made upon the scrotum by means of a bandage, for the purpose of aiding absorption. In connection with this, an infusion of some diuretic agent may be used, such as, Pyrola Maculata, Aralia Hispida, etc. 
Occasionally, in long-standing cases, where a large amount of fluid is present, and the tunica vaginalis becomes thickened and insensible, which is seldom the case with children, being more common to persons somewhat advanced, the fluid will have to be discharged by means of a trocar, after which stimulants are to be injected, such as brandy-and-water, Tincture of Sanguinaria and Capsicum, and even a solution of Sesquicarbonate of Potash, which are to be continued until the cure is effected. 


P AET II. 
MANIFESTATIONS OF DISEASE IN THE VEGETATIVE OR DIGESTIVE SYSTEM. 
INTRODUCTION. 
If every part and parcel of this system should be suddenly destroyed, it would not be followed by a corresponding suspension or destruction of life; consequently, in point of importance, it is only secondary to that, the consideration of which we have just concluded. 
In the digestive process, life can be continued for a considerable time, with a very feeble exercise of the nutritive process, but in the respiratory, there must be precisely function enough—the blood must be oxygenized—and the suspension of a few respirations never fails to extinguish the candle of life. 
Life may be continued, until destroyed by waste, so long as the nervous system shall maintain its integrity, but this it cannot do without the co-operation of the respiratory and circulatory functions. To explain — the lungs must discharge their function upon the blood, and the blood must be conveyed to the nervous apparatus, or life is at once extinct. It does not appear, then, according to Prof. Meigs, that "the source of all vital power is in the nervous mass," for, no matter how perfectly this mass preserves its integrity, its power will depend upon the thoroughness of its oxygenation; yet it is true, that unless the skin and the digestive apparatus discharge properly their functions, the blood cannot be of a good quality; but this imperfection affects nutrition much more than nervous innervation—this last process depending more especially upon the presence of oxygen. 
535 


536 
MANIFESTATIONS OF DISEASE 
Without regarding the pulmonary function as the only direct source of innervation to the nervous system, we cannot appreciate its great importance. The nervous and circulatory systems hold to the lungs the relation of servants—while the lungs exist, in relation to life and the power of life, as a sine qua non. 
But, however important the cerebro-spinal system may be to our present existence and external relations, yet the vegetative is not less indispensable to the development of our bodies and their perpetuity to old age ; and as a large portion of our second Book was appropriated to the proper care and development of this system, the necessity of saying much about it, in this place, becomes unnecessary. 
In our investigation of the previous forms of disease, we found them associated with certain conditions of the base of the brain and the spinal column, which were so obvious as to give to our labors somewhat of a scientific accuracy; but as the various forms of disease, incidental to this system, depend mainly upon the ganglionic, yet, for our preservation, it is made to hold intimate relations with the cerebro-spinal system of nervous communication, as to envelop them in much obscurity—an obscurity that is well calculated to test the perceptive and discriminating capacities of the practical physician. 
We cannot say what may not be discovered in relation to this subject, but as yet we know very little more than that we are particularly ignorant of the modus operandi of that nervous influence to which they are subject. 
It should be remembered, that of the existence and functions of this system we have not, in a state of health, any consciousness, and that a connection between it and the cerebro-spinal only becomes known to us in a state of disease; it happens, therefore, that while the morbid action is going on, in one part, the manifestation of existing disease will be in a remote and a very different part—that, for illustration, the patient may suffer severely with a pain in the head or in a tooth, while the stomach is the true seat of the morbid action —that while some part of the ganglionic or splanchnic system is being undermined by serious disease, we have to search for the particular part through its innumerable sympathies in the cerebro-spinal. 


IN THE DIGESTIVE SYSTEM. 
537 
Thus it appears, that although we have divided the manifestations of disease into two great families, which, in reality, differ as widely from each other as any two great families in natural history, yet, so numerous are the points of connection between the two, that it would scarcely have appeared as a violation of order to have treated of both as one. 
In our division, we have included in the cerebro-spinal system, the respiratory apparatus, because we have, in part, a voluntary agency over it, and because its strength and development incidentally result from the exercise of our voluntary agency. We have also embraced in the same family the circulatory apparatus, although we have no voluntary agency over it, because of the second reason above assigned for the respiratory. 
In fact, we adopted the division we have made, because the functions embraced by the first part can be referred to the base of the brain, directly, for the efficiency they manifest. By this division, therefore, we have been enabled to treat of all that is embraced in the first part with more utility and lucidity than we could have done under any other. 
Every teacher adopts some plan by which he expects to facilitate the performance of his function—and in this consists the greatest importance of classification, for nature, in a great measure repudiates any classification that man can make. 


CLASS I. 
MANIFESTATIONS OF DISEASE IN PARTS LOCATED ABOVE THE DIAPHRAGM. 
ORDER I, 
INFLAMMATORY FORMS OF DISEASE IN PARTS LOCATED ABOVE THE DIAPHRAGM. 
Genus I.—Stomatitis— 
Inflammation of the Mouth. 
Remarks. — This affection appears under a considerable variety of forms, which result from differences of cause and of constitution. This form of disease appears with such marked differences, in different individuals, as to have caused pathologists to divide it into six or seven sub-forms, for its better elucidation and treatment. 
Species I. — Stomatitis Erythematic — Common Inflamma- 
tion of the Mouth. 
This inflammation may so spread itself as to occupy the whole of the lining membrane of the mouth, but, more generally, it appears in patches. It is sometimes very superficial or erythematic in its character, but at other times it involves the entire thickness of the membrane, and, in some instances, involves the sub-mucous tissue and the adjacent glands, and thereby produces considerable pain and swelling. 
The superficial or erythematic form is characterized by redness, heat, and sometimes with dryness of the mouth and tongue. It varies considerably in its duration and intensity; with regard to the first, it may be transitory, or it may continue for a long time. In young infants, it is but rarely attended by febrile symptoms or derangement; but in children of eight or nine months it is apt to be attended with much 
538 


DISEASE ABOVE THE DIAPHRAGM. 
539 
pain and febrile derangement. The epithelium sometimes becomes opake, and occasionally rises into blisters, and becomes detached. 
In such states of the system as indicate a more than ordinary depravity, superficial ulcers appear, which may spread or become deep, as well as extensive, and finally, if the constitution be too depraved and feeble to sustain such an inflammatory action as may be essential to the removal of the disease, gangrene may supervene. 
When this affection happens to involve the gums, after the teeth have appeared, they swell and rise between the teeth, and frequently ulcerate, and this destructive action may continue until the teeth are disengaged or removed; but such instances as this are very rare. 
There is a mild variety of this affection which has been denominated catarrhal—the secretions of the mouth are abundant—the tongue is furred, and the taste blunted. This has been, very carelessly, mistaken for disease of the stomach. Such a suspicion should not be found in the absence of all direct gastric symptoms. Stomatitis may accompany gastritis or enteritis, but, in such cases, the symptoms, if attended to, will permit of no mistake. 
Causes. — When it is idiopathic, it results generally from some chemical or mechanical cause—the latter can very seldom be a cause in infancy, but the former may, as by an accidental use of acid substances. At this ettrly age, it is most generally symptomatic of gastric irritation or disease. It may sometimes result from an extension of either variety of angina. 
Treatment.—If the disease have resulted from chemical or mechanical means, the occasional use of a little Sweet Oil, applied with a hair pencil or a feather may alone prove sufficient, but should it prove more obstinate, resort must be had to astringent washes, as infusions of Geranium, and in case of much inflammation, a solution of Borax should be freely used as a wash. 
If it shall be symptomatic, our first duty should be the removal or mitigation of the disease of which it is a consequent. 


540 
INFLAMMATORY FORMS OF DISEASE 
Species II.— Stomatitis with altered secretion — Infantile 
Sore-Mouth — Thrush. 
This form of disease commences with an erythematic inflammation of the epithelium of the mouth, or the surface of the tongue ; and after two or three days, small, white points are presented upon its extremity or sides, or upon the internal surface of the lip, particularly the inferior one, and they appear to crown the papillae of the surface to which they adhere. These increase in number and coalesce so as to form patches, which may finally cover the tongue, the roof of the mouth, the inside of the cheeks, and sometimes the fauces. 
The progress of this form, from its most simple to its more complicated character, presents, through its excretion or exudation, three distinct results or phenomena: the first we have named, consisting of white points ; the second, is that of variously-sized shreds ; and the third, is that of a pellicle or membrane covering all of the diseased parts. This membrane assumes, sometimes, a yellowish or a reddish color, but these are adventitious circumstances —having nothing to do with the disease—mere stains from the presence of bile, or sanguineous exhalation. 
The true seat of the disease appears to be the surface of the epithelium, and not the parts below it; and the state of it, which the white points represent, may be regarded as the first or mild stage, and if it progress no further—the white point3 disappearing—the attack may be considered as mild. 
When the points coalesce to the formation of patches, which thicken and exfoliate and leave the surfaces they occupied red and inflamed, to produce another crop to exfoliate in like manner, without further increase of the inflammation, then there is a termination of the disease in the second degree. 
When the inflammation so spreads as to render the patches confluent —forming follicles of greater thickness and extent, then it is regarded as malignant. Post mortem examinations have discovered patches of the exudation in the oesophagus, stomach, and small intestines. 
In the course of the disease, in either of its forms, the exu- ; dations may exfoliate and be replaced several times, and consequently, there is no definite period for its reign—it may vary 


ABOVE THE DIAPHRAGM. 
541 
from a few days to several weeks. Diarrhea, flatus, and colic pains are frequently attendant upon it. The breath of the child often has an acid odor — the contents of the stomach, when thrown up, are green, and smell like the breath, and this acidity may be the occasion of that redness which is sometimes seen about the anus in this complaint. 
The skin is usually hot and dry and the thirst insatiable, and yet fever is scarcely ever manifested, and the pulse is as rarely affected. 
No age can be regarded as entirely exempt from this disease, but infancy is peculiarly liable to it, and equally so, perhaps, in all seasons of the year. It is not now considered to be contagious. 
Causes. — Improper nutrition, foul air, and improper or deficient attention to the skin, may probably be regarded as the principal exciting causes in early infancy. The remote cause, it is said, may consist in that predisposition of the mucous membranes of infancy to inflammation—a consequence of their sanguineous repletion. We think it to be far more probable that it consists in some feebleness or depravity of the constitution—a want of vital force; and hence, instead of a predisposition to it, there was only an organic liability to it. And it should be remembered that neither fat nor lymph indicate an adequate vital force. In the first part of this Book, we had several illustrations of this truth. 
Considerable difference of opinion prevails in the profession as regards the true source of thrush; some have maintained that it is always sympathetic, while others are very positive that it is sometimes idiopathic. We are willing to admit the latter conclusion, in a very large proportion of instances. We view it as a disease, when idiopathic, as having its origin in a feeble vital force, and this explains why it is so much more frequently met with in hospitals than in private practice. 
Dr. Eberle says, that " feeble and sickly children scarcely ever escape from this disease." Now, when it is remembered that the feeble children are very generally the sickly ones, our conclusion, that it depends greatly upon an original organic and feeble viable condition of the system, is rendered even more than probable. He further states, that " bad and old milk, and thick farinaceous preparations, sweetened with brown 


542 
INFLAMMATORY FORMS OF DISEASE 
sugar or molasses, are especially apt to give rise to the disease." Here, again, we find our leading argument to be sustained. The nutritive system is incapable of converting the carbon into fat, and the lungs cannot combine it with oxygen, and disease is the consequence. 
Treatment.—As in this form of disease the bowels are, if not always, very generally, in a deranged condition. A superabundance of acid is thought to be generally present, as the evacuations, if diarrhea be not present, are usually of a green color. We are not willing to take it as granted that the green color of the fasces is a certain proof that they are acid— we do not know that it is ever the case, but we are sure that it is not always the case. Green evacuations, are sometimes, and so far as we know to the contrary, entirely insipid and insensible to any test for the presence of acid. Nevertheless, the green color is an evidence that the bowels are not in a normal condition, and therefore it would be judicious to employ the Compound Powder of Rhubarb, or the Syrup of Rhubarb and Potash, to change this condition and restore the vitiated excretions to a state of health. 
In the event the stools are frequent, sparing, aqueous, painful, and straining, a small portion of Paregoric may be added to the above agents, and injections of Starch-water or mucilage in small quantities, administered immediately after each alvine evacuation; sometimes infusions or decoctions of astringent vegetables may be advantageously employed, as of Blackberry root, Dewberry root, etc. 
When the diarrheal evacuations shall have a green color, which is sometimes the case, the use of Magnesia and of Limewater has been recommended, but in the generality of cases, we prefer the course above-named to any other. 
When the bowels indicate the existence of much irritation, the discharges are scant}' and possibly stained or streaked with blood, Dr. Dewees strongly recommends the use of the Oil of Butter two or three times a day. For the same purpose, he thinks very favorably of Gum Arabic water. 
But in this plan of treatment, even though we shall succeed in preventing a prostrating debility, a circumstance that not unfrequently results from it, we have incomparably more confidence in the efficacy of a purely revulsive treatment, because 


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a thorough equalization of the circulation will be followed by an improved condition of the alvine secretions; therefore, in addition to the means above pointed out, the whole external surface should be once or twice a day bathed with a warm, weak alkaline wash, and dried with some degree of friction. 
The most proper food for the child is its mother's milk, provided she be in good health, but even then she should, for the time being, live upon simple and very digestible food. 
Local applications, in the treatment of this form of disease, are not to be dispensed with. During the inflammatory stage stimulating applications should be applied under the jaw, as the Compound Capsicum Liniment or the Compound Tincture of Camphor, which, in very young infants, may be diluted by the addition of sufficient Olive Oil; and, for a mouth wash, or rather, as a remedy for the sores contained within it, a decoction of Hydrastis Canadensis may be used several times a day, and even a portion of it may occasionally be swallowed; or Borax may be added to the decoction in nnany instances, with decided advantage. 
Species III. — Stomatitis Follicular — Inflammation of the 
Mucous Follicles of the Mouth. 
In the appearance of aphthae and thrush, and in their constitutional symptoms, there is a very striking analogy; but still we cannot declare, with Prof. Dewees, that we can perceive no difference between them as described by C. M. Billard. The resemblance is one of appearance, and the difference is one of reality—of anatomical location; and when we consider that both are located in the same districts, we should not consider it strange that the constitutional symptoms should scarcely admit of a distinction. We concede that the distinction appears to us as one of fact—of science, rather more than one of therapeutical utility. 
In muguet or thrush, the disease is confined to the surface of the epithelium, says Billard ; but in aphthae, it is confined to the muciparous follicles of the mucous membrane. Now, if these be the facts, then certainly they are not one and the same disease, although it may be difficult to determine a difference between the symptoms. 
Prof. Wood regards thrush and aphthae as distinct forms of 


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disease, but he does not agree with Billard in considering follicular inflammation and aphthae as one and the same. He admits that the muciparous glands may be sometimes the seat of aphthous ulcerations. He teaches that aphthae is a vesicular inflammation and embraces all the small ulcers, with whitish surfaces, which are frequently to be seen in the mouth. 
This misunderstanding between pathologists is not as to the true seat and character of those forms of disease which visit the mouth, but as to which of them belongs, truly, the name of aphthae. It is fortunate that this difficulty can avail but little, if anything, in practice, because the treatment must be about the same in all three of the inflammations —the diffused, follicular, and vesicular. 
After digesting the information which we have been able to glean concerning these forms of disease, we are disposed to conclude that the one which is generally regarded as aphthae, in this district of country, is the thrush, or muguet of French writers —the infantile sore-mouth of common denomination. 
As Prof. Wood, no doubt, understands that form of disease which is generally understood to be aphthee, by the profession of this country, it is perhaps best, for practical purposes at least, that we adopt his views. 
The mucous follicles are so exceedingly small that they cannot, ordinarily, be seen; but the infinity of their number sufficiently compensates for their smallness; but, when they become inflamed, they may be felt with the. finger although they may not be seen, and when first seen they are small, hard, round, whitish eminences, surrounded by a reddish circle. When the inflammation takes its natural or uninterrupted course, these eminences become soft in their centers and ulcerate, throwing out a whitish matter which is disposed to adhere to the surface. 
These ulcers are either isolated or confluent, and when the latter, they present a continuous, whitened, and ulcerating surface. It is common to adults and infants, but more frequently appears in the latter, and with them it is sometimes mistaken for the thrush. 
It is said to attend at the conclusion of the exanthematous fevers and chronic inflammations of the viscera in general. 


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The treatment of this form of disease, so far as is nowknown, does not ditfer from that of aphtha, to which we refer. 
Species IV. — Stomatitis Vesicular — Aphthce — Ulcerous 
Inflammation of the Mouth. 
The term aphtha? is applied to all those small and whitish ulcers which frequently appear within the mouth, without reference to their particular seat or source. 
This form of disease generally begins on the inner surface of the inferior lip, or within the angles of the lips, and consists of white vesicles, which may be few or many. From these points it spreads rapidly upon the buccal parieties and surfaces of the mouth and gums. At other times, it appears simultaneously, and in the same form, upon several portions of the buccal cavity. Wherever it may begin, it resembles a coagulum of milk. In its severer forms, as in the thrush, the eruption becomes darkish or reddish, and probably because of the presence of blood. 
Aphthse is thought by many to be altogether symptomatic— that it is always preceded by some gastric derangement, but as it sometimes attacks children whose stomachs and bowels are in excellent health, we are justified in doubting its purely symptomatic character. It is thought to appear, sometimes, epidemically, and if it do, we cannot well doubt that it is sometimes idiopathic. 
As in the thrush, so in Aphthse, the stomach, the bowels, and the brain appear to participate in the inflammation of the mouth—the desire to sleep is unusual, and the bowels are troubled with aqueous, acrid, and greenish stools, attended more or less with flatus. 
Young children, when the disease is severe, emaciate rapidly—they are harassed greatly by colics, diarrhea, and gastric irritability. The last is sometimes so great, that scarcely anything is retained. The oesophagus is sometimes so closed up with aphthae, that the little which the stomach may retain is with great difficulty swallowed. 
It is useless to pursue the symptoms of this disease further, because it is impossible to define an appreciable difference between the general symptoms of it and thrush and Dr. Eberle uses the two names synonymously. 
35 


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INFLAMMATORY FORMS OF DISEASE 
Aphthse is not so common to early infancy as to a more advanced stage of childhood, and after this it may attack any age. It is not confined to the mucous membrane of the mouth —Prof. Dewees says, that he has seen it " most plentifully within the labia pudendi as well as on the internal face of the prepuce." After this remark, we think it rather surprising that he should seriously doubt as to the occurrence of aphthae upon the mucous lining of the stomach and bowels. 
Causes. —Feeble children, and those whose constitution has become depraved by the use of improper food, air, etc., are the most liable to it. Prof. Dewees thinks that farinaceous diet predisposes to the disease, more especially when sweetened with brown sugar or molasses. We would, a priori, adjudge sugar and fats as calculated to produce the disease, especially with the feeble—particularly the latter. 
Treatment.—Same as that of thrush. 
Species V. — Stomatitis Pustular — Cancrum Oris — Canker; Ulcerative Inflammation of the Mouth. 
The disease of which we are about to treat must not be regarded as being a dependant upon, or as a sequent of, any one of the preceding varieties of stomatitis; but as being one which is entirely independent of them, and, also, as being one to which new-born infants and young children are frequently liable. It may locate itself indifferently upon any portion of the buccal cavity. It may select the base of the tongue, the fraenum, the palatine arch, the gums, the lips, or the internal surface of the cheeks. It has been confounded with aphthae, but by the time we conclude, it will be discovered to be an entirely different form of disease. 
It is but rarely, if ever, noticed before it becomes an ulcer of considerable magnitude, of a grayish color and surrounded by an inflamed border. The adjacent or contiguous parts are usually so far involved as to be inflamed and swollen. If it be located in the cheek or in either of the lips, the swelling will be exposed to external observation, and the cutaneous surface will be red and shining. The internal swelling is sometimes so great as to render an examination of the ulcer very difficult. 
The ulcer, perhaps, never penetrates through the cheek, noi 


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destroys the part in which it is located, except, possibly, in some of the fatal instances, and they are exceedingly rare; and though rarely fatal, it is nevertheless a painful disease. 
It is usually attended with fever, constipation, a copious flow of saliva and a fetid breath, but this fetor is distinct from that of gangrene. When located in the gums, it is apt to expose the alveolar processes, and though it may continue for weeks or months it is not apt to be attended with worse consequences. 
Causes.—The causes of this disease are fully as obscure as those of thrush and aphthae. While, on the one hand, it has been referred to improper nourishment and depravity of constitution, it has, on the other hand, been known to appear under very opposite circumstances—apparently so, at least. 
Writers have not yet learned to consider very feeble and often-ailing children, and very obese ones, as being very similarly related to disease and death. The latter may escape for a long time those irritations which for a similar period distressed the former, and yet be equally destitute of vital force; and this truth becomes manifest as soon as the fat-producing process becomes disturbed or arrested. 
If we were to indicate any one article as being the most productive of juvenile disease, it would be sugar — saccharine matter; and for two reasons: first, all children are fond of it; and second, parents, almost universally, believe that it is healthy and nutritious. In some sections of our country, it constitutes a leading article of juvenile diet. Ulcers and eruptions are common to those who intemperately indulge in alcoholic drinks ; how then can children escape similar afflictions who use much saccharine matter ? Both are carbonaceous, and both are, measurably, destitute of nourishment. Those infantile and juvenile constitutions which cannot convert sugar into fat, we would, a priori, suppose to be most liable to the present forms of disease, and such we find to be the fact. 
We know that hundreds of children have suffered whose only food had been the mother's milk, but let it be remembered, that too many mothers indulge in gross and carbonaceous food. 
Treatment. —In the treatment of this affection, the most 


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important indication is to arrest the sloughing and prevent its further progress, and if this be not accomplished, the disease will rapidly proceed to a fatal termination, notwithstanding a favorable condition of the pulse, appetite, and mind. And, probably, a reason why the disease generally resists the treatment employed, is, that after the affection has been properly recognized, the local applications are either of too mild a char acter or have been insufficiently applied; and this may be owing to the difficulty which attends the effectual application of any caustic to the gangrenous parts in the interior of the mouth, both from the swollen and resisting condition of the cheek, and the struggles of the child to free itself from a painful operation. 
A writer, in speaking of the application of caustic in this disease, remarks: 
"Ineffectual cauterization, however, is useless, or worse than useless; and though every endeavor should be made to prevent the needless destruction of healthy parts, yet of the two evils, that of doing too much is unquestionably less than that of doing too little. It is of importance, moreover, not only that the cauterization should be done effectually, but also that it should be practiced early." 
The sloughing advances rapidly from within outward, and when once it has penetrated through the substance of the cheek, the chances of cure are but few; consequently, the treatment must, from the commencement, be active and energetic. The caustics which have been recommended are strong Hydrochloric or Nitric Acid, which must be applied to the gangrene in the interior of the mouth, by means of a piece of sponge or lint fastened to a quill, at the same time properly protecting the tongue and other healthy parts, as far as possible, from the action of the caustic. 
We have never used the Sulphate of Zinc in this disease, yet, from its known success in other gangrenous affections, we should deem it an important local agent in arresting the sloughing; but whatever agent is employed, the mouth must be carefully examined every six or eight hours, to ascertain whether the sloughing has been checked, or whether it has extended into the parts beyond the yellow eschar produced by the acid; and the cauterization should be repeated sufficiently 


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often to completely arrest the disease. During the whole course of treatment, the mouth must be frequently washed with astringent decoctions, and the diet should be of a generous and nutritious character, supporting the patient's strength also by Wine, Porter, Quinine, or other tonics and stimulants. 
Great success has obtained in this affection by the following treatment: 
A mild aperient of Rhubarb and Magnesia was administered, together with four grains of Chlorate of Potash dissolved in water sweetened with syrup, which last dose was repeated every four hours. The mouth was washed with a weak solution of Chloride of Soda. Recovery took place in about six days, while, in one case, which was treated with tonics and alteratives, three weeks ensued before a cure was effected. This treatment is worthy a trial in cases of a similar character. 
Species VI. — Stomatitis Mercurial* — Inflammation and Sloughing of the Mouth, caused by Mercury. 
The people of this country, unfortunately, are so well acquainted with this variety of sore mouth, that any description of it would seem to be a work of supererogation; nevertheless, a brief account of it will not be out of place to those who desire to learn how to treat it. 
* In the social division of labor, it became the business of one class of men to study the human organization and its organic manifestations, in both health and disease, and, al6o, the therapeutical relation, to this organization, of all external objects, for the purpose of mitigating or removing the derangements and lesions to which it is incidentally liable. In other words, a class of men were, and are still, set apart for the purpose of treating, and, if possible, curing the diseases with which the individuals of society become afflicted. TMs class is now distinguished from all others by the title of Doctors of Medicine. It is especially their business and their duty to cure, and not to produce disease. 
Notwithstanding this high and imperious duty, we have before us, and constituting a part of a nosological system, a highly unmanageable and frequently fatal disease, which, seventy-five times in every hundred cases, is produced by the profession in their efforts to cure the various forms of disease, which, compared with it, are, absolutely, insignificant. 
This species of stomatitis does more mischief—produces more suffering, more mortality, in the United States, every one year, than the other species have since the creation of man ; and is it, like the others, one of God's scourges 


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After the disease becomes fully developed, those who visit the patient do not require to be informed as to the nature of the disease—it is announced to them, as soon as the door is opened, by the patient's breath. From first to last, this is a distinguishing symptom. The first indication that the patient has, that he is, to use a common phrase, salivated, is the copper or brass-like taste with which the tongue is impressed. The next indication is a sense of soreness of the gums of the inferior incisores, and finally, all doubt is removed by an obvious increase of the saliva. 
When the complaint is first made, of soreness of the gums, a close examination will detect a transverse opacity of the gums just below their edges, resembling a white band, attended with some redness and tumefaction about the necks of the teeth. In a little more time, the inflammation extends to the periosteal linings of the alveoli, causing pain when the jaws are closed upon each other; by the same time, the inflammation seems to have affected the muscles of the jaws, as the patient has now to make some effort to open them—there exists in them a sensation of stiffness. 
The disease progresses—all the parts in the mouth become 
because of man's disobedience? Not at all. He has forbidden the use of Mercury in language so plain, and in terms so strong, that simple must be the man who cannot understand it, and obdurate the one who will not obey it. 
We do not assert that the cause of this nosological addition was, necessarily, the work of the medical profession, because we are aware that this form of Btomatitis sometimes occurs in the Mercury mines of Spain, and also, that it has been produced in some other commercial situations. But what does all this amount to, when compared witn that which we have, almost daily, produced in our midst, by the medical profession? The former is merely a homoeopathic globule, while the latter is a genuine Oook dose of calomel. 
Is the inquiry made of us : " Do you never use calomel ?" We answer—in such cities as Cincinnati, Philadelphia, etc., we would never have occasion to use it, because, in these and similarly provided cities, we could always command more safe and effective agents. We would use it under no circumstances, except such as would enable us to feel sure of God's pardon for such a violation of his ordinances. We would use it, if we could not do better, and we will use it, when we cannot do better; and we consider it as granted, that all of our medical brethren, in this respect, act as we do j that is, they would not use it, if they could lo better, aud as they do persist in using it, the inference is plain. 
In considering mercurial stomatitis we could not avoid the preceding reflections, and we have written that others may learn how we, who have in this wise sinned, feel upon the subject.—P. 


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sore from the extension of the inflammation. The cheeks, throat, salivary glands, and tongue are all painful. The last organ, the tongue, is covered with a brownish, or possibly a yellowish, fur, and so swollen as to fill the buccal cavity. 
Ulceration commences generally in the gums, but it is soon extended to the jaws, cheeks, throat, tongue, palatal, and ethmoidal bones. All are destroyed, if life continue long enough. 
This is a rapid and general sketch of the disease, as it usually appears in adults. Now, suppose the disease to attack an infant, in which, as is very generally the case, the tissues are all soft and incomplete, and then we have such an exhibition as should induce the civil authorities to hold that physician to be guilty of a capital offense, who should administer mercury in any form to an infant. 
Prof. Wood remarks, that the " pre-occupation of the system by a very violent disease, presents, in many instances, a complete obstacle to its action upon the mouth." 
Is he sure that it does not present an equally complete obstacle to its action upon any part of the system ? This is a question of which the profession at large seems never to have thought. We were taught to make calomel, blue-mass, etc., the sheet-anchor of our hope in all congestive forms of disease. We did so until the mortality in that department of our practice forced upon us an investigation of the subject, and then we discovered that calomel is as inert as brick-dust in all congested forms of disease. 
Prof. Wood adds, that " in yellow fever, it is sometimes utterly impossible to induce the mercurial salivation." 
Yes, and in such cases, and by such a practice, it is as utterly impossible to save the patient. It is, to us, much more than probable, that the cases to which he has referred were highly congested, and if so, the whole difficulty is explained. 
We are fully aware the preceding paragraphs are, scientifically and systematically, out of place ; but we feel equally sure that those students for whom the work is especially intended, will not only appreciate them, but also our motive for introducing them. 
Treatment. —From all the cases we have witnessed, we 


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have but little confidence in any treatment either in this or the ulcerative form of stomatitis — for, notwithstanding the most energetic measures, all hasten rapidly to a fatal result; nevertheless, the treatment suggested for cancrum oris would, be equally indicated under the present affection. 
Genus II. — Angina. 
Species I.— Angina Simplex — Common Inflammation of the Fauces. 
Under this caption is embraced all the parts which together constitute the posterior walls of the mouth—the parts which we can see when the mouth is widely opened and the tongue depressed. They consist of the half arches, the velum pendulum, the uvula, the tonsils, and the superior portion of the pharynx. 
All of these parts may be implicated, more or less, by the various forms of stomatitis, and also by several of the cutaneous diseases, of which we have also treated. All -of these will be excluded from the present and the succeeding subjects of this class. 
Before entering directly upon the subject before us, it becomes necessary to prepare the reader for judging accurately as to the existence of disease in these parts in very young infants. 
From birth up to the exfoliation of the epidermis, the fauces are generally highly congested, and the redness might be mistaken for that of inflammation; hence it is not safe to rely upon the appearance of these parts, before the ninth or tenth day, exclusively —other indications should greatly contribute to the announcement of the fact. 
This congestion is usually distributed in a uniform manner, but in some instances, it appears to exist in more or less distinct ramifications. This fact is a strong confirmation of a very prevalent opinion, that there exists an intimate sympathy between the cutaneous and mucous surfaces. 
With these remarks, we proceed to the consideration of simple angina, or an erythematic inflammation of the parts which constitute the fauces. The subject might be divided into as many varieties as there are parts, but this would be more technical than useful, as it but seldom happens that all the 


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parts are not more or less involved; and whether it be so or not, the treatment is the same. 
If the disease should make its attack after the first ten or twelve days, its existence will be indicated by a bright-red color and some tumefaction—if the patient be old enough to make known its condition, then the most certain indication will be the expression of some pain in swallowing; if it be under ten or twelve days old, the existence of disease will be indicated by the high color of the parts, being disposed of in separate points or spots. "When the disease is a little more advanced, the red surface will be marked by whitish patches, particularly on the tonsils—their whitishness, consisting probably of coagulated lymph, produced by the inflamed follicles. The parts will also become hot and dry, and from their soreness, much pain will attend all efforts at deglutition. If the tumefaction should be considerable, drinks will sometimes regurgitate through the nostrils, and the cry will be somewhat nasal or hoarse. A viscid mucus may be secreted, in the progress of the disease, which may prove very troublesome, and therefore, the nurse should give particular attention to it. 
It is common for this disease to run its course without producing fever; but it is sometimes otherwise the case. The inflammation often continues for several days, and gradually declining, terminates generally by resolution. Any other mode of termination is particularly rare in children. 
Causes. — A moist atmosphere is alone sufficient to restrain the cutaneous function in feeble children, and when of a reduced temperature, it is still more effective, consequently it is very probable that this form of disease is more frequently than otherwise produced by the agency of such an atmosphere. 
Some persons possess a strong organic liability to angina under very slight exposures to a cold and damp air, more especially when they are warm or perspiring. It sometimes results, sympathetically, from gastric derangement or disease. When it occurs in a scrofulous or phthisical organization, it is more obstinate and difficult to treat. 
Dr. Wood remarks, that it appears sometimes to be of a rheumatic nature, as it occasionally alternates with manifestations of that affection. We regard this remark as being very 


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INFLAMMATORY FORMS OF DISEASE 
probably correct, when the subject is of a rheumatic organization. 
Treatment. — The treatment of this affection may commence with the administration of some mild evacuant, as the Compound Powder of Rhubarb, the Compound Powder of Jalap in small proportions, or the Compound Tincture of Jalap, which may be repeated occasionally as required—to be followed by a warm, stimulating foot-bath, or if there should be much arterial excitement, a warm bath, and the surface must be bathed with a weak, warm, alkaline solution as often as the severity of the disease may require. 
At the same time, the throat and neck should be bathed several times a day with some stimulating liniment, after which a piece of flannel should be bandaged around the throat, and in severe cases, a fomentation of Hops and Mullen leaves. A gargle or wash may likewise be used a number of times through the day, as for instance the following: 
Salvia Officinalis, Hyssopus Officinalis, aa 3j, Borate of Soda, 3j, Aqua Bulliens, oct.ij. Mix; 
let them steep an hour, then strain and sweeten with Honey. Should the child be too young to gargle, this must be applied on a piece of linen rag to the inflamed parts, and some of it may even be swallowed. Sometimes the substitution of two drachms of Alum for the Borax, will have a more beneficial influence. 
In very many severe and obstinate cases, a solution of the Nitrate of Silver, five or ten grains to an ounce of water, may be applied two or four times a day with advantage. 
The patient should be kept in bed, in a dry and warm room, and its diet should be confined to toast-water, gruel, toast-bread, and similar articles, until all febrile symptoms disappear. 
At any time, when the secretions about the fauces become very abundant and tenacious, interfering with respiration, the Compound Tincture of Lobelia or the Acetous Emetic Tincture may be given in sufficient quantities to produce emesis. 


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Species II. — Angina Membranacece — Inflammation of the Fauces with altered Secretion. 
When we see a child refuse the breast, give evidence of difficult deglutition, such as an expression of pain, the existence of this disease should be suspected. 
Although this disease commences like ordinary sore-throat, with redness of the fauces, yet, very generally, when first seen by the physician, the fauces will present irregularlycircumscribed, whitish, or possibly yellowish-white or ashcolored spots, which may be confined to some part of the fauces, or scattered indiscriminately over the whole of their surface. 
These patches closely resemble the surface of ulcers, while, in reality, they consist of a concreted exudation upon a surface which has suffered no apparent lesion. These concretions are sometimes translucent, dense, tough, or they may be soft and pultaceous. 
The tonsils are usually more or less swollen, and the membrane around their borders is red and inflamed. The inflammation and tumefaction extend sometimes to the cervical and submaxillary glands, and even to the parotids. 
Like other imflammatory forms of disease, it is sometimes mild, and at others very severe. In the former, the patches are few and more regularly bounded — the fever is probably absent, and the tumefaction very inconsiderable. But, whatever may be the extent of these symptoms, deglutition is very apt to be painful. In the severe forms, deglutition is very painful, and frequently, in attempts to swallow fluids, they are returned through the nose. 
When the scabs have completed their process of formation, it is not long before they begin to disappear, sometimes by absorption, at others, by softening and mixing with the saliva, and at others, by separating into irregular patches. They are frequently renewed, and occasionally several times, each becoming more white and delicate, until they finally disappear, leaving on the surface a puriform mucus. 
In the nasal passages, the disease sometimes rages with considerable violence, as indicated by fetid discharges from the 


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INFLAMMATORY FORMS OF DISEASE 
nose. Vitiated secretions, often stained with blood, are frequently discharged from the mouth. 
In the course of the complaint, the larynx, trachea, and even bronchia are invaded, and lined to such an extent with the concreted exudation as to interrupt respiration, and sometimes to such an extent as to cause a fatal result; and in this tendency consists the greatest danger of the disease. 
The disease, in its violent form, is attended by constitutional symptoms, and continues from two to three weeks. 
Causes. —As to the cause of this malady, we could speculate, as others have done, but for this we have neither inclination nor time. It is the opinion of some that it is contagious— we do not believe it, but we cannot say that it is not. 
Treatment. — A similar course to that recommended in common inflammation of the fauces may be resorted to with advantage. 
A gargle or wash may be used, composed of: 
Hydrastis Canadensis, Cortex Rhus Glabrum, aa 3j. Mix. 
Add a quart of water, boil down to one pint, strain, and add one ounce of Alum. This will be found quite valuable in many instances. 
Another preparation, which we have often used with de cided benefit, is, 
Strong decoction of Hydrastis, oct.j, 
Salt, 3ij, 
Pepper, 3j, 
Vinegar, 3ss. 
This may be gargled, or used as a wash, and occasionally a portion of it may be swallowed. 
When the affection assumes a gangrenous tendency, the parts must be washed with Yeast and Sweet Oil, or a solution of Sulphate of Zinc, with the internal use of tonics and stimulants for the accompanying prostration, as Quinine, Hydrastin, Porter, Wine, etc.; and in this condition care should be taken not to further increase the debility by purgation or diaphoresis. 


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Species III. — Angina Tonsillaris — Tonsillitis — Quinsy — Inflammation of the Tonsils. 
In the preceding species, the surface of the tonsils was involved, but now we have to treat of inflammation of their substance. The local disease is either preceded, or immediately followed, by febrile symptoms, or they are introduced together. Rigors usually introduce the fever, which is attended by headache and a strong and full pulse. 
A difficulty in swallowing is the first announcement of local disturbance by those who can make their condition known. In severe cases, so painful is deglutition as to produce, apparently, a spasmodic action of the muscles involved in the function ; and if both sides are equally involved, the function becomes almost impossible, so much so that it frequently happens, in attempts to swallow fluids, that they are thrown back through the nares. 
In consequence of a pressure of these bodies upon the eustachian tubes, the hearing is frequently much impaired ; respiration, however, is but little disturbed, except in very severe cases when a sense of suffocation is felt. The fauces, at first, present redness, with tumefaction of one or both tonsils, and when of both, the swelling may increase until they almost meet. 
A diffused whiteness may appear upon their surface, or it may be in spots, and probably concreted — a morbid product of the mucous follicles. The uvula is generally much swollen and elongated, and the contiguous parts considerably inflamed. 
The disease is not always unattended with external inflammation, with tumefaction of the cervical glands and cellular tissue, to such an extent as to render the inferior jaw almost immovable. 
This inflammation, when slight or successfully treated, will end in resolution, but frequently it terminates in suppuration, which, when established, will be announced by rigors, softness of the tumors, and probably by a pale spot, indicating its nearest approach to the surface, and some fluctuation. The sufferings, at this stage, are exceedingly great, but not greater than is the relief which attends the rupture of the tumors. 
Causes.—Improper exposure to atmospherical changes is, 


NON-INFLAMMATORY FORMS OF DISEASE 
558 
probably, the most usual cause—the atmosphere is sometimes thought to contain an epidemic cause for it, which may be similar to that of scarlatina and measles, as it frequently prevails with them. 
Treatment.—The course already named in the two preceding forms of disease, may be pursued in this, with equal benefit, the first indication being, as with them, the removal or alleviation of inflammation. 
In the early part of quinsy, an emetic will almost always be found useful, often affording relief at once, after which the previous treatment may be energetically pursued, that is, stimulating gargles or washes, stimulating liniments to the throat, and a warm fomentation of Hops and Mullen leaves, together with frequent bathing of the surface of the body. 
In adults, the inhalation of vapor from a decoction of bitter herbs, repeated several times a day, and continued for ten or fifteen minutes, gives relief, and materially assists in reducing the inflammation. 
When suppuration takes place, it must be watched to prevent it from causing death from suffocation ; and should this be threatened, the tongue must be held down by a spoon or tongue-holder, and the enlarged tonsils be punctured with a lancet, carefully guarded to prevent it from wounding or injuring any other portion of the mouth or tongue. 
The diet and regimen must be the same as in the two preceding forms of angina. 
ORDER II. 
NON-INFLAMMATORY FORMS OF DISEASE IN PARTS LOCATED ABOVE THE DIAPHRAGM. 
Genus I.—Stomatitis Gangrenous—Necrosis Infantilis— Death of the Mouth from insufficient Vitality. 
This form of disease is, by some, regarded as a variety of stomatitis, and is consequently denominated gangrenous inflammation of the mouth. We, too, consider this affection as a modification or variety of that which is called stomatitis, 


ABOVE THE DIAPHRAGM. 
559 
but, as we do not regard inflammation as being ever a cause of gangrene, and as this form is not preceded by inflammation, we could not treat of it as a member of an inflammatory order. 
In constitutions which are too feeble to maintain, successfully, an inflammatory action, gangrene may succeed thrush or aphthae, and then be mistaken for what is known as gangrenous stomatitis, or in other words, gangreena oris; the mistake, however, would be but little in point of fact, because it is very probable that a less degree of vital force in an assault of thrush would have produced gangrsena oris. 
We are informed by pathological anatomists, that this affection never depends upon, or results from, any other form of disease, consequently it must be the necessary result of deficient vital action, and in confirmation of this result, we are informed that the class of children in which it is idiopathically found, are not only feeble, physically, but manifest, mentally, a want of vital energy; the respiration is feeble, the circulation's sluggish, and the cellular tissue betrays a constant tendency to become ©edematous, particularly in dependent parts. 
Under circumstances of such languor and feebleness, it is not difficult to conceive that the capillary circulation may be replaced by serous infiltrations, which may act almost as effectually in producing the death of a part, as a ligature. The sluggishness which attends ulcers, in highly-lymphatic persons, gives support, in our judgment, to these views; and as our practice must be in accordance with our pathological opinions, it was necessary that we should briefly express them, whether ill or well-founded. But, upon a question of this kind, on which all confess their ignorance, all possible suggestions are admissible. 
Prof. Wood informs us that this affection occurs usually between the first and second dentition, but, according to Billard, it occurs in early infancy, and all the cases he has cited appeared within the first month. It is said, further, that it may also attack adults. 
Like the ulcerative variety, it may attack, indifferently, any part of the mouth, and, generally, when first observed, it presents a whitish or ash-colored eschar, and as the death of the 


560 
NON-INFLAMMATORY FORMS OF DISEASE 
part advances, the slough spreads; the breath is very offensive, having a gangrenous odor, and the saliva flows copiously. If the attack be upon the gums, it penetrates the osseous structure, followed by necrosis of the alveolar processes, and the teeth fall out. If the attack be in the cheek, the outside will be marked with an ash-colored spot, which soon becomes livid or black — enlarges rapidly, and speedily, the cheek is destroyed ; the mischief however continues—the superior jaw, the palatal and ethmoidal bones are invaded, but rarely destroyed, before death arrests the process. 
Sometimes a slight inflammation may be observed to attend this work of destruction, and occasionally a little febrile action may spring up; but it is thought that neither of them precedes the gangrene, but are rather produced by it—in other words, they indicate the feebleness of the system in an effort to arrest the progress of death in the parts assailed. 
Causes. — Gangrene may supervene inflammation of the mouth, as of any other part of the system; but, in this form, it is not certain that it precedes the mortification at all. One would, a priori, suppose that an inflammation capable of producing mortification could not be attended with any doubt, and if such were the fact, there would not be any. Dr. Wood thinks it probable that it depends upon some peculiar morbid condition of the system. Admit that it does, and what does it avail ? He has not suggested the character of the supposed morbidity. In children of such extreme debility, we may safely suppose the existence of very imperfect depuration, and hence there is, very probably, " morbidity " enough to overcome the resistance of the vital force, and death of the part, and possibly of the patient, must be the result. 
Treatment.—Our final success, in this form of disease, must depend upon the use of proper food, stimulants, and tonics ; but the local invasion will scarcely be arrested or removed without the use of local means. 
This affection, if promptly attended to in its early stage, is generally curable, but that constitutional infirmity, of which it may be esteemed an evidence, will scarcely allow the patient to live more than a few years. If, however, the sloughing has been considerable, a fatal termination may be expected. 
The remedies demanded by the constitutional debility and 


ABOVE THE DIAPHRAGM. 
561 
depravity are the Compound Syrup of Stillingia, which should be given in connection with the following: 
S. Quinia, 
Hydrastin, 
Myricin, aa 3ss. Mix; 
divide into twenty powders, for a child of six months old, of which three or four may be given daily. Where the child is too young to take the powders, a solution of them or tincture, may be used instead. 
With this tonic, alterative, and nutritious course, similar local means may be adopted as in cancrum oris. 
Madeira wine or good brandy may be used as stimulants, or still better, the Aromatic Spirit of Ammonia; and for diet, the patient may use wine-whey, brandy milk-punch, yolk of egg in wine, rich soups, animal jellies, and tender meats. 
Genus II.—Irritations of Dentition— 
Teething. 
This subject is too frequently, treated as though the teeth were foreign bodies, having neither anatomical nor physiological relations with the system in general, mechanically forcing themselves through anatomical parts, and thereby producing a long« train of the most fearful pathological consequences. 
Normally, the process of dentition produces no more trouble or suffering than any other one belonging to the system; nevertheless, we are aware that the period assigned to it, is, in civil society, one of disease and death. But are these results to be attributed to the process of dentition ? Will any one assert that the several parts of all children, as a general fact, are not in physiological harmony with each other ! As very many children do not survive this period, is it not conclusive that they acquired, after birth, a constitutional infirmity, or that one was entailed upon them ? 
If parents desire children so constituted as to be able to pass through this period of their existence, they should not procrastinate a preparation for it until the period arrives. Physicians cannot save life in a constitution that is incompatible with it. We do not know that any of the children who have died, during thiB period, from the real or supposed disturbances 
36 


562 
NON-INFLAMMATORY FORMS OF DISEASE 
of dentition, died, by a single hour, prematurely. If they had lived, their lives might have been wretched to themselves and useless to society. We certainly have a right, in a great degree, to such an inference. If mothers do not like it, let them live all the time, and particularly during gestation, in conformity with the institutions which were ordained for their government. 
Finally, in this place, we have to say to both sexes, if your constitutions are gout}', scrofulous, or otherwise unsound, deny to yourselves all the supposed advantages of matrimony; and if you will not do this, then do not complain at the premature loss of your children. 
We are pleased to see that medical writers are beginning to attach more importance to the period of dentition, than to this process, in the abstract —to view it as one in which many important revolutions take place in both the habits and developments of the infantile economy. 
A healthy child begins to cut its teeth at a certain time, and in a certain order; now, if this time and this order are not punctually observed, is the fault in the teeth? is it in the jaws, or both united ? Is it not rather in some constitutional infirmity, which might result in any one form of disease common to infancy, under the provocation of an adequate excitant ? 
We have said that this is a revolutionary period in the history of our existence, and, like other revolutions, it is pregnant with some mischief and always with much good—the mischief falls upon those who are unable to contend with it, and the good upon those who are, and they always constitute a large majority in the end. As an illustration of this principle, we will invite attention to a few examples. 
It may be observed, that while the mother's milk is the indispensable food for the child, that it does not slaver — that its mouth is comparatively dry; but as the time approaches when it must be subjected to a change of food, the salivary glands manifest an increased activity, and this happens in the fourth or fifth month, long before the teeth prove a source of irritation. No other change will be announced before the beginning of the eighth month, when two teeth will appear in the middle of the inferior jaw. All is quiet again for some 


ABOVE THE DIAPHRAGM. 
563 
time, when two more teeth appear in the middle of the superior jaw; and thus of the others which are yet to appear. 
While these changes are going on in the mouth, there are others of equal importance, under a similar state of development, in the stomach, intestines, liver, brain, etc. 
Those capable of only a moderate share of reflection, must now perceive that a cause which is capable of materially affecting any one of these important movements must give to the delicate constitution of an infant such a shock as may result in very serious mischief, and more especially so must it prove to the delicate and constitutionally infirm. Thus, it is obvious that the dental process is only one, among many others, which renders the period of dentition one of danger and difficulty to the feeble. It would be, pathologically, just as correct to speak of the various forms of disease of the osseous, cerebral, gastric, intestinal, and hepatic development, respectively, as of the dental. 
The fact that physicians have too generally looked to the dental process, during this period, as the source of its dangers, has been attended with much mischief; it has caused them to overlook the other important changes which are progressing, and to neglect the interruptions to which they are incidentally subjected. 
Some children pass through all these changes without apparent difficulty. And why should they not? They are all normal. We have heard nothing said by graziers and hunters of dental disease among the inferior animals; and if man had lived, up to this time, as much in accordance with his organic laws, as the inferior animals have, the so-called dental diseases, would now be regarded as of very rare occurrence. 
As the condition of the teeth with certain people, and of the same people under different circumstances, may serve to shed some light upon the difficulties of the first dentition, we beg leave to invite attention to a few interesting facts upon this subject. 
In the south, the plantation negroes have, very generally, fine, white, sound teeth, while those who live as family servants, and have descended, through several generations, from family servants, have, very rarely, sound teeth. They present, 


564 
NON-INFLAMMATORY FORMS OF DISEASE 
also, other and equally remarkable differences—their heads are larger and rounder. 
The Osage Indians have, with scarcely an exception, sound and beautiful teeth, and they are set in large and beautifullyturned arches. 
The Cherokee, Creek, Choctaw, and Chickasaw Indians may be said to be as much distinguished for unsound teeth, as the Osages are for sound ones. Of more than one hundred crania of the former peoples, we do not remember one in which all the teeth were sound, and in a majority of them they were very unsound. 
The lowest and most down-trodden portion of the Irish population have cramped and irregularly-turned jaws, with teeth tangled and irregularly planted—but they are generally sound. 
Now, a proper application of these facts must enlighten us not only upon the subject of dentition, but also upon the modes of life and of civil institutions; but with the two latter we have nothing to do, except so far as they may bear upon the main question. 
The plantation negroes have few or no responsibilities— their lives are devoted to three great functions—feeding, working, and resting — their food is proper in quality and never intemperately used in quantity, and among their children the derangements of dentition are few and far between. 
In family domestics, there is greater responsibility, and their heads are larger — their duties are more varied, and therefore they are rounder. In their food and beverages they are frequently intemperate as to quantity, and as frequently imprudent as to quality. Their teeth are frequently in a worse condition than is common to the whites, because they are guilty of more excesses. The dentition of their children, to say the least, is such as is common to the whites. 
The Osages, at the time of our acquaintance with them, had had no intercourse with the whites, except occasional interviews—their modes of life were simple and temperate and their responsibilities few and light. Their jaws were not precociously ossified — they furnished ample room for all the teeth, and consequently they existed as a useful and a healthy 


ABOVE THE DIAPHRAGM. 
565 
family to the latest periods of life. Now, we believe that an intelligent, refined, and elevated civilization is just as compatible with sound and beautiful teeth, as the Osage simple savagism. All that is requisite is obedience to the organic laws. The obvious difference between American civilization and Osage savagism is this: the latter have not the means wherewith to infract the organic laws—their existence is in that state of necessary conformity which is common to all of the wild animals. The former, the Americans, have the means to outrage these laws, but have not the necessary intelligence and moral government to avoid it, in the use of them. The only remedy is a wide diffusion of the natural sciences, and until this is effected, we must be content to suffer an abridgment of our own lives and the premature loss of our children. From this fate, religion and church morality, though proper and useful —even indispensable in their places, canno' save us. 
The Cherokee Indians, and the other tribes named in connection with them, have, as peoples, homely jaws and mouths, and rotten teeth. Has this always been the case with them ? The contrary is very strongly to be presumed. 
They have had an extensive intercourse with the most depraved of the white races for more than a hundred years, and wherever this class of white men place their feet, there they plant their vices, and there is no soil so congenial as a savage one. These tribes have succeeded remarkably well in acquiring the vices of the white race, but their organizations were, and are still, too low to imitate, and much less to acquire, their virtues. 
We have, for many years, discovered that between social and mental troubles, on the one hand, and deformed jaws and teeth, on the other, there exists the relation of cause and effect, and the same relation exists between the abuses of the appetite and decayed teeth. The Irish population, beforenamed, very clearly illustrates the first, and so do the Indian tribes last named —but they illustrate both. The second conclusion is illustrated also by our family servants. We have never yet seen crooked jaws and tangled teeth unassociated with mental obliquities. 
The preceding facts justify these conclusions — healthy 


566 
NON-INFLAMMATORY FORMS OF DISEASE 
digestion is attended with sound teeth, and a happily-balanced mind with a harmonious face. 
It must now be obvious that dentition, viewed as a separate process, has but little agency in producing the affections usually denominated the " diseases of dentition." 
It may be thought by some that we have digressed largely from the intrinsic merits of the question, but if we succeed in making the reader think—in enlarging his views of the subject, such criticism will give us no trouble. 
"While we do not believe that dentition produces a single disease, yet it serves, under feeble conditions of the constitution, as an exciting cause, occasionally, to some painful attendants, which now claim our attention. 
Among those children who are constitutionally necessitated to suffer more or less from the process of dentition, we find the gums tumid and tense, the mouth hot, and the precise position of each tooth is distinguishable for some time before its appearance. In another class, we find the appearance of the teeth to have been preceded or attended by an intense redness of the mucous membrane, a copious flow of saliva, with aphthous ulcerations on the tongue, upon the outer surface of the avolse, and in the duplications of the lips, while the gums themselves may be neither swollen nor painful. 
Some degree of febrile action may be looked for in both of these states, with considerable fretfulness, peevishness, and even more direct manifestations of pain. Another morbid condition of the mouth, attended with considerable fever and disorder of the chylopoetic viscera, will sometimes be met with. In such cases the gums become very hot, tender, and swollen, more particularly over some particular tooth, upon which a tumor-like projection is formed. Little ulcerations, having a sloughy appearance, frequently form on the gum, and more particularly about some tooth that has just appeared through it. This affection is painful and difficult to remove; it has been named odontitis infantum. 
Many persons, acting upon mechanical principles—regarding the teeth and gums as so many nails forced into a piece of leather, and cutting holes upon the opposite side to aid their egress, proceed with the gum-lancet to aid the teeth in making their appearance. They seem not to reflect that this 


ABOVE THE DIAPHRAGM. 
567 
is a physiological process, and that a mechanical division of the gum cannot advance the appearance of the tooth. The projection of the tooth and the absorption of the gum are but separate parts of the same process. All such mechanical meddling with physiological processes only injures the child, and proves the operator to be uninformed upon the subject. 
If there be instances which legitimately call for the use of the gum-lancet, they are exceedingly few — so few, that we cannot reconcile with our physiological judgment in the premises, the idea that such a case ever existed. But if such cases ever exist, they are those in which the operation can do no mischief, and therefore, when we can do nothing else, we may be justified in doing it, because of the possibility that it may produce some relief. Such cases are easily defined—they are those in which the tooth is so nearly through the gum as to produce a conviction that it will be through in one or two days. When the operation is performed, the instrument should be carried to the tooth. 
When the object is to relieve tumefaction and inflammation, temporary relief may sometimes be had by scarrifying the gums, and the importance of this operation is, in our opinion, greatly overrated; at all events, it is an operation that differs widely from the other, and is performed for a very different purpose. 
There are cases of constitutional disturbance, which may continue for several days and even weeks, during which time the dental process continues perfectly stationary. In such cases, we are told that we might try the experiment of lancing the gums. But why do a useless thing, especially as it will inflict some pain ? Has not the morbid irritation, in other parts of the system, suspended the process of dental protrusion and alveolar absorption ? We must restore the system to its normal condition by such means as the constitutional disturbance may indicate, then the lancet will not be required nor indicated. 
In cases of convulsions for which we can assign no probable cause, the gum-lancet may be used upon the principle that calomel is generally administered—it may do good, although we cannot tell how, or wherefore. It may relieve the convul sions by causing the loss of a drop or two of blood, or it may 


568 
NON-INFLAMMATORY FORMS OF DISEASE 
do it by producing a change of local irritation, or it may do it by producing a shock to the nervous system, or it may do it by some means which we cannot anticipate—at all events, it will do no harm, and after all, this is perhaps the best reason that can be assigned. If as much could be said in favor of the present indiscriminate use of calomel, we could better tolerate its use. 
As the period of dentition is one of revolutionary action, we should be careful not to provoke evils which, by care, may be avoided ; consequently, we should make no change in any of the habits or customs of the child during this process, except in the periods of repose—as between the shedding of the two inferior and the two superior incisors, and so on. 
In that severe affliction which sometimes happens to infants, denominated odontitis, the gum-lancet can do no good, but may do much mischief. The operation would be very painful, and then the morbid inflammation which accompanies the inflammation of the gums, might seize upon the fresh wound and increase the sufferings of the patient. 
"We are told by writers on infantile disease, that the old prejudice concerning disease of the skin which appears at this period, being salutary in its influence, is not without a foundation in truth; that instances of convulsions or other cerebral signs of mischief have been known to succeed a sudden disappearance of cutaneous eruption. 
We admit the facts, and regret to say that we have nowhere seen a rationale of them for the guidance of the student. When this is once had, the student can never hesitate in his course. 
Let it be ever present in the mind of every physician, that no organization can manifest, at one and the same moment, two equal or supreme actions. Now, the application of this law will explain the whole difficulty. It will do more—it will sustain a conclusion which we advanced a short time since, viz: the process of dentition produces no disease. 
If nothing morbid be in the system, there will be no cutaneous eruption; but the eruption exists, hence there is morbidity in the system. If this eruption be dried up, the constitutional morbidity will seek some other channel for its manifestation. If the existing morbidity of the constitution 


ABOVE THE DIAPHRAGM. 
569 
be eradicated, then the removal of the eruption will not be succeeded by convulsions or any other manifestation of disease, because there does not exist any disease or morbid quality to manifest. In other words, it is not in the power of the system to maintain a manifestation of an equally morbid condition through the skin and the brain at the same time. 
A circumstance in the physical history of the writer will do more to illustrate the principle we have laid down, than any language of definition we can command. When a medical student, at Lexington, he suffered much with dyspepsia—the gastric derangement was manifested in various ways, and sometimes by toothache, but never by any pain or sense of ill being in the stomach. Upon one occasion it was through a most violent toothache—he entertained fear that serious consequences might result upon the extraction of it. After bearing with it three or four days and nights without intermission, he consulted Professors Drake and Dudley, and they expressed the opinion that he might venture to have it extracted ; but so strong were his apprehensions, that he endured it four days more, and then ventured and had it extracted. In less than an hour after the operation, he had a violent attack of asthma, and all the rest he obtained, in another week, was in a sitting posture. He had never had this disease before, nor has he had it since. 
The principle now being made clear, we can calculate the chances for the little sufferer. If the brain be large and the chest small, or if it be large and prominent in its circumference at the parietal ridge, by all means suffer the eruption to continue, but, if possible, not to increase. If the general health of the child be feeble, the same course may be the most advisable. With the patient before him, the physician can decide better than we can at this distance from him ; but of one thing he may be sure — if the cutaneous eruption be cured, and there remains in the system any morbid quality, it is very probable that it will be manifested through the dental process. 
But sometimes the eruption spontaneously dries up, and this is because a stronger action is being generated in the dental process. In such a case, it may be advisable to increase 


570 
DISEASE ABOVE THE DIAPHRAGM. 
the cutaneous irritation by other means. Finally, the physician must aim at the least of impending evils. 
[Note. —If physicians really desire to be of service to this class of their patients, they should make themselves thoroughly acquainted with the anatomy, physiology, and pathology of the teeth. The ignorance that obtains in the profession, on this subject, is shameful. We understand thoroughly the import of the language we are using. How could it be otherwise? Ninetyfive per cent, of the students have no other advantages upon the subject than works of general anatomy, and a half-hour's lecture from the anatomical professor. It has been our full and thorough conviction that no medical school is complete without a professor of dental anatomy, physiology, and pathology, and he should have received a thorough medical education. We once heard a graduate of an eastern college gravely remark that he had not shed all of his jaw-teeth ! We do not know how often infants, suffering from dentition, had been confided to his care !! ] 


CLASS II. 
MANIFESTATIONS OP DISEASE IN THE DIGESTIVE APPARATUS LOCATED BELOW THE DIAPHRAGM. 
ORDER I. 
INFLAMMATORY FORMS OF DISEASE IN THE DIGESTIVE APPARATUS LOCATED BELOW THE DIAPHRAGM. 
Genus I. — Peritonitis— 
Inflammation of the Peritoneum. 
This disease sometimes attacks the fetus, and the causes must necessarily be peculiarly obscure, but the revelations of post mortem examinations have discovered two cases that were, very probably, occasioned by strangulation of the intestines.—(Cy. Prac. Med.) The many examples of peritoneal adhesions, which have been detected in infants that lived but a few hours after birth, show that inflammation occurs frequently to intra-uterine life. 
The causes of this affection during lactation are, perhaps, not much less obscure than during gestation. We can, in some cases, readily suppose it to be occasioned by improper food, and a few more cases by wet clothing. 
Its early symptoms, or those of the first or inflammatory stage are quite obscure, so much so, as to frequently pass unnoticed; and the first information that is had, in most cases, consists of that tension and tumefaction which have resulted from effusion. The slight pains which had previously been manifested were attributed to flatulence or some other trivial affection of the bowels. As in adult peritonitis, pressure upon the abdomen occasions a sensation of soreness to be revealed in some part of the abdomen, but most generally 
(571> 


572 
INFLAMMATORY FORMS OF DISEASE 
about the umbilicus. Coughing and sneezing also awaken this sensation. The cutaneous tissue upon all parts of the surface is pale, and the pathognomy of the face indicates languor, suffering, and discontent. At night the child is restless, its sleep is broken and unrefreshing; the appetite is variable; the bowels are usually affected with constipation and diarrhea alternately; the tongue, along its middle, bears a white fur, while the edges are clean and of a pale-red color; the pulse during the forenoon is normal, but toward evening it becomes contracted, quick, and accelerated ; the skin, like the pulse, is quite normal in its temperature, until the evening exacerbation arrives, when it becomes abnormally elevated. It is proper to add, that in some cases the abnormal pain is constant, quite severe, and attended with vomiting, and a greater severity of the previously-enumerated symptoms. 
The duration of this disease, as in adult life, is very various, but at sometime between the fifth and twentieth day, effusion into the peritoneal cavity takes place, and the abdomen consequently becomes enlarged ; and that it is really effused serum, percussion leaves no doubt. The effusion, however, if not arrested, goes on still further to enlarge the abdomen, the skin of the superior parts of the thighs hangs in folds, the extremities become emaciated, and so does every other part of the body, except the face and the parts before-named—and in this extremely reduced and prostrated condition, the patient, under a consuming febrile excitement, sinks into death. 
Diagnosis.—It is all important, in some respects, that a mistake in the premises should not be made. The pain of colic is more severe, spasmodic, and intermitting, while that of peritonitis is constant, rarely so severe with infants; and then, again, pressure gives relief in colic, and pain in the other. 
Parents, and the unprofessional in general, are apt to mistake this disease for that of worms, and to administer anthelmintics, which perhaps never fail to increase the mischief. As there is no certain symptom for the presence of worms, we must be guided by the presence or absence of those which characterize peritonitis. 
Prognosis.— This is not necessarily a fatal disease—under proper treatment, in its first stage, it yields quite readily; 


BELOW THE DIAPHRAGM. 
573 
and even in the seeond, when effusion has manifestly taken place, it may still be arrested by judicious treatment. The great difficulty to contend with is the obscurity of the early symptoms — we cannot always discover the nature of the malady with which we have to contend. 
Treatment.— The patient should be kept in bed and not allowed to change his position often, and not even the bedclothes should be allowed to press upon the abdomen. Notwithstanding constipation is a frequent accompaniment, we do not regard it proper to induce free catharsis, for this, in all cases, would be attended by an increase of all the above-named symptoms; and even where laxatives have to be used, they should be regarded as secondary agents; hence, so soon as the disease has been fully diagnosticated, apply warm fomentations over the stomach and bowels or cloths wrung out of the decoction of bitter herbs, which should be as hot as the patient can bear; these should be repeated as often as they become cool, until the active symptoms have subsided, which may be from twenty-four to sixty hours. 
To remove the constipation, injections of Starch-water, with a small quantity of table salt and the Antispasmodic Tincture, should be given. 
If this combination should not be sufficiently active, and violent pain be present, the Sudorific Tincture may be added. The Neutralizing Cordial may be administered in laxative doses, until mild evacuations have been produced. 
We do not regard it necessary to make use of counterirritation in this disease, but rely entirely upon the above treatment, which, if adopted in the early stage of the disease, there need be very little apprehension of effusions or depositions taking place. 
Genus II.—Cholera Infantum— 
Inflammation or high Irritation of the Stomach and Bowels. 
This form of disease is unknown to European society, and but little known in our own country, except in our middle and southern states. 
If to those conditions of the mucous membrane of the intestines which constitute feculent and catarrhal diarrhea, we add 


574 
INFLAMMATORY FORMS OF DISEASE 
a derangement of the liver and an erythematic inflammation of the mucous lining of the stomach, passing sometimes into a state of congestion, we shall be able to form a pretty accurate conception of cholera infantum. 
The exciting causes correspond with this synthesis—improper food and atmospheric exposures of the body, as by the use of insufficient clothing. We shall find the evacuations from the bowels and the condition of the stomach still further sustaining the above estimate of it. 
The natural faeces are frequently greatly retained, while the others are sometimes thin and serous or watery, sometimes more consistent and consisting principally of mucus occasionally containing some blood. The color is variable, being green, yellow, white, or brown, inodorous or very offensive, but generally having a sourish smell. Sometimes the alvine irritability is such that the ingesta lienterically pass through the intestines. 
Although the intestinal actions, in the beginning, may only indicate a diarrhea, yet the stomach is generally affected from the start, and when the attack is violent, the vomitings and purgings are attended with such spasmodic actions as to resemble the cholera morbus of adult life. 
The fever, which soon follows the first symptoms, is irregularly remittent, having its highest exacerbations in the evening. The brain is greatly involved, as is manifested by the delirium and even frenzy which attend it. The eyes, by their fierce or languid expression, when awake, and half-closed condition, when asleep, are indicative of the same. 
The pulse is generally small, quick, and feeble, or irritated and corded, but rarely full or strong. The thirst is intense and cold water is urgently demanded, and as soon as it is swallowed it is rejected. With all this, there is an unequal distribution of temperature, while the extremities are cold, the body is very hot. 
Emaciation progresses in this affection with great rapidity— the complexion becomes pallid, the flesh flabby, and such is the demand of the respiratory function, that the fat becomes entirely absorbed, livid spots appear which finally pass into ulcerations. 
The eyes and cheeks become sunken, the lips shriveled, the 


BELOW THE DIAPHRAGM. 
575 
integuments corrugated, except on the forehead, and nose pointed. Now, such is the character of the disease, that at this stage it is possible for the patient to recover, but still it is probable that he will not. 
In many instances, the vomiting, in connection with the above symptoms, continues to the close of life; but more generally it ceases, leaving a diarrhea to wear out the patient. In still more advanced stages of the disease, several other fearful symptoms are generated—the abdomen becomes tumid or sunken, the mouth becomes moist and aphthous, petechias and a small, vesicular eruption appear on the breast, the skin becomes of a dull and dirty hue, and the conjunctiva appears bloodshot. The circulation has become exceedingly languid, the patient very restless and plaintively moaning, coma comes on and terminates the suffering, but not always without symptoms of hydrocephalus. 
The vesicular eruption on the breast, the discharge of living worms, and the thrusting of the fingers into the back part of the mouth, as though desirous of withdrawing something, are regarded as invariably fatal symptoms: but the tenacity with which the infantile system clings to life, in this form of disease, most generally, is truly remarkable: the struggle seems to be one of time, and if the physician can stay, even to some extent, the progress of the disease, to a more advanced season, the patient may recover, however improbable it might appear from the exceedingly worn-out condition of the patient. 
In duration, the disease varies from a few hours to weeks, and from weeks to months; and in accordance with an old adage, it may almost be truly said of it, that " while there is life there is hope." 
Causes.—Much has been said about the cause of this disease—it is maintained by very many that the process of dentition, the existence of worms, and exposure to cold have much to do in producing a predisposition to it. But all of these causes operate upon children in the second dentition, and yet they do not have this disease. Again, all these causes act upon children, under two years of age, during the cold months, as well as the warm ones, and yet they are not assailed by it. The children of other countries, and in the 


INFLAMMATORY FORMS OF DISEASE 
576 
same latitude, are operated upon as much, by the same causes, as are the children of this country, and yet they do not have the disease. Is it safe, then, to infer that these causes have any agency in the production of it ? As it occurs during the process of first dentition, it is very convenient for those who have not candor enough to confess their ignorance, to avail themselves of the coincidence, as of a cloak with which to hide their ignorance. 
Prof. Wood, in treating of this disease, says, that the first indication is to remove the causes, and that while these are permitted to continue, the physician can do but little to promote a cure. Now, as we are sure that the causes have not been discovered, we are equally sure that they are never removed unless by accident, hence we may charitably suppose that the astonishing fatality of the allopathic practice, in this disease, is to be charged to the non-removal of the causes. 
As the disease is confined to a certain district of country, we hold it to be impossible to remove the causes, but it is possible to remove the child out of the midst of them. 
We are told that this disease prevails much more in small courts, alleys, and narrow streets, than in other and better ventilated parts of the city. If this be a fact, one step is made toward a discovery of the conditions under which it is produced. It is our conviction, that, in the south at least, the alleys and narrow streets of the cities, and low situations of the country, are much more exempt from summer and fall diseases than the less crowded and better ventilated portions, and the more elevated ones of the country, so far as regards adult life. Our observations in the city of Baltimore, in ilississippi, Alabama, and Louisiana, but more especially in the city of New Orleans, forced us to this conclusion. If this statement be true, then, we have made another step in the progress of this inquiry. 
Again, it is an admitted fact that the disease is measurably confined to our middle and southern states, and will it not be admitted that these states produce a greater amount of evaporation than any other district, of the same magnitude, in the world ? If this be admitted, we have safely made a third step. 
In the next and last place, it is already admitted that it prevails more in our cities, than in the country, while the 


BELOW THE DIAPHRAGM. 
577 
disease of adults, during the same season, prevail much more in the country. 
Now, although we shall have safely taken these four steps, it does not follow that we shall discover the precise cause of cholera infantum; but it does follow that we have made a useful advance toward it, and that too, without pressing into our surface that other cloak which was invented to cover ignorance—miasmata. 
We will now venture another step: to chemists, we believe, it is well understood, that where there is the greatest amount of evaporation, there is the greatest reduction of temperature and the greatest evolution of electricity. The predisposing cause or causes now lie concealed in the preceding facts, for assuredly it is not doubted that all children, during the first two years of their existence, because of the peculiar condition of their systems at this age, are susceptible (not predisposed) to the influence of the cause of this disease, no matter in what it may consist; and by its continued influence, for a time longer or shorter, a predisposition to it will be produced, when a slight exposure to cold, too much cold drink, or an improper article of food may excite the predisposition into action, and cholera infantum is the result. 
Admitting that we have truly advanced thus far, it will be admitted, although we have not discovered the entity that causes or predisposes to the disease, and although we cannot remove it, that we have shown, that by the removal of the child, even fifty or a hundred yards, we may place it in a condition very nearly the opposite of the one in which it contracted the disease, and this can, most generally, be done. 
Inasmuch as we have not got obvious facts to lead us further, and inasmuch as we are entitled to the privilege of indulging in such inferences, from the facts we have, as suggestion may furnish, we will attempt a nearer approximation to the predisposing cause of the disease before us. 
The great amount of electricity evolved in ventilated and evaporating situations may be assumed as the cause of the various forms of summer disease in adults, for it is true, that there is not a morass or swamp in our countay, about which a man may not live and have good health, provided he will live in the woods, or even sleep in them. About the country 
37 


578 
INFLAMMATORY FORMS OF DISEASE 
farms there is more evaporation than in our cities, and he is more liable to sickness in the former than in the latter. 
Now, with regard to children, it may be assumed that their cutaneous function is rendered imperfect by the surrounding humidity—a humidity that could not injuriously contend with the force of an adult skin. In the next place, may it not be safely assumed that this humid state of the atmosphere impedes, to an equal extent, the pulmonary function, preventing a thorough elimination of the carbon of the venous blood — and preventing such an absorption of oxygen as maybe essential to the elimination of the metamorphosed tissues? If these two functions shall be embarrassed, it is obvious that an excess of duty will be imposed upon the liver and kidneys and cause them to fail. If we are justified in the preceding conclusions, have we not found a sufficient cause for the disease ? 
But we have not yet done. Considering the soft, serous, immature, and developing condition of infancy, may not its organism require that electrical atmosphere which evaporation produces in freely-ventilated situations ? To us, this seems to be exceedingly probable. 
It appears far more than probable that we shall never be able to understand the modus operandi of any of the occult causes in creating predispositions to disease; but it is possible, by a careful observation and comparison of facts, to obtain a knowledge of the conditions under which it is produced. When we shall have acquired this knowledge, although we shall be no more able to change or modify them, we will be able to deport ourselves wisely with reference to them. 
Treatment. — Although, under Allopathic treatment, this disease proves very fatal, yet, as far as our observation and. inquiries have extended, the treatment which we herein lay down as Eclectic, has been almost uniformly successful — the failures being mere exceptions to the general rule. 
The agent on which we principally depend for the removal of infantile summer complaint, is the Syrup of Rhubarb and Potassa, which removes nausea and vomiting, when present, acts mildly upon the stomach and bowels, and restores the evacuations to a healthy condition. 
If febrile symptoms are present, the whole surface of the 


BELOW THE DIAPHRAGM. 
579 
body and limbs should be sponged two or three times daily with a weak alkaline solution rendered stimulant by the addition of a small quantity of whisky or spirits; and in obstinate cases, attended with high fever, the Compound Tincture of Virginia Snakeroot may be added to the above syrup, in the proportion of one part of the tincture to four of the syrup. 
Where the discharges from the bowels are frequent, and attended with pain, we employ the following injection, used cold, to be administered immediately after each evacuation, and retained in the rectum as long as possible. 
Sr. Ulmus Fulva, 
Cort. Prunus Virginiana, aa gss, 
Aqua, octj. Mix, 
let it stand two or three hours, and it is ready for use. The quantity to be used as an injection must vary from one to two drachms; larger quantities increase the disposition to strain or defecate, which should always be avoided. Usually, we add a few drops of the Compound Tincture of Virginia Snakeroot to each enema, and in protracted cases, we add about one-fourth part of the Saturated Tincture of Prickly-ash berries. This injection has a decided influence in moderating inflammation and relieving pain. 
Where vomiting is obstinate and frequent, a Mustard poultice, applied over the epigastric region, will be found useful, in connection with the internal use of the syrup and tincture, as above-named; and if the patient at any time during the disease becomes prostrated, stimulants must be administered, as diluted Brandy, Wine-whey, or Aromatic Spirits of Ammonia. 
Cooling mucilaginous drinks should be frequently given when irritability of stomach and accompanying nausea or vomiting are absent. 
After the inflammatory or febrile form of the disease has been removed, should diarrhea remain, astringents, with tonics, must be given ; as, 
Hydrastin, 
S. Qninia, aa grs. ij, 
Geraniin, grs. xvi. Mix, 
Divide into sixteen powders, of which one must be given 


580 
NON-INFLAMMATORY FORMS OF DISEASE 
every hour or two, according to the urgency of the case, and continued until the excessive evacuations have ceased. 
Occasionally, very obstinate cases of cholera infantum occur, in which the employment of Leptandrin, to overcome biliary derangement, in conjunction wtith the other means already recommended, will exert a highly-beneficial influence. 
The child's clothing should be often changed, the diet should be light, as boiled milk, with powdered Cinnamon added, or milk thickened with "Wheat or Rice flour; and, if possible, it should be removed from the city to the country, or at all events, some distance from its home; and, under all circumstances, it should not be confined within a closed room, but should be exposed as much as possible to the air, but not to the influence of the sun's immediate action. 
ORDER II. 
NON-INFLAMMATORY FORMS OF DISEASE IN THE DIGESTIVE APPARATUS LOCATED BELOW THE DIAPHRAGM. Genus I.—Gastric Indigestion—Dyspepsia. 
This affection, in infants, as in adults, is marked by every grade of importance, because attended by every possible variety of gastric disturbance. Infants often throw up the milk they have swallowed, which appears sometimes unaltered, and at others, coagulated into masses of greater or less size. Sometimes it amounts only to simple regurgitation, attended with a little cough or hiccough. Sometimes, when it sucks too much, the contractile irritability of the stomach forces a portion of it up; and, lastly, when true indigestion is present, the matters thrown up show that such action has not been had upon them as would indicate a normal digestive process. 
While considering this subject, it should be recollected that the form of this viscus, in infants, and its position in the abdomen, are such as greatly to qualify it for the discharge of its contents, and hence the great ease with which they vomit. 


BELOW THE DIAPHRAGM. 
581 
The vomiting of infants, however, must not always be regarded as indicative of disease in the organ itself. It is a symptom of pleural or pulmonary inflammation, of the onset of cerebral disease, and frequently a precursor of the various forms of eruptive disease. It may also attend infantile diarrhea, and upon the use of improper food, it may attend signs of intestinal disturbance. 
The stomach, in this period of existence, frequently becomes so irritable, as uniformly, almost, to reject its contents; but this symptom is not always essential to the fact that this organ is incapable of performing, with necessary ability, its proper function, as attending circumstances will generally render very obvious. 
Sometimes, in infants, while no indications of intestinal disturbance exist, they will be suddenly attacked with violent vomiting, and although the stomach thus indicates an exceeding irritability, its desire for the breast is unabated —it sucks but to vomit, which may happen immediately or be procrastinated for a short time. 
Causes. —When the child has been usually healthy, such attacks as these may, very generally, be attributed to some derangement in the health of the mother or to some indiscretion. She has perhaps been absent and allowed it to be absent from the breast longer than usual, and then allowed it to indulge to excess, or the child has been fatigued, exposed to the sun, or been roused, in an untimely manner, from its sleep. 
Treatment. —No matter what the cause has been, the child should be taken from the breast, and a proper course of treatment commenced, not only for the removal of the existing irritability, but also as a prophylaxis. 
A tea-spoonful of cold water may be given to it, which, if retained, may be followed in thirty minutes by one or two more; and if these shall also be retained, then a little isinglass, or something else equally simple, may be dissolved in water and administered in the same way. 
If the vomiting shall have ceased for eight or ten hours, it may be allowed the breast or cow's milk diluted with water, but they should be used with the same temperance. 
If the stomach bear this course for ten, twelve, or more 


582 
NON-INFLAMMATORY FORMS OF DISEASE 
hours, depending upon the violence of the case, then it may be restored to the breast, under the precaution to guard against full indulgence. 
But should the vomiting be preceded or attended by intestinal disturbance or gastric symptoms of a more serious character, a resort to medicine is indispensable. 
In connection with the treatment above prescribed, a very mild aperient, as the Syrup of Rhei and Potassa, or a small portion of Leptandrin, may be given ; and if the vomiting shall have continued for several hours, the application of a Mustard or Cayenne Pepper poultice to the epigastrium will be likely to afford much relief. The physician must now rely upon his acquaintance with the general principles of the profession. 
Normally, the appetite is proportioned to the demands of the system —if therefore, the process of development shall measurably cease, the only obvious symptom may be anorexia. The child seems to have no special disease, but it gradually becomes paler and leaner. This state of the patient may consist in an inability of the stomach to digest even the smallest quantity of nourishment. But even this, under such circumstances, only indicates a general pathological state, which may be, as it often is, produced by a chamber too elevated in temperature, and badly ventilated. 
In dyspeptic conditions of the stomach, anorexia is more an attendant symptom, than is a gormandizing desire to feed. It often happens that the child never appears satisfied except when sucking; and when it has indulged to repletion, it seems very uncomfortable until it has disgorged it. The relief which this process brings is immediately followed by a renewed desire to suck again. 
As regards the bowels, in these various phases of dyspepsia, nothing specific can be laid down; but this much may be said — anorexia is generally attended with constipation, while diarrhea as commonly attends over and constant feeding ; and yet the evacuations do not appear to indicate, to even a remote extent, the amount of deranged gastric action under which they are produced. 
It is far better to remove constipation in infants, as well as in adults, by soap suppositories, than by any internal admin- 


BELOW THE DIAPHRAGM. 
583 
istration of medicine. Frictions with some mild liniment, often prove advantageous. 
When the repeated vomitings have an acid exhalation, and are attended with a ropy mucus, and this too in the absence of evident signs of gastric inflammation, it will be proper to administer an antacid. In this disease, medicine may palliate or remove a symptom, but it is not wise to rely upon it, to make a cure. This has to be effected by a proper attention to diet, rest, ventilation, and temperature. It will be the duty of the mother to note the effect of every variety of infantile diet upon the child, to discover the one that will best agree with it. 
This gastric irritability may be produced by poison, which may have been associated with its food, from having been prepared in improper vessels, or it may have handled and placed in its mouth some metallic instrument coated with a poisonous oxide; but such occasions, while infants are at the breast, must be extremely rare. 
We should never omit to give particular attention to the color of the matters vomited up, because they may indicate their history; when they result from indigestion, and their seat is the stomach, they are very generally white, but sometimes a little yellow, and more frequently semi-fluid than coagulated. 
Mothers and nurses usually regard the regurgitations of milk, by infants, as ominous of health—no doubt but that it serves frequently as a prophylaxis, for in such instances, its ingesta was too abundant for the demands of health. But when the milk is retained, and then firmly coagulated and rejected with pain, we cannot form a very flattering conclusion. 
The casein of the milk is the first to coagulate, but then its coagula is never hard, like that which is vomited up. The normal coagula, when formed, is speedily dissolved by the gastric juices, and adapted to the purposes of assimilation; but this coagulation is a very different matter from that into which milk spontaneously runs. This is a step in the process of putrefaction, and generates a free acid which has none of the solvent power of the gastric juice, but impedes digestion, and hence the impropriety of feeding a child on sour milk. 


584 
NON-INFLAMMATORY FORMS OF DISEASE 
Now, it is possible, indeed very probable, that the stomach of an infant may be so deprived of its normal juices as to aid, by its temperature, the spontaneous process of acetous fermentation to the production of pain in the stomach and diarrhea— for certainly, it can be a matter of no difference as to whether this process is effected or commenced before or after its admission into the stomach. 
The vomiting of coagulated milk is frequently thought to indicate the existence of too much acid in the stomach; but this is not necessarily the case. It may only indicate such a condition of the stomach as disqualifies it for producing its juices in a sufficient quantity, or in a normal quality. In either event, the milk passes into the acetous fermentation. 
In all cases of this kind, the eructations are nauseous and the breath offensive. In cases of this kind, and they are certainly distinguishable, the mineral acids will be highly serviceable. Some of these cases are attended with diarrhea, which consists of pale, light-yellow evacuations —indicating a demand for an alterative medicine. 
A majority of infantile forms of disease, happening before the period of weaning, may generally be referred to some cognizable or occult morbus in the mother. In the infant, disease, beyond all question, exists, and it depends upon the exciting cause, as to whether it will be manifested in the form of dyspepsia, cutaneous eruption, or by disease of some other character. 
The various forms of disease which attack children, after they are weaned, are not to be regarded, necessarily, as independent of the same remote cause. 
Genus II. —Intestinal Indigestion. 
We frequently see children afflicted with diarrhea without the presence of enteritis or inflammation of the intestines. They are reduced to a state of marasmus and death by a want of nourishment, and yet have had a full supply of food—they die of hunger, with an insatiable appetite and plenty of food that was agreeable to its taste. 
This diarrhea consists of a thin white mucus, frequently containing lumps of coagulated milk, unaltered by the stomach or the intestines. After death, the mucous membrane of the 


BELOW THE DIAPHRAGM. 
585 
intestines is found to be without color throughout its whole extent, unless there shall still exist, in various parts of its surface, patches or streaks, retaining its normal color and condition. 
The causes of such defective nutrition may exist in the nature of the milk, in the manner in which it is taken, or in some great defect in the digestive system of the child. The milk of one woman may agree very well with some children, and be at the same time destructive to others; if, therefore, the quality of the milk be suspected to be the cause, some other food should be tried, such as cow's milk and water, or barley-water and milk. Such a change is sometimes found to be successful. 
If the milk flow very rapidly, the child may receive more than a proper supply at each time the breast is given to it, and as this practice would do more mischief than even a slight insufficiency, it should be carefully attended to. If the difficulty is inherent in the child, it may not be impossible to find such food as will agree with and nourish it. At all events, when the child manifests continual hunger, seizes the breast with great eagerness, has a pale face, and withal is becoming more and more emaciated, we should attend immediately to both the quality and quantity of the food, because medicine can do no permanent good so long as there shall be a fault in either of these respects. 
Genus III.—Colic. 
This complaint, in young infants, is peculiarly distressing, and, with many, it is an occurrence of every day. It is divisible into two distinct varieties, one of which may be occasioned by a considerable variety of causes, as badlydigested food (which very frequently happens to those infants who are artificially fed), or some morbid quality in the milk of the mother, which may result from disease in her system, or from outbreaks of temper; and when this is the cause, the consequence upon the child may be convulsions. 
This form of disease may also arise from the neglect of the nurse to keep the extremities warm. Flatulence is the result of all these causes, except the last, which appears to affect, principally, the muciparous follicles, and to a degree that may 


586 
NON-INFLAMMATORY FORMS OF DISEASE 
result in inflammation. This variety of colic has been denominated erratic. 
The other form of this complaint is called the periodical, because it returns pretty regularly at a certain period of the day, and usually in the afternoon. This variety of colic does not appear incompatible with the health, as it usually quits the child at the age of three months, and hence it gives old women no concern — they call it the "three-months bellyache." 
The cause of this colic is greatly concealed, but not more so than are the adequate means for its removal. Constipation is a very constant attendant upon it. • 
Erratic colic may occur at any time of the day and without being traceable to any probable, and much less certain, cause. Its subjects are most generally, those of a feeble constitution. The patient may take the breast with a good appetite, and the mother may furnish an abundance of milk, but because of some morbid quality in the latter, the stomach of the former becomes filled with a fluid which it cannot digest, but which becomes acid, producing in the child, probably, a diarrhea with green stools, or they may consist of ill-digested food, without any abnormal frequency. If the food be improper, whether of milk or otherwise, the child will manifest uneasiness as soon as it has done feeding. The abdomen becomes tense with manifestations of much pain. From these symptoms the patient is frequently and suddenly relieved by an eructation of gas, or by its passage through the large intestines. 
The treatment, of course, should commence with a removal of the cause, if it can be discovered. If acidity attend the disease, Magnesia will be indicated, more especially if a tendency to constipation shall exist. 
Sweet Oil, by the teaspoonful, three or four times a day, often proves a valuable remedy. 
Particular attention should be paid to the quality and quantity of the food, and if the patient be fed entirely by the breast then a suitable change should be made in the diet of the nurse. If it be nourished by the spoon or bottle, an occasional emetic will be useful to empty the stomach of indigestible crudities. 
If the colic have been produced by cold or wet, it will be 


BELOW THE DIAPHRAGM. 
587 
advisable to use a pediluvium, and at the same time warm fomentations with a flannel cloth with frictions with a warm hand to the abdomen. These means usually produce a revulsion to the surface. This course, with antispasmodics, as warm Mint teas, will generally suffice to remove the difficulty. 
Upon the periodical form of colic, constipation is a very common attendant, and yet "purgative medicines do not prove advantageous; but when it has been more than usually protracted, it may be advisable to administer an injection of molasses and water, or try a suppository of soap. 
The difficulty which is here intended to be removed, is confined to the large intestines, and therefore it can never be advisable to produce an increase of action in the stomach and small intestines to reach it—mischief must be the result. As this disease observes periodicity, it may be broken up by the prompt use of antispasmodics; but for the suffering of the child, the disease should produce but little concern, as it is not dangerous. 
Genus IV.—Diarrhea. 
This form of disease is peculiar to no age, yet it does, beyond all question, occur most frequently during infancy ; and it is proper to remark, further, that it is liable, at this early age, to assume a more dangerous character than at a more advanced one. In it the discharges or evacuations are more frequent and liquid, and sometimes more copious than is normal. Inasmuch as it is occasioned by very different causes, and obtains under very different conditions of the system, it has, for the purpose of elucidation, been divided into several species, as the Feculent, Bilious, Mucous, Chylous, Lienteric, and Chronic. 
Species I.— Feculent Diarrhea. 
This is treated of as the most simple form of the disease— in it the condition of the bowels appears, pathologically, to consist in such an irritation as may be produced by the direct action of offensive or acrid matters upon the mucous lining of the intestinal canal. Even the ordinary contents of the bowels may prove so irritating as to produce excessive peristaltic action, because of a pre-existing irritability of the mucous membrane, occasioned by unknown or inappreciable causes. 


588 
NON-INFLAMMATORY FORMS OF DISEASE 
When it originates in the irritation caused by acrid or otherwise offending causes, acting directly upon the mucous membrane, it will most likely cure itself by the expulsion of the offending substances; but when it results from some morbidly-irritable condition of the bowels—such as will not tolerate the presence of their most mild and ordinary contents, then we must not expect a spontaneous cure. When, therefore, the disease has existed three or four days, we may conclude that it depends upon some pre-existing morbid irritability of the bowels, rather than upon the presence of acrid substances. 
In this form of the disease, the evacuations resemble those which are usually produced by the action of cathartics—they are feculent, but less so when the immediate cause is the morbid irritability of the bowels, and under such circumstance it is more difficult to manage, because the irritation sometimes amounts to a subacute inflammation. 
Causes. —The most frequent cause of this form of diarrhea consists in improprieties of diet—the patient may have fed too much, or the food may have been highly indigestible; in either event, some of the food may pass through the stomach in a comparatively crude condition. From the presence of such food, the bowels may become so highly irritable, as, after its expulsion, to refuse to retain the most bland that can be given ; when the cause depends upon an incompatibility between the child and the mother's milk, the diarrhea is feculent throughout its course — depending upon a simple irritability of the mucous lining of the bowels. That constitutional irritation which attends dentition, not unfrequently occasions this form of diarrhea. 
Treatment.—In this form of diarrhea, the Syrup of Rhubarb and Potassa, given in doses suitable to the child's age, will be all the therapeutic treatment generally required; it should be given every hour until it has operated upon the bowels, after which its repetition every three or four hours will be sufficient. 
The child's diet should be especially attended to, and should consist principally of boiled milk, boiled milk-and-bread, toast-water, boiled Rice, Sago, etc., but no meats or vegetables, except the Rice. 


BELOW THE DIAPHRAGM. 
589 
If at the breast, the milk should be examined, and if found unhealthy, the nurse must be changed, or the infant weaned ; but if healthy, it should not be allowed to suck as much at a time as generally. 
Children sucking, should, as a general rule, be allowed no other food than the breast milk. 
Species II.— Bilious Diarrhea. 
This form of the disease not unfrequently appears in the feculent character, through that irritation which the presence of bile produces upon the mucous membrane of the bowels; but the color of the evacuations will indicate the source of the irritation. The appetite is frequently good, although the digestive powers of the intestines are much enfeebled. 
In this feculent form of diarrhea, nausea and vomiting occur more frequently than in any other, and it generally supervenes feeding, and rarely fail3 to end in colic pains and brisk purging. 
But the true bilious form of diarrhea betrays a much higher grade of biliary action than is indicated by the preceding symptoms. The bile is produced in an excessive quantity, and it is reasonable to suppose that its quality is greatly vitiated. The evacuations are mixed with much yellowish or greenish-looking bile, and generally the urine is much stained with it, and after having progressed a few days, the eyes and skin assume a jaundiced appearance. 
So far as can be inferred from the appearance of the bile, it is entirely normal in quality but extremely copious in quantity ; but in other instances, its appearance is very unnatural and its quality is so acrid as to occasion considerable burning and irritation about the anus. When the evacuations are of this character we should be prepared to apprehend a supervention of some inflammatory irritation of the mucous membrane. 
It is not uncommon for the bile, in the course of several days, to become replaced, entirely, by an aqueous fluid or secretion, which is attended with considerable irritation of the stomach. This suspension of bilious secretion is, most probably, occasioned by a venous congestion of the liver. 
Causes. —A modification of bilious diarrhea is frequently 


590 
NON-INFLAMMATORY FORMS OF DISEASE 
induced, among children of two or three months of age, by such feeding as is calculated to tax heavily the digestive apparatus, such as bad milk and other improper food. Attending this variety there is apt to be much acidity of the intestinal canal, which occasions griping. The evacuations are usually of a bright-green color. 
But bilious diarrhea, properly so considered, usually occurs about the close of the hot season, and is occasioned, in our opinion, by such a debility of the cutaneous system, as incapacitates it for the discharge of its function, and consequently the liver is vicariously called into action to depurate for the skin ; and this cutaneous debility is occasioned by solar heat, under circumstances of defective evaporation, as a humid atmosphere. 
Our observations in the south have brought us to the conclusion, that adults, in the hot season, do best in a humid atmosphere, and children in a dry one. For the reason above assigned, populous cities and marshy districts are more productive of the disease than situations of a contrary character. Under such circumstances, other etiologists consider malaria to be the cause. In the first place, we deny the existence of such a poison; and in the second, nothing is gained by the admission of it—it affords no pathological information. To say that malaria caused it, is equivalent to saying that it had a cause. 
Treatment. — The treatment recommended for cholera infantum is that which we have found the most successful in this form of diarrhea. 
Species III.— Mucous or Catarrhal Diarrhea. 
This form of diarrhea differs widely, in some respects, from the two preceding—this is measurably confined to the large intestines, while the two former more especially belong to the small ones. 
The evacuations are sometimes pure mucus, but in the more severe forms of the disease, the mucus becomes opake and whitish. "With the mucous discharges, there is frequently mixed feculent matter — sometimes mucus alone precedes the feculent matter, and at other times succeeds it. 
The discharges are occasionally, especially when they are 


BELOW THE DTAPHRAGM. 
591 
opake or streaked with blood, as is sometimes the case, preceded by tormina — they are very rarely copious, but sometimes not only frequent but attended by tenesmus and some straining. So far as we know, it only becomes requisite to aggravate it so far as to make inflammation requisite for its removal. 
Causes. —This form is regarded by some as a catarrhal affection of the bowels, and, like other affections of the kind, is produced by cold, acting upon an excited condition of the cutaneous exhalants, whereby their function is suppressed. We do not, however, regard cold alone as the cause of this variety of diarrhea. Any cause calculated to suspend the function of the cutaneous exhalants may cause it; consequently, under some modifying influence, it is produced by the same general cause that occasions bilious diarrhea. When thus occasioned, it is more liable to pass into dysentery, or to become chronic. 
Species IV.— Chylous Diarrhea. 
It would have been, in our opinion, much more intelligible to have nominated this form of diarrhea, the anti-bilious, because bile is as certainly absent in this form, as it is present in the second. This is not all: it is evidently a misnomer to call it chylous, because the immense quantity that is sometimes evacuated precludes the idea of its being chyle. 
This form of diarrhea is indicated by light-colored evacuations —such as are of a dirty white, sometimes almost of a milky whiteness, and when very abundant, they considerably resemble the rice-water discharges of cholera. With adults, one of the symptoms is an uneasiness in the abdomen, with very little acute pain, but with great depression of spirits. From this symptom, we would infer a very positive congestion of the liver and portal circle at large. The skin is more or less shrunk, and a feeling of prostration is a very general attendant. 
There does not appear in the course of this form of disease, a single symptom that indicates the existence of an intense irritation. The hands and feet are cold—the process of nutrition is greatly suspended, and hence the work of emaciation 


592 
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progresses with much rapidity, and when considerably procrastinated, the skin becomes'sallow. 
In view of the above facts, the most probable conclusion appears to be, that the mucous membrane of the small intestines is highly congested, and that the chylous-looking evacuations are effected for its removal. 
In the character of the evacuations, in the feeling of dis tress and prostration, in the shrunken condition of the skin, m the absence of bile, in the rapid emaciation of the patient, and its indisposition to terminate favorably, it has a considerable resemblance to cholera. 
Causes. — The immediate cause may be a suspension of hepatic action, and consequently the chyme is not converted into chyle — not adapted to nutrition, and it is rejected with serous matter. But it seems to us more probable that there is a failure of the liver to perform its function, and possibly the lungs, also, more or less; consequently, there is too much carbon in the blood, which, in not being eliminated, has become to act upon the system as a foreign body, producing catharsis or this particular form of diarrhea. 
This would seem to be the most probable conclusion, if the experiments of Tiedman and Gmelin are to be relied upon— namely, that bile is not necessary to the production of chyle. We think it very questionable whether the remote cause of this form of diarrhea can be determined with much probability of accuracy. The exciting causes may be cold and improper food, and the remote may be the same as in bilious diarrhea, in conjunction with some peculiarity of constitution, possibly some debility of the pulmonary system —a question which our observation has not settled. 
Species V. — Lienterio Diarrhea. 
This form of diarrhea appears, in some measure, to be allied to the preceding —such a modification of it as might be supposed to follow a reduction of portal congestion, with an increase of gastric irritation. As it consists in a rapid transportation of alimentary matter through the bowels, almost unchanged, it would seem to have its principal source in the stomach, for as soon as food enters it, it is forced, by a rapid 


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peristaltic motion, into the intestines, which as speedily hurry it through at their inferior extremity. The appearance of the evacuations leaves scarcely any room to doubt that the gastric secretions are suspended. 
The evacuations, in this form of diarrhea, consist of the food which was taken but a short time previously. At the onset of the disease, however, the evacuations do not occur until several hours after eating; but as it advances, if uninterrupted, the intervals between the reception of the food and its evacuations become more and more brief, until at last there is no delay between its reception by the stomach and its rejection by the anus. 
In this condition of the malady, the patient feels considerable uneasiness in the epigastric and umbilical regions soon after eating, which, in a little time, is followed by severe tormina, and to this succeeds, with much haste, a diarrheal evacuation of offending matter. The griping, however, is not a necessary symptom —it is frequently absent, in whole or in part. 
The appetite is variable, sometimes voracious, at others capricious—loathing some articles of food, and desiring such as may be very objectionable, from its crude, acrid, or exciting nature. Pressure upon the abdomen but rarely produces a sensation of pain or soreness; but jumping or jolting, coughing or sneezing does. In some instances, the evacuations are mixed with dark-green bilious matter, or with a fluid resembling a solution of verdigris. 
This form, like the preceding, indicates no disposition to terminate favorably, and consequently it should never be neglected. It is very apt to appear as a sequelae to the other varieties, but more frequently of dysentery, and this fact would seem to strengthen the pathological views above advanced. When, under such circumstances, a single article of diet is known to pass through the bowels, unchanged, the commencement of this form may pretty safely be suspected; and in a short time the suspicion will be found confirmed, by a similar passage of other articles of food, until finally, all the ingesta, indiscriminately, is rapidly passed through the digestive apparatus, without the least indication of having been acted upon by them. 
38 


594 
NON-INFLAMMATORY FORMS OF DISEASE 
In lienteric diarrhea, the stomach must be regarded as the principal seat of the disease, and consequently it may be esteemed as a violent attack of indigestion. 
Causes. —When it appears as the sequelae of other forms of disease, the exciting causes may be an improper exposure to cold, or improper food, or a voracious use of such as may be otherwise unexceptionable ; it is, however, more apt to appear, under all circumstances, gradually—having its remote cause in food of an irritating character, or in improperly managed diarrhea in either of the preceding forms, or dysentery. 
Species VI. — Chronic Diarrhea — Weaning Brash. 
It is thought that either of the preceding forms of diarrhea ma} 7 , in children, become chronic, but we are much inclined to the opinion that the bilious variety, caused as it is by direct and sympathetic impressions, is the one which most generally runs into the chronic state, or may assume the chronic form. The general character of the evacuations, in our judgment, sustains this opinion. This conclusion is rendered very probable by the fact that every variety of vitiation in the function of the liver would tend to the maintenance of the diarrhea. 
An undue continuance or neglect of the feculent and catarrhal species may so weaken and impair the mucous membrane of the intestines, as to render it more obnoxious to the vitiated secretions of the liver and all other sources of irritation. 
It is usually announced by griping pain and purging, with yellow or green evacuations, depending upon the violence of the attack. If this introduction of it shall be neglected for a few days, retching, and sometimes vomiting of bile-colored dejections, will follow. These manifestations will soon be succeeded by a loathing of all kinds of food ¦ — attended, as might be expected, with restlessness, thirst, fever, emaciation, and softness of the flesh. 
After the existence of the disease for some weeks, peevishness, griping pain, and a discontented expression of the face, become the distinguishing features of it. In the progress of the disease, great and many changes become manifest in the evacuations; their color is sometimes normal—at other times, ash-colored and slimy, and sometimes, without knowing the 


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history of the affection, we would judge it to he lienteric. It terminates fatally, sometimes, in two, three, or four weeks, but in such instances, it is apt to be by convulsions, occasioned by the intense irritation of the stomach and bowels; but a fatal termination rarely occurs under six or seven weeks; and then again, the disease may continue three or four months and terminate in convalescence. 
In consequence of the frequent coincidence in the appearance of the teeth and this disease, and the prevalent impression that a diarrhea at such a time is salutary in its influence, it is frequently neglected, until it results in the loss of the child. 
In this country, it mostly prevails in July, 'August, and September, and it is more frequent and fatal in damp summers and situations, than in dry ones. It is thought by some, that in the beginning of this disease, the mucous membrane of the small intestines is alone diseased, and that as it advances the liver, through intestino-hepatic sympathy, becomes involved, and by the increased quantity of its secretion, or the morbid character of it, the disease becomes more permanently established and much increased in violence. 
"We cannot indorse this view of the subject; if the disease commenced in the mucous membrane, what caused it ? It has not been shown, nor even contended, that it is either feculent or catarrhal in the beginning, and if it be neither of these, then it must be sympathetic, and if sympathetic, then the morbid condition is really somewhere else than in the mucous membrane of the intestines. These considerations, in connection with the season of the year in which it usually occurs, induce us to believe that it is more probably a result of an enfeebled condition of the skin acting through cutaneo-hepatic and intestinal sympathy. 
The difference between the two opinions, thus advanced, in view of the treatment, is one of immense impo.tance; the latter indicates a course of practice which could not do mischief, while that indicated by the former might reach the symptom, but missing the cause, the disease would not be removed. 
Dr. Cheyne informs us that post mortem examinations 


NON-INFLAMMATORY FORMS OF DISEASE 
596 
reveal many contractions and intus-susceptions in the alimentary canal, from the stomach downward — that they are of a spasmodic kind, and they are without " adhesions or even the marks of inflammation." In these facts we have one of the reasons why we have treated of diarrheas as non-inflammatory forms of disease. 
In this form, the liver, being highly excited, secretes much bile, but the excess of this action sometimes exhausts it, and then it produces but little, if any ; consequently, the evacuations will sometimes have a clay color, and the disposition of the patient will be more restless and gloomy in this respect. As a prophylaxis, children should not be weaned during the months in which this form of disease mostly prevails. 
The conviction is very general, in the popular female mind, and with many physicians, that the great danger of diarrhea, to. our infantile population, is in consequence of teething. We have in several instances repudiated this idea, and we are gratified to find that we are sustained by such authority as that of Dr. Cheyne. He observes: ».« 
" Notwithstanding my most diligent inquiries, I have seldom been able to deduce any of the derangements of the infantile system from teething; and 1 have been inclined to think, that those physicians who have represented this function (dentition) as teeming with danger, have not accustomed themselves to that careful investigation, without which these diseases cannot be understood. The weaning-brash, I have the strongest reason to believe, has no connection with teething, farther than they sometimes meet in the same child. I have known this disease, in many instances, where the gums were neither swelled, indurated, nor inflamed, and where there was no salivation, nor the least appearance of pain in the mouth. I have seen it where children were cutting their teeth easily; and where many of them came without difficulty before weaning; still the disease has supervened. But, perhaps, the strongest argument that ean be used, would arise from the observation, which I have frequently made, that this disease occurs in children of three months ; and I have often known it several months before teething came on." 
Causes. — Fruit is very generally included among the 


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exciting causes of diarrhea in the summer, consequently, we feel that a few remarks, of a discriminating character, are required of us. t 
We are of those who possess an abiding faith in the wisdom of all the plans and purposes of nature. Now, inasmuch as fruit is a product of the summer and fall only, and as it was intended for food, rather than as a temptation for us to sin, we believe that it is adapted to us during the season of its maturity. Then, it cannot, in the abstract, be pregnant with danger to those who use it properly and temperately. To use it properly, it must be ripe, and being ripe, we should divest it of the skin, which was intended for its protection and development, and not for food. It should not, furthermore, be used with our habitual food, particularly in its raw state. To use it temperately, it should not be taken in such quantities as to supersede, to any extent, the demand for the usual or more nutritious food. Furthermore, it should be taken about midtime between the regular meals. It is our conviction that ripe fruit, thus used, would prove a prophylaxis against the various forms of disease incidental to the season. 
As to chronic diarrhea, it may be stated, that a procrastination of early attention, improper treatment, and a neglect of the predisposing and exciting causes must be regarded as the general sources of this form of disease. 
The children most liable to it are those who have been prematurely weaned, and after weaning, improperly fed, as to both the quantity and quality of the food; but it is not confined to these, for it frequently obtains under widely different circumstances, and therefore, in many instances, atmospherical. 
Treatment. — The treatment of these various forms of diarrhea is so nearly alike, that we will consider them under one head. 
In the early part of the attack, the Syrup of Rhubarb and Potassa will generally be found fully sufficient to check the excessive discharges, allay vomiting when present, and remove the morbid condition on which the diarrhea depends ; it may be given every hour or half hour, in doses suitable to the child's age, and continued until it exerts a laxative effect, when the intervals between the doses should be lengthened 


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to two, three, or four hours, according to the urgency of the case. 
In addition to this, especially when the symptoms are obstinate, or have been of long duration, the whole system should be bathed with a warm alkaline bath, two or three times a day, and this should be pursued in all the forms of diarrhea, whether acute or chronic. 
If nausea or vomiting are present, and do not cease on the continued use of the syrup, a Mustard poultice, applied over the epigastrium, will be found advantageous, and a few drops of Paregoric may be added to each dose of the syrup. 
If there is much fever, with pain in the stomach or bowels, the Compound Tincture of Virginia Snakeroot, in proper doses, may be administered every hour or two, with the application of warm fomentations to the bowels, of bitter herbs, or even warm water. 
When there is prostration, with cold extremities, increased heat of the head, and restlessness, applications to the head, as for instance, the Cooling Lotion, with rubefacients to the extremities, and some stimulating liniment over the whole length of the spine, will be beneficial, and their employment should be persevered in. 
When tenesmus is present, a few drops of the Compound Tincture of Virginia Snakeroot, in one or two teaspoonfuls of cold water injected into the rectum, immediately after each alvine evacuation, and retained there as long as possible, will speedily remove this disagreeable symptom. In some cases, the wet-sheet around the lower part of the body, will prove a valuable auxiliary. 
The above course of treatment will generally be found effectual in overcoming any of the forms of this disease, but, should they run into the chronic form, other means will be demanded. 
Thus, in chronic diarrhea, the following has proved invariably successful, as far as we have used it: 
Syrup of Rhubarb and Potassa, giv, Hydrastin, grs. xii. Mix. 
Of this, a teaspoonful may be given every hour, to a child five years old, or proportionate to its age. If the discharges 


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599 
are frequent, twenty grains of Geraniin, or even more, may be added to the above compound. 
Tonics should be administered whenever they can conveniently, and we prefer the following: 
S. Quinia, 
Hydrastin, 
Leptandrin, aa grs. v. Mix, 
And divide into fifteen powders, of which one may be given every two, three, or four hours, to a child four or five years of age. 
In the mucous form of diarrhea, as well as in the chylous, alterative doses of Podophyllin and Leptandrin combined, or of Leptandrin and Geraniin, or of Lupulin and Geraniin, according to the indications present, will always be required before permanency of cure can be expected. 
In lienteric diarrhea, after the employment of the means heretofore named, tonics and astringents will be required to effect a cure; a combination of Quinia, Hydrastin, and Geraniin may be used, or Cornine and Geraniin. 
But, notwithstanding the therapeutical treatment, if the prophylactic is neglected, the disease may prove fatal. 
Especial attention should be given to the diet of the child, which must be mild, nourishing, and digestible, avoiding everything calculated to irritate the stomach, or which the child dislikes. All candies, preserves, and nick-nacks must be imperatively prohibited. 
The dress should be adapted to the season, and be kept as clean as possible. 
Exercise in the open air, if the condition of the child will permit, is of the utmost importance, and if this is impossible, the chamber in which the child is confined should be well ventilated, allowing fresh air to circulate freely through it. 
Genus Y. — Invekmination — Worms. 
It has been asserted and contradicted, that so lono- as children are exclusively fed and nourished by the breast, they will be exempt from worms. 
Dr. Dewees says, that he never saw children under ten 


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NON-INFLAMMATORY FORMS OF DISEASE 
months of age have worms, and only two so early as that, and they were weaned at the age of four months. 
The worms which have been most frequently found in the human system have been divided into three genera: I. Helminthia Alvi, alvine worms; II. Helminthia Podices, anal worms ; III. Helminthia Erratica, erratic worms. 
Of the first genus there are five species, and they inhabit the stomach and the intestinal canal. The indications of their presence are, foul breath, pale countenance, sore and irritable nostrils, emaciated body, swollen abdomen, and a pungent and gnawing pain in the stomach; but it is proper to add, that all of these symptoms are simulated by other causes of irritation, and hence we have no certain diagnostic symptom. The first species of the genus has been described by Dr. Good, as follows: 
Species I. — Ascaris Lumbricoides — Long Round-Worm. 
" The head of the long, round-worm is slightly incurvated, with a transverse contraction beneath it; mouth triangular; body transparent; color, light yellow, with a faint line down the side ; gregarious, vivacious; from six to fifteen inches long; inhabits principally the ilium, but sometimes ascends into the stomach, and creeps out of the mouth and nostrils ; occasionally travels to the rectum, and passes away at the anus." 
Species II.— Tricocephalus — Long Thread-Worm. 
"The body of the long thread-worm is, above, slightly crenate; beneath smooth, finely striated on the forepart; the head obtuse, and furnished with a slender retractile proboscis; tail, or thinner part, twice as long as the thicker, terminating in a fine hair-like point, about two inches long; in color, resembles the preceding; gregarious, and found chiefly in the intestines of sickly children; generally in the caecum." 
Species III. — Tcenia Solium — Long Tape- Worm. 
" In the long tape-worm, the articulations are long and narrow, with marginal pores, by which it attaches itself to the intestines, one on each joint, generally alternate; ovaries arborescent; head, with a terminal mouth, surrounded with 


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two rows of radiate hooks or holders; and a little below, on the flattened surface, four tuberculate orifices or suckers, two on each side: it is from thirty to forty feet long, and has been found sixty. Inhabits the intestines of mankind, generally at the upper part, where it feeds on the chyle and juices already animalized. Is sometimes solitary, but commonly in considerable numbers; and adheres so firmly to the intestines, that it is removed with great difficulty. It is said to have the power of reproducing parts which have been broken off; but this assertion wants proof. The animal is oviparous, and discharges its numerous eggs from the apertures on the joints. The broken-off joints have, when discharged, the appearance of gourd seeds ; and it is hence denominated gourd-worm by many medical writers." 
Species IV.— Taenia Vulgaris — Broad Tape - Worm. 
The articulations of the broad tape-worm are short and broad, with a pore in the center of each joint, and stellate ovaries around them; body broader in the middle, and tapering toward both ends; head resembling the last; inhabits the upper part of the intestines, and feeds on the chyle; from three to fifteen feet long; usually in families of three or four. 
Species Y.— Fasciola — Fluke. 
The body of the fluke is flattish, with an aperture or pore at the head, and generally another beneath; the intestines fluxuous; ovaries lateral; hermaphrodite and oviparous." 
Of the preceding five varieties, the first much more frequently occurs, but they are all occasionally met with in practice. 
Genus II.—Helminthia Podicis— 
Anal Worms, 
Of this genus there are three species ; they live just within the verge of the anus, and frequently prove exceedingly troublesome, particularly by the itching they occasion at the anus. The species are: 


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NON-INFLAMMATORY FORMS OF DISEASE 
Species I. — Ascaris Vermicularis — Thread-Worm — Maw- 
Worm. 
" The head of the thread-worm is subolate nodose, and divided into three vesicles, in the middle of which it receives nourishment; skin at the sides of the body firmly crenate or wrinkled; tail finely tapering, and terminating in a point; gregarious; viviparous; about half an inch long; sometimes it gets into the intestines, and occasionally as high as the stomach." 
Spectes II.— Scarabacus — Beetle- Grubs. 
"This species has not been accurately described. The following seem to be the chief: gray larve, with yellow legs, and ferruginous head; have six feet; are annulate, hairy, vesicular at the end of the abdomen, and furnished with a horny head. 
Species III.— (Estrus — Bots. 
" The larves of the oestrus, breeze, or gad-fly, are called bots, and are of a round figure; pale green; tail obtusely truncated ; head tapering; mouth horny, with two lips, and two re-curved black claws on each side of the mouth." 
Genus III.—Helminthia Erkatica — 
Erratic Worms. 
Of this genus but little is known. According to Dr. Good, they are, " the larves of insects, introduced by accident, and without finding a proper habitation in the stomach and intestines, producing spasmodic colic, with severe gripings, and occasionally, vomiting or dejection of blood." 
"Worms have probably been the torment of children almost ever since they commenced having an existence, and yet, we are exceedingly ignorant upon the subject. We have thought it proper to place the preceding descriptions before Eclectic students, under a hope that they may be induced to observe and to investigate the subject. It presents a large and promising field for professional labor, usefulness, and fame. If, in nature, there be a symptom which indicates the existence of either of the varieties of the first genus, to the exclusion of others, it has not been discovered. Nay, more, if there be 


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a symptom which could certainly distinguish the existence of any of the alvine worms from other sources of irritation, it has not been discovered. The first and only certain indication we can have of their existence, is the seeing of them. 
Causes.—The source of intestinal worms has been for a long time a subject of discussion; it is maintained by one party that their origin is external to the human body — that they are from germs or ovse of preceding animals of the same species; the other party maintains that they are spontaneously or equivocally produced by some species of affinity in the matter which exists in the system — that the first which appears in the system was produced by a living organic parentage. We have neither time nor space for the discussion of this subject; but we may remark that they exist—that the species had a beginning, and no matter when this beginning was, it was without organic parentage, and so far as we know, they can now commence without organic parentage, as readily as the first of the species did. Our investigations have satisfied us that it is about as difficult to change a species as it is to produce one, and hence it is probable that we shall incline to the opinion of their spontaneous origin until their representatives shall be found outside of the human system. 
Of the same nature is the inquiry into the origin of some contagious forms of disease. We do not expect to witness a case of small-pox or syphilis which did not have its cause in some previous organization ; but how did the first case originate ? May not either or both of them still originate spontaneously, when or under the circumstances that first produced them, which were certainly equivocal ? In water, at a temperature of 156° of Pah., at the Hot Springs, Arkansas, animals live and manifest an active life, and yet, in this same spring, fish, snakes, and toads instantly scald to death. Where were these little animals before the appearance of these springs ? 
A healthy condition of the system appears to be, in a very great degree, incompatible with the existence of these parasites; it is reasonable to infer then, that they did not produce all of that depravity of the system with which they are found to be assorted. Their existence, therefore, may be attributed to 9 generis depravity in the function of the mucous 


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membrane of the intestinal canal; and, although no age is exempt from this depravity, yet it much more frequently obtains with children above the age of infancy. Their existence is usually attributed to an accumulation of mucus, feeble digestion, badly-regulated diet, a damp atmosphere, etc. Much of this appears to be assumed—we find them under such circumstances, generally, but it does not, therefore, follow that they were produced under them—much of this derangement may have been produced by them. 
We have found worms under circumstances, where, a priori, we would not have expected them, and the reverse. It seems to us that a helminthic diathesis just as certainly obtains in society as a scrofulous one; but, at the same time, we do not doubt that the causes above named, serve greatly to aggravate this innate predisposition, more especially the anti-electrical condition of the atmosphere, for this we regard as the most fruitful source of juvenile disease. In such an atmosphere, no amount of care as to diet, and no amount of medical attention can prevent the generation of these parasites, during the proper age of the child for their existence, or during the inadaptation of the system to the atmosphere. 
Treatment.— Many agents have been recommended for the removal of worms, and the majority of them fulfill the indications for which they are given, yet their mere expulsion is seldom followed by any permanent benefit, if the condition of the intestines is not likewise especially attended to, by the employment of tonics or other agents suited to their particular condition. 
Pinkroot is, perhaps, as much relied upon for the removal of worms as any other simple agent. It is usually given combined with Senna, or with the Compound Powder of Jalap, in the proportion of from five to ten grains of the powdered Pinkroot, to the same quantity of the cathartic, and which may be given in molasses, or infusion, and repeated two or three times a day, to a child three years old, for several successive days. Infants several months old use it in the form of infusion. 
A very excellent vermifuge, which we are in the habit of employing, is made as follows: 


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Castor Oil, 3j, 
Oil of Wormseed, 3j, Oil of Anise, 3ss, Tinct. of Myrrh, 3ss, Spirits of Turpentine, gtts.x, Croton Oil, gtt. j. Mix. 
To a child three years old, a half teaspoonful may be given every two hours, for ten or twelve hours, or until active purgation has been produced. 
Another vermifuge, which has been used effectually, is: 
Tfc. Oil of "Wormwood, Oil of Tansy, aa 3j, Spirits of Turpentine, giss, Castor Oil, 3jj. Mix. 
The dose for a child, three or four years old, is a teaspoonful every hour until it operates. 
A preparation, composed of a medley of agents has been found very useful in the treatment of intestinal entozoa, but on account of its complexity, we have never used it —it is prepared as follows: 
Lime Water, oct. j, Oil of Wormwood, Spirits of Turpentine, aa 3j 
Tinct of Myrrh, 3iij, Essence of Anise, 3ij, 
Molasses, oct.ss, ' Oil of Tansy, 3ss, Castor Oil, oct. ss, 
Croton Oil, 3j. Mix 
The dose of this preparation is a teaspoonful two or three times a day. 
For the removal of the thread-worm, ascaris vermicularis, in addition to the above internal remedies, infusions or decoctions of bitter substances must be injected into the rectum, as of Aloes, Bitter-root, etc., or an enema of Spirits of Turpentine, one drachm, in milk, one gill. 
But, although, as before said, these agents may expel the worms, but small advantage will accrue to the patient, unless others are employed to restore the impaired condition of the 


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intestines to one of strength and health. For this purpose, we prefer the following preparation: 
Br. Hydrastis Canadensis, Calumba, Chamomile Flowers, Prickly-Ash Berries, Sassafras Bark, aa 3ss. Mix. 
Upon these articles, coarsely bruised, pour one pint of boiling water; let them stand until cold ; then add one pint of Sherry or Port Wine, and sweeten with loaf-sugar. The dose to a child, one year old, is a teaspoonful three times a day;—and with this, a proper attention should be paid to diet, allowing no indigestible substances to be received into the stomach, or such as acidify. 
Genus VI. — Costtveness — 
Tardy Action of the Bowels. 
Constipation .of the bowels, in children, as well as in adults, is frequently produced by certain varieties of ingesta, and it may also be constitutional; when, therefore, a physician is consulted upon the subject, his first business is to ascertain whether it is, and has been, habitual with the child, or only occasional, and irregular. 
With some persons, a certain kind of food invariably produces constipation. With many adults, sweet potatoes have this effect; and with many children, all the preparations of rice and boiled milk will produce the same result. That which will produce this effect in one child, may not do it in another; hence, it becomes the duty of the nurse or mother, as the case may be, to notice the effect which the various articles of a child's food produces upon its bowels, and when the one is discovered which causes such a result, its use should be discontinued. 
Nurses who are defective in patience, and still more so in honesty, frequently keep concealed about their persons, an article far more mischievous than any article of food—we allude to laudanum. Some mothers, not knowing the consequences, are guilty of administering to the infant the same 


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drug, or some preparation of it, and for the purpose of keeping it quiet. Parents should exercise an unceasing vigilance over their nurses with reference to this subject. 
Suppositories and injections are much more applicable to such accidental cases of constipation than medicine, because they excite the inactive part, which is usually the rectum, without preternaturally exciting the whole intestinal canal; but when these means fail, then it may be proper to administer some mild purgative, as Olive Oil, Castor Oil, the Compound Tincture of Jalap, or Syrup of Elderberries. 
When the constipation is constitutional, and entirely compatible with the health and happiness of the child, it is recommended to let it alone. 
The constitutional habit is such, sometimes, as to produce a stool but once in every eight or ten days ; we have seen men of sound health whose bowels manifested the same peculiar constitutionality, but we have always found an unpleasant circumstance connected with it—without a daily change of linen, and a frequent washing of the skin, an unpleasant odor was constantly emanating from the surface to the annoyance of others. Now, in view of this circumstance, we would not let the child alone which had such a constitutional peculiarity. 
As we believe that the vegetative organs can be trained or educated, as well as the animal, we would attempt to train the bowels of such infants to a more decent habit: and this may be done by a proper attention to diet. The Graham bran-bread principles, properly applied, might effect the desired change. For the bread, substitute mush, which might be variously seasoned to please the taste. 
Genus VII. —Prolapsus of the Rectum. 
The mucous lining of the rectum is attached to the next outer membrane of the bowels by loose cellular tissue, and in the affection, above denominated, this mucous membrane separates so far from the one to which it is attached as to permit a duplicature of it to protrude out of the body, forming what may be called a thick red ring at the anus. 
In a feeble child, it may be produced by crying or by coughing, the large stools which sometimes attend purgative 


608 
NON INFLAMMATORY FORMS OF DISEASE 
medicines, and also by any bowel disease which is attended with tenesmus. 
The greatest danger that attends this affection is a liability, through neglect, of its becoming a habit of the part that may continue through life. We, at one time had the acquaintance of a gentleman, thirty years of age, whose memory could not reach back to the time when he did not have a prolapsus of the rectum every time he attempted to stool, and every time before he arose, he had the prolapsus to reduce. In view of such a consequence, it is obvious that the utmost attention should be given to it when it occurs. 
As the sphincter of the anus acts as a ligature upon the protruded part, consequently, when it has been down for a few hours, its appearance becomes truly alarming; the stricture prevents the return of the venous blood, and then it soon becomes swollen and inflamed —assuming a livid color, which may pass to a black one. The stricture becomes so confirmed, as to give rise to much trouble sometimes in the reduction of the protrusion. 
When an attempt is to be made to reduce the prolapsed bowel, the child should be placed across the lap of the nurse, with the chest more depressed than the hips, the part should be lubricated with Sweet Oil or fresh Lard, gentle pressure should then be so conducted as to force a portion of blood from it, and when it is sufficiently reduced it may then be urged by pressure, made with the fingers, upward and backward, until it passes within the anus. The tumor, when reduced, may be retained in its normal position by the use of a T bandage, and compresses wetted with cold water. If it should manifest a tendency to descend or prolapse as often as defecation shall be attempted, the circumference of the anus should be supported during the discharge of this function. 
Sometimes the prolapsed portion becomes so large, through a failure to return it in proper time, that any attempt to reduce it, before the blood contained in it is disgorged, would prove not only mischievous but entirely unavailing. For this purpose, the child sflould lie upon its back, with its hips higher than its shoulders, and its knees drawn up, with the part uncovered, and kept wet with lead-water. 


BOOK IV. 
TREATMENT OF THOSE FORMS OF DISEASE TO WHICH 
ADULTS, MORE THAN CHILDREN, ARE LIABLE. 




PREFACE. 
When this work was commenced it wa3 the purpose of the authors to treat only of those forms of disease which have been observed to afflict children rather than adults, but such are the known wants of the Eclectic branch of the profession, as regards works of practice, that they have been induced to add a fourth book, to embrace those which pertain to adult, rather than to infantile life. Some of those which have been embraced, by the preceding Book, are common to adults as well as to and consequently they have been so treated. This book will also contain a few which have been known to assail children, but the treatment is adapted to both ages. There are also a few visceral affections which present very different forms in the two ages respectively, and they of course will be treated of again. 
In this wise, so far as their abilities will permit, they hope to give satisfaction to their professional brethren. 
CLASSIFICATION OF THE VARIOUS FORMS OF DISEASE. 
Although the forms or manifestations of disease are too numerous to admit of computation, yet all may be arranged under two heads or classes, the febrile and non-febrile. 
There is no form of disease that will not readily fall into one class or the other, and between those of the two classes respectively, there is no repugnance of character. It is true, that sometimes a form which is essentially, in its 
(613) 


614 
PREFACE. 
general character, non-febrile, may become febrile, but this is a mere circumstance, and as an objection, its magnitude is not greater than will occur in any other division that may be attempted; at all events, it suits the circumstances of our present purpose better than any other that has been suggested to us. 
As it is almost impossible for any physician, in the beginning of any form of disease, to entertain a doubt as to which class it belongs, so this division keeps constantly before his mind the leading idea of his duty. The limits, furthermore, that bound the two classes, are, usually so clearly defined, that the pulse alone will generally furnish a sufficient diagnosis. 
"We shall begin with the febrile class, or that which is distinguished by a special manifestation of the vital force— such as will frequently, without the aid of medicine, restore the patient to health. There is yet another reason why we should begin with the febrile class—it is more simple, because it is more easy to reduce force than increase it. 


CLASS I. 
PYREXIA OR FEBRILE FORMS OF DISEASE IN GENERAL. 
PATHOLOGICAL AND ETIOLOGICAL CONSIDERATIONS. 
The opinions upon the nature and character of fever are about as various and as numerous as have been their many writers, and if we commence their investigation with Hippocrates, who lived 361 years before the Christian era, and who was probably the first systematic writer on the subject, we shall find them, as we travel down to the present time, to depart more and more from our conceptions of the truth. 
He regarded the human system as being under the direction of a conservative, and in some sense, intelligent principle, which he denominated nature. Under such a conviction he must have believed that pathological manifestations were governed by laws as fixed and as determinate as those of gravitation—that all pathological action is just as legitimate and as normal, under the circumstances, as any purely physiological one. This inference from the preceding premise, is completely sustained by his opinion of disease, as set forth by the Edinburg Practice, Yol. I, page 6; viz: " He imagined disease to be only a disturbance of the animal economy, with which nature was perpetually at variance, and using her utmost endeavors to expel the offending cause," 
Jn this simple, consistent and beautiful faith, he appears to have been well grounded; for Dr. Thatcher, page 4, says, that " he studied and copied nature with the greatest care and assiduity, as the only sure basis of medical science; and so extensive was his knowledge, and so accurate were his observations, that he has been constantly held in veneration through succeeding generations." From existing 
615 


616 
FEBRILE FORMS OF DISEASE 
indications, it would seem, however, that " succeeding generations" venerated him, not because of his talents or the accuracy of his observations and discriminations, but as they generally do any old antiquated ruin—a proper veneration would have dictated a closer conformity to the immutable and salutary laws which he was the first to discover and proclaim. 
"We have remarked, in one of the preceding books, that the animal system, as a machine or organization, does not act intelligently, but in accordance with the laws of that pre-existing intelligence which designed it. Between this opinion and that of Hippocrates, there is not, practically, a shade of difference, and it is to be presumed that no one can be found who is so much of an accidentalist, as to deny that the human organization, either in the abstract, or in its relations with the external world, does indicate wisdom or intelligence in its design. If this conclusion be admitted as correct, then it follows that Hippocrates was in the possession of a great discovery, when he remarked that "Nature cures disease"—that is, disease is removed from the system by the agency of those laws of the organization which exist and act in conformity with a wise or an intelligent design. It follows again, with equal conclusiveness, that man has no power to cure disease—he can only aid " nature" by acting in conformity with her laws, and when he acts otherwise, he is sure to defeat her intentions. This conviction should be ever present in the mind of every physician, when at the bedside of the sick. 
We have examined very many of our standard and most distinguished authors on the pathology of fever, but our taste, judgment, prejudice, partiality, or whatever else it may be, is too fastidious to adopt or indorse any opinion we have found, except that of John Hunter in the abstract, and that of Tissot, in connection with its treatment. The former says, that "fever, in all cases or of all kinds, is a disturbed action, like inflammation itself." And " inflammation," he says, "is not to be considered a disease, but as a salutary operation either to some violence or some dis- 


FEBRILE FORMS OF DISEASE. 
617 
ease." He again remarks, that " pure inflammation is rather an effort of nature than a disease." Then, according to Hunter, we may say that "pure" fever " is rather an effort than a disease;" and consequently as fever is but action, all fever must be pure. 
The latter author, Tissot, says, that " a fever, therefore, that has a quicker pulse than natural, and an increased degree of heat, is always salutary with respect to the morbific cause; for the effect of the morbific cause is excellently fitted to remove the cause itself.* Hence a fever is justly defined by the celebrated Sydenham, to be a "vigorous effort of nature to throw off the morbific matter, which is extremely inimical to the human body, and thus recover the patient." 
" A fever, therefore, which is not too violent, but suited to the morbific causes, ought not to be extinguished, if it could be done, but rather kept up to promote their expulsion." 
It would seem that there is no war between the Eclectics and the Old School Allopathists of former days—the former are actively engaged in repairing, enlarging and elevating the original edifice; while the modern Allopathists are not only hostile to those who abide in the faith, but have disowned their parentage, as will presently appear. 
Thatcher, Gregory, Clutterbuck, Eush, Watson, Eberle, Wood, and Cheyne regard fever as a disease. Thatcher calls it, "the disease" and the others though not so brief, agree with him. All of them have failed to find a definition of fever; and why? Simply because they have regarded it, as they have inflammation, to be a disease, and therefore like the latter, in the language of Dr. John Thompson, is in every case, either an " effect, a concomitant, a cause, a symptom or a consequence." We should indeed think it difficult to define such a proteus. 
Under an abiding conviction that no one can be a good or a safe practitioner who is directed by false principles, it 
* This is to be understood according to the definition of Sydenham. 


618 
FEBRILE FORMS OF DISEASE. 
becomes our duty to dwell on this subject to such an extent as we may deem necessary to an exposure of the prevailing errors, and the defense of those which our convictions of truth compel us to adopt. 
As it has not been our good fortune to find such a definition, or conception of fever as we can adopt, we are called upon to add one more to the long catalogue with which our medical libraries are now burdened. We would therefore, define fever to be that amount of vital action, cceteris paribus, which any given, but general, obstruction to the vital functions can produce. It follows consequently that, that amount of obstruction which would produce but a slight fever in one of strong vital force, might produce death in another of extremely feeble vital force. Consequently there can be no grade of fever which can not be thus readily understood, so far as regards its modes of manifestation. 
As to the location of fever and its proximate cause, or as we would say, as to the nature of the disease that produces fever, there are many and widely different opinions. 
Dr. Cheyne, Cyc. Prac. Med., in opposition to some of the opinions we have quoted says, that " we find the early medical writers entertaining the idea, that the system waged war against something noxious within itself, and that in the attempt to expel the offending agent, a violent commotion was excited." By this plausible theory, the duties of the physician were restricted to assisting nature in her efforts to get rid of what was deemed injurious to the welfare of the body; in fact, fever was imagined to be a natural and salutary process, indispensably necessary to throw off whatever was noxious, whether generated within the body or introduced by external causes." 
This extract shows very clearly that the author considers fever to be disease, and that the physician has something more to do than to assist nature. This is particularly that feature of the Old School practice which we lament—they take it upon themselves to remove disease, and so far from helping nature, they throw about one half of her out-door 


619 
FEBRILE FORMS OF DISEASE. 
in the form of blood, and the remaining half they poison to death; but we, more humble in our pretensions, will feel entirely satisfied with our efforts, when we shall become qualified to render the necessary aid. Beyond this humble position we have no ambition. 
We are very much mistaken, however, if the author has not shown himself to be exceedingly inconsistent. In the same paper he remarks: "It is more than probable that in what is usually called idiopathic fever, there is alteration either of the solids or fluids, although its precise locality can not in every case be detected ; but without disease in either the one system or the other, we maintain that fever can not exist." This is precisely our position—when there is no disease in the system there can be no demand for fever. In the previous extract, the inference is clear that fever is disease, and that all those are in great error who regard it as an effort of the vital force to cast out disease, and now he says, that unless there is disease fever " can not exist." Fever, then, is an effect, and not a disease, nor is it the cause of the disease. Then it follows, that the fever is a friend of the system —an effort of the vital force, or rather an accumulation of it for the purpose of removing disease, or else it is an enemy of the system, and if so, then it is disease, and as such, it is superadded to the disease that caused it. Verily, if this is the case we need not to marvel at the difficulty of comprehending it. No matter where we turn, we find nothing but confusion as to what fever is, and when we inquire as to its proximate origin, we obtain nothing more satisfactory. 
Many have, some yet do contend, that the cause of fever is to be sought in the fluids, while others are equally sure that it is in the solids. Some have referred it to the nervous system, and some again have attributed it to some mysterious or occult organic inflammation. Fever has been hunted for more than two thousand years, and yet its hiding places are as little known as when the search commenced. 
Dr. Stevens is of opinion that a morbid condition of the blood is the first link in the chain of morbid phenomena 


620 
FEBRILE FORMS OF DISEASE. 
that causes fever—that the aerial or miasmatic poison reaches the blood through the respiratory function. He seems to have founded this opinion upon such facts as this: he states that on opening the heart in fatal cases of yellow fever, he found, instead of blood, a dissolved fluid nearly as thin as water and black as ink. In both sides of the heart the fluid was equally black, and throughout the vascular system all distinction between venous and arterial blood was completely lost. 
If this supposed aerial poison has the power to do all this mischief by acting directly on the blood, it must be considered as exceedingly singular that human genius can devise no means to detect its presence in the atmosphere, or in the blood, or under any other possible circumstance. To the doctrines of fever, we know of but one parallel, and that is geology—with regard to both, many facts have been accumulated, but the advocates of both seem to have banished common sense from the field of their investigations, and given themselves up to the most extravagant speculation concerning them—summoning to their aid the most occult, hidden and extraordinary causes —such as would elucidate nothing if admitted. 
As to the remote cause of fever, there is a pretty general unanimity of opinion, it is an aerial poison, miasm, malaria, an ignisfatuus, a something, a nothing, and yet it produces the most fatal types of fever. It is not our purpose to enter into a discussion of this subject, or to do more than simply to record our own convictions of it. In many years traveling through the United States, we have observed enough to satisfy us that heat and moisture, with the plus and minus electricity they occasion, and the variously modified modes of life among the people, are adequate to all the febrile results we have noticed in connection with them. 
"With a few brief remarks upon the modus operandi of these causes in producing fever, we conclude this introduction to our subject. 
We can not believe that any one will venture to contend 


621 
FEBRILE FORMS OF DISEASE. 
that fever ever did take place under a proper performance of the depurating function. Inflammation results from local obstructions or lesions. Now suppose such obstruction or lesion shall be general—universal in the system, what else could or should be expected than such a reaction as constitutes fever ? Every part and parcel of the solids is so over excited, or under excited, that no one part, however small or comparatively unimportant, is able to eliminate its metamorphosed portions, the absorbents are as it were dead. The glandular structures, too, are in a similar condition, and hence all the impurities of the venous blood, because of defective depuration, becomes mixed or blended with the arterial, and this morbidly excites every part and fever results. 
It is well known that a hot dry season is measurably exempt from febrile epedemics, but if rain be added to this heat, then they appear.* We are told that it is because the two combined promote vegetable decomposition. If this explanation be adopted, how shall we account for some epidemics in sandy deserts, far removed from any source of malaria ? It is well known that children and negroes are greatly exempt from the malarious fevers of the South. If then, these fevers are produced by a poison, how does it happen that they are exempted ? If our position be correct, this fact is easily explained. The black surface of the negro radiates not only a large portion of his animal heat, but also a large portion of that solar heat that falls upon him ; and another large portion is removed by the evaporation of his perspirable matter. With these advantages his skin maintains its integrity, and as no morbid sympathy is engendered between it and the liver, the kidneys and other glandular structures, a proper depuration of the system does not become suspended. And as to children, they are confined mostly to the house. But they have another 
* This is not the fact, with reference to the yellow fever of New Orleans— a hot dry season is the most productive of it; we admit the statement, however, as regards interimttents. 


622 
FEBRILE FORMS OF DISEASE. 
means of protection—it is that thick coat of adeps which is common to their age, and to some forms of these epidemics such men are equally invulnerable. 
No medical philosopher, we should think, could have labored for many weeks, contrary to his custom, in a hot sun, with the other epidemic requisite, and not comprehend how it was he contracted fever. He exhausted his skin—many internal organs sympathized with it, particularly the liver and the mucus membrane of the bowels, and thus, without the prevalence of moisture, he may be seized with Dysentery—but with the moisture he will have some form of fever—his skin is too feeble to contend with a greatly reduced electric condition of the atmosphere, constriction of it ensues, then comes a chill, and then a reaction which is denominated fever. As the obstruction is universal, the result is fever, and can not be inflammation, and therefore, it appears about as consistent to talk about a general or an universal congestion, as about an inflammatory fever. 
These views of fever strike us as being the legitimate results of common sense and common observation, and do, with clearness and force, point out the necessary indications of treatment. "With a normal depuration, fever can not obtain, and without it, it can not be cured, but it may be replaced by a mercurial disease, or some other, or the patient may be killed, or suffered to die for the want of an adequate treatment. 
"We are aware that very many apparently conclusive facts can be brought to bear in favor of malarious poison, but let it be remembered that laws or rules have no exceptions, and therefore, the production of a single epidemic, of the same kind, under circumstances that positively contra-indicate the existence of such a poison, is enough to destroy the doctrine—one affirmative fact is worth any number of negative ones. 
As being confirmatory and explanatory of the preceding views, we beg leave to make a few extracts from " The East Tennessee Record of Medicine and Surgery for May, 


623 
FEBRILE FORMS OF DISEASE. 
1853." Dr. Deaderick, the writer, says, that " Jefferson and the adjacent counties where by far the greatest part of my desultory practice occurred, are remarkable for their salubrity ; the face of the country mountainous and hilly ; the soil dry, rocky, and gravelly ; the water (a great portion limestone), excellent, and the streams, large and small, passing rapidly off over gravelly or rocky beds. Consequently we were seldom or never assailed by the epidemics incident to marshy and miasmatic countries. In a course of more than twenty-two years, I do not believe that I met with more than a dozen cases of intermittent fever. The most frequent were the common remittent and continued (synocha) fevers, which seemed incidentally to be occasioned by frequent rains, succeeded by bright sun and sultry weather. In general, these fevers required free use of the lancet, the proper application of which, in conjunction with other appropriate appliances, rarely failed in conducting them to a favorable termination." 
The doctor now states, that some twenty years since, he moved some hundred miles southwest of his former residence, " where the face of the country is by no means so mountainous and broken. On the contrary, there is in every direction considerable bodies of level land, upon the uncultivated part of which, the water, in many places, remains after copious rains, until dissipated by evaporation and absorption. The water-courses pursue their sluggish course over muddy bottoms, and during tire winter and spring seasons, innumerable wet-weather springs and rivulets, which disappear in the summer, are everywhere seen. With this dissimilarity in the local features of the two sections under notice, there exists a corresponding difference in the characteristics of their febrile diseases. Intermittents are vastly more frequent, and in the remittent and continued fevers there is an unequivocal approximation of the character of those in more decidedly paludal and miasmatic regions. 
u In the fevers here, the force and excitement in the sanguineous system are not exalted, the thirst and heat of body 


624 
FEBRILE FORMS OF DISEASE. 
less ; nevertheless a greater tendency to congestion and inflammation in some of the viscera, especially in the mucous membrane of the intestines, and convalescence more tedious. In short, many of the cases might be, perhaps, with propriety, termed typhoid; consequently more caution is requisite in the use of the lancet, which is rarely admissible, excepting at an early period of the attack." 
Our observations in the south entirely confirm those of Dr. Deaderick, so far as they were alike extended — we noticed the particular constitution of the patient, and found that in low and wet situations — such as possessed a low caloric and electric condition, the patients generally possessed a comparatively feeble vital force, or Professor Hall's high dynamis, and therefore could not bear a greater reduction of these stimuli. In the cases of continued or remittent (synocha) fever, to be confined to constitutions of high vital force, or according to Professor Hall's Zoonomia, high stimulus; and therefore could not bear more, as the high caloric and electric atmosphere, as described in the first extract from Dr. Deaderick. 
But, to conclude our considerations with reference to fever in general, we remark, that it does not matter what may be the number or the variety of the forms under which it may appear, it is essentially a unit — it has an increased action of all the fibrous tissues for the removal of disease or obstruction ; nevertheless, for the convenience of study, its forms may be divided, and with much propriety, into two orders : first, those which result from general obstruction, and therefore attended with fever; and secondly, those that result from obstruction, and consequently attended with inflammation. 
During the prevalence of Asiatic cholera, it is, we believe, pretty well ascertained, that the fact, which we placed before the Medical Society of Cincinnati, in 1834, and subsequently communicated through the press to the public, namely, that the conflagration of the nitrate ,of potash and sulphur could not be maintained, is now pretty 


FEBRILE FORMS OF DISEASE. 
625 
well established, and yet we have not learned that any one has attempted to explain the fact by the supposed existence of poison. Indeed, it may be clearly presumed that no poison could be generated on the surface of the earth, and so change the atmosphere as to disqualify it for the support of combustion; and yet there never was a malarious atmosphere more fatal to human life than was this. 
"We have too much to learn about the atmosphere, as regards caloric, electricity and humidity, to conclude, when it is fatal to animal life, that there is in it some foreign poison. The conclusion in this instance, has been as much too hastily drawn, as that of the geologists in referring mineral coal to a vegetable origin, upon the flimsy evidence that the coal shales contain vegetable impressions. Such hasty generalization has, and now is doing much to retard the advancement of science. Of this, we have one flagrant example : the whole medical world has admitted that some forms of disease are hereditary, and this general admission has closed the door to any useful investigation on the subject—and yet the character of the error has but to be named to be clearly perceived. 
We have not dwelt upon this subject, to the least extent, with any expectation or even a desire to convert any one to our convictions of the truth, but for the purpose of awaking fresh observation —for the purpose of breaking up or disturbing that settled conviction of the truth of a conclusion which may possibly be false. 
Finally, when we come to treat of the special forms of fever, special elucidations of this subject will occasionally be introduced. 
ORDER I. 
This order, in the present book will embrace two genera: continued fever and periodic fever. 
INTRODUCTION. 
Before proceeding to the consideration of these genera, it may be profitable to dwell a while on the phenomena that 


626 
FEBRILE FORMS OF DISEASE. 
usually constitute the course, type, and stages of fever. The course of a fever is determined by its phenomena being continued, remitting or intermitting, and that series of phenomena which characterize this course may be usefully divided into the following periods or stages; 1, the forming ; 2, the cold ; 3, the hot; 4, the sweating, and 5th the final. There are so many interesting and useful phenomena in the first, that we have preferred to embrace it, though contrary to the custom of many. As the final period, that of convalescence or dissolution is of equal interest with the first, we have, in company with some authors, thought it best to include it also. 
It should be remembered, however, that we are not to expect to find all of these stages clearly defined in any one of the febrile forms, except the intermitting, nevertheless, periodicity characterizes, more or less, every form of disease ; but this law is not particularly conspicuous in the violent and continuous forms of fever, and yet, it but rarely happens that the primary or oppressive, the febrile or exciting, and the declining stages of all forms of fever are not sufficiently marked to be clearly observed. 
1. Period of formation. —This is, in reality the period in which the vital forces are preparing for the removal of existing disease, or obstruction to the normal manifestation of the physiological functions, it is that period which intervenes between the first morbid sensations, and the introduction of the febrile phenomena. Its duration varies exceedingly, and this depends more upon the resisting character of the invaded constitution than upon other contingencies. In the highly vital, this period is occasionally so short as not to be observed —the febrile attack is absolutely one of surprise and astonishment. In such constitutions the faculty of animal sensibility is so strong, and therefore vigilant, that upon the slightest invasion, the other vital powers are immediately summoned to resistance. 
In constitutions of a contrary character, this period may be greatly prolonged. The obstruction is permitted to increase and spread, until at length the physiological 


FEBRILE FORMS OF DISEASE. 
627 
functions become very much arrested —too much so for a normal continuance of life, and then a struggle ensues which is indicated by a rigor or a chill, which is succeeded by fever. 
The first indication of this prodromal stage is an indisposition to attend to business; a feeling of weariness, an indefinable anxiety—the appetite still being good. Then succeeds a sense of lassitude; disturbed sleep; loss of appetite; yawning and stretching; wandering pains in the limbs and back; and unpleasant sensations in the stomach ; harsh and dry skin; irregularity of the bowels, but most generally constipated; some headache; flatulence; nausea; the drying up of old sores; giddiness ; tremors of the extremeties; slight creeping sensations of cold, and an indisposition to be satisfied with the usual modes of existence. In reviewing these symptoms, as a group, we are bound to perceive that the nervous system has become greatly impaired, and that its susceptibility to normal impressions has become blunted. 
2. The period of rigor or chill. —The first indication of the approach of this stage, is a sensation of chilliness which may be confined to the loins, or to one or more of the extremities, or to the spine, while the other portions of the body feel to be comfortably warm. This state of the system gradually passes into one of tremor, which first becomes manifest in the inferior jaw, and thence extending to the entire muscular system. In the firmer class of constitutions it but rarely exceeds a chill and slight tremor; but in less resisting constitutions it is sometimes very severe, so much so, that it has, according to authorities, produced convulsions. 
The patient has not only a sensation of cold, but his skin does become cold, and Dr. Wilson Philip says, that its temperature has been known to fall as low as 70° Fahrenheit. This condition of the animal temperature becomes indicated by the paleness of the lips, nails, fingers and toes —sometimes they become of a purple or livid color. The skin, on most parts of the body becomes greatly constricted 
40 


628 
FEBRILE FORMS OF DISEASE. 
and drawn into little elevations or papules, like those of the feathered tribe, when the feathers are removed. The pulse, during this stage, is small and quick and frequently irregular; the breathing, like the pulse, is hurried and labors under a feeling of constriction in the prsecordia. 
During this stage, the patient makes no demand for food, but his thirst is sometimes very considerable; the secretions are not only in a great measure suspended, but much deranged—the saliva is scanty and viscid; in some instances much gastric derangement obtains, as frequent wretching and vomiting; and, occasionally this irritation is extended to the bowels and liver, which is attended with a purging of bilious matter. These symptoms, however, are mostly confined to southern latitudes, but in all latitudes this stage is so mild, that the patient himself, does not become conscious of it—it is indicated only by some paleness of the lips and a little coolness of the hands and feet. 
The length of time occupied by this stage is very variable—continuing from a few minutes to four or five hours, but one hour and a half may be assumed as the average duration. It may be valuable to remark, however, that this period is generally more protracted in southern than temperate latitudes; but in all latitudes it may be well to add, that the more this stage is contracted, the more protracted and severe will the hot one be. "When we reflect that the chill is always in the inverse ratio to the vital or reactive force, the reason of this is readily understood; and hence it is that when the vital resistance or reaction can not be effected the patient dies in the chill. 
When the reaction has been effected and completed, flushings of heat become blended with those of the chill—the patient breathes with more ease, and gradually removes piece after piece, the bed clothing off his body, and finally from his extremities. The hot stage has commenced. 
3. The period of increased temperature. —When the tern • perature begins to rise out of the rigor, it is felt by the patient to be a great relief, but when it reaches its maximum intensity, he finds himself as uncomfortable as when 


629 
FEBRILE FORMS OF DISEASE. 
at the other extreme. He first becomes sensible to the introduction of this stage about the face and eyes, and then the thorax, the abdomen and finally the extremities. When the reaction is rendered difficult, sensations of heat and cold alternate, and frequently for some time, but finally, in such cases, the former obtains the ascendency. The patient finally begins to feel hot, and the sensation is not delusive, for the condition of his surface produces the same sensation to the tact of others, and further, it becomes demonstrable by elevating the mercury to 105°, and in a few instances to 107°, when the bulb of the thermometer is placed under the tongue. 
With this increase of temperature there is usually a very considerable acceleration of the circulation, but in this particular there is much variation. When the vital force and the obstruction are so related as to render the reaction easy, the pulse is full, strong, and quick, but without a remarkable frequency, not much more, than is common to health. But when the condition is reversed, the pulse, in all respects, falls below the normal standard, except as to its frequency, being sometimes increased to 110, and from this to 160 beats in a minute; but while there is good velocity, there is indicated a great want of arterial power, for it is soft and easily compressed. If inflammation be located in any special part, it will be indicated by a tense, small, and contracted pulse. 
The brain, as a matter of course, participates with the other parts of the system, and hence, in this stage, the senses, except those of smelling and tasting, become more acute, the brain is very frequently afflicted with pain, more particularly with those who possess dense and fibrous constitutions ; and, moreover, if the fever run very high, delirium is a very general consequence. It is quite common in this stage for the patient to complain much of pain in the back, the extremeties and other portions of the body ; he is also troubled with a morbid vigilance—an indefinable uneasiness, and restlessness. 
The digestive system is not without equal manifestations 


630 
FEBRILE FORMS OF DISEASE. 
of derangement. A loathing of food and warm drinks, with a desire of cold drinks, are peculiarly characteristic of this stage. Nausea and vomiting, constipation or diarrhea, but more frequently the former; a disagreeable taste in the mouth, a furred tongue with clean tip and edges, are also very common symptoms. 
The secretions are generally very much arrested; the urine is scanty and high colored; the skin, tongue, and mouth are usually dry, and, in the most favorable cases, the bowels are dry and constipated. 
The duration of this stage is as uncertain as that of the preceding; it sometimes ceases in a few hours, but in many instances it continues for days and even weeks. Finally, it should be remembered, that all of these symptoms become very much modified, in different cases, by circumstances incidental to the cause, the constitution or the peculiarities of the occasion. 
4. The period of perspiration. —When the previous stage has become so far reduced in temperature as to admit of secretion, perspiration begins to break forth upon the superior portions of the body and gradually extends over the whole surface. It is sometimes, as to quantity, quite moderate, but in many instances it becomes highly profuse. When this period has continued for some time, it subsides, leaving all the functions very much in their normal condition, except that they are much weakened. 
The preceding four periods succeed each other in regular order; nevertheless, they present much diversity of charac ter in the different forms of the disease, as may be noticed when we come to treat of them individually. 
5. The period of conclusion. —The disease, for the removal of which the fever was instituted, was proximately occasioned by an insufficient depuration, so when this function begins to re-establish itself, and, this stage begins in a favorable manner, the patient will recover, in the event of no unfavorable interruption. On the other hand, if the function of depuration be not re-established the chemical agencies acquire an ascendency over the vital, then 


FEBRILE FORMS OF DISEASE. 
631 
this period is occupied by the progress of dissolution. Hence it is, that when the declination is favorable, its begining is indicated frequently by the spontaneous occurrence of a profuse perspiration, urination, bilious or serous discharges from the bowels, which have been denominated critical. i 
We can not avoid, in this place, to notice a remark of Dr. Wood's, who says, "It has been conjectured that these evacuations were the means by which nature effected the cure of the complaint; and the idea at one time extensively prevailed, that through their instrumentality, offensive matter, which served to sustain the fever, were eliminated from the system. Without attempting here to confute this hypothetical notion, it is sufficient to say that the discharges are the necessary results of a certain grade of irritation in the organs, and, if they serve to relieve the disorder in which they originate, it is only one of the numerous instances, in which nature has contrived to make noxious influences subservient to their own removal." 
If the bills of mortality could either speak or write, they would publish a most lamentable account of those who practice upon the doctrine here set forth by this distinguished Professor. It is too glaringly absurd to require of us more than a very few common sense interrogatories and comments. 
Will the Doctor or any one else affirm that the patient, would or could have recovered without the elimination of the morbid and offensive matter which is now under consideration? How did that "certain grade of irritation in the organs" happen? Was this matter elaborated by the irritation, or was it the cause of the irritation? If the "instances" of such eliminations are "numerous," should we attribute them to nature's bungling, or to a law of her settled poliey? If nature very frequently bungles in this way, it would be a happy circumstance to society if the Doctors would suffer her to manage all cases in her own way. 
If secretion becomes arrested or deranged, by miasmatic poison (?), heat, cold, minus or plus electricity, or any 


632 
FEBRILE FORMS OF DISEASE. 
other cause, and the matter which ought, normally, to have been eliminated, is not, will it not act upon the irritability of the system as foreign matter? And if the retention of such matter did not produce a " certain grade of irritation,"and even fever, could the system be in a normal or physiological condition? Is there not, sometimes, too much carbon, urea, or lime, or phosphorus in both the fluids and solids of the system? Has the system any other remedy for this, its condition, than secretion and depuration by the skin, kidneys, liver, the mucus membrane of the bowels, etc? And are not those eliminations which take place in the crisis of fever, of this character? Do they not absolutely produce it, and thus terminate the fever by removing its cause? 
In such instances nature has effected the very result, which should be the object of the physician from the moment he visits a patient; indeed, he was called for the purpose of helping her to do in less time, that which she may ultimately effect without help. 
One of the most indubitable evidences of the commencement of this period—of the re-establishment of secretion, is the moistening and cleaning of the tongue. This cleaning process commences at the point and edges, and gradually progresses till the whole is clean and brought to a normal appearance. These changes in the tongue indicate, no doubt, that nature is "contriving" to do the same for the whole gastro-intestinal canal, in connection with a general secretory movement —the execution of the plan " which nature has contrived to" remove a "certain grade of irritation in the organs," instead of being the result of it. 
With the indications of returning health, above named, may be expected a pari passu movement of all the secretions and a corresponding return of the senses, appetites and propensities to their normal condition. 
Before dismissing this subject it is proper that we add a few remarks upon what is usually denominated the types of fever, and as Dr. Eberle's descriptions are better or more clear than those of most of writers, we shall adopt his account of them. 


FEBRILE FORMS OF DISEASE. 
633 
He says, "The space of time occupied by one paroxysm of a fever and its succeeding intermission, or which intervenes between the regular periodical exacerbations of paroxysmal fever, is called the revolution of a fever. The revolutions of fevers are various in point of duration ; some fevers completing theirs in twenty-four hours; others in forty-eight, while others require seventy-two, and some even ninety-six hours.' The form which a fever assumes, in this respect, is called its type; so that a fever which occupies twenty-four hours, from the commencement of one paroxysm to another, is said to be of the quotidian type; while one which revolves every forty-eight hours, is of the tertian type ; and when this period is extended to seventytwo hours, the fever is of the quartan type; and a period of ninety-six hours constitutes the quintan type. The quotidian, the tertian, and the quartan types, constitute the three principal and primary types of fever; all of which are, however, subject to modifications which may readily mislead the careless observer, so as to confound them, or mistake one for the other, especially the quotidian and the tertian. 
" It has been observed, that in fevers of the quotidian type, the paroxysms generally come on in the morning — a circumstance, which has been almost invariably verified in my own experience, and which is, indeed, so constant, that Cullen was induced to notice it in his definition of a quotidian. Tertians commonly come on toward noon; but they are much less regular, in this respect than fevers of the preceding type. Two simple tertians sometimes go on cotemporaneously in the same patient; so that, instead of the paroxysms recurring only every other day, they occur daily, as in a quotidian. These cases are called double tertians, and are distinguised from quotidians by the paroxysms of the alternate days being similar in relation to the precise time of their occurrence, grade of violence, duration, and other circumstances. Thus the paroxysms on the odd days, will perhaps recur at nine o'clock in the forenoon, while those which happen on the 


634 
FEBRILE FORMS OF DISEASE. 
even days will come on at two or three o'clock in the afternoon, so that, although each day has its paroxysms, the fever can not be properly considered as a quotidian, but the cotemporaneous progress of two simple tertians, the one having commenced a day sooner than the other. Fevers, however, rarely assume the double tertian type from their commencement. They usually begin and continue for some time in the simple tertian type —the duplication occurring afterward ; and when the type thus becomes doubled, the new or accessory paroxysms are in general considerably milder than those of the original or simple tertian. It is asserted, that a double tertian seldom terminates without first assuming the single tertian type, the accessory or weaker paroxysm disappearing first." 
Genus. I.— Continued Fever. 
Introduction.—It will be remembered that we divided the various forms of fever into two orders, and the first of these again into two genera —the continued and the periodic, and although this arrangement has many practical advantages, yet it is not strictly true. It appears so far as observation has extended, that the functions, of every variety of organization are subjected to a species of periodicity, and this law is common to both health and disease. Consequently it is exceedingly rare to witness any variety of febrile action which does not, to some extent, indicate the presence of this law. And yet the decrease or abatement of febrile action, in this genus, is so inconsiderable, when compared with the other, as to leave no room for a mistake in the diagnosis. 
The modifications of this genus are so numerous and prominent as to have led to considerable confusion among writers, and the names which the several modifications have received, are almost as numerous as have been the writers. The two extremes of this genus, as relates to the energy of their action, has caused it to be divided into two species the sthenic and asthenic, or inflammatory and typhous. That there is a very great difference between the highest grade of the sthenic and that of the asthenic no 


635 
FEBRILE FORMS OF DISEASE. 
one will question, but to regard a fever as inflammatory that originates in general obstruction, is equivalent to contending for an impossibility, nevertheless, as a name, it is now understood, and hence we shall not depart from its accepted use. In order to convey some idea of the grades of febrile manifestations, they have been divided into three varieties: synocha, synochus, and typhous. The first is intended to embrace those febrile forms which have been denominated inflammatory; the third is intended to embrace those which exhibit the lowest degree of febrile action, and the second those of an intermediate character. The first has been again divided into two sub-varieties : the idiopathic and symptomatic. This division is another that inculcates a false idea, because both are, in truth, symptomatic. The first is symptomatic of a reduction of nervous irritability and a constriction of the capillary vessels, and the second, of a pre-existing inflammation or local lesion of the solids. To distinguish the former from the latter after this explanation, we may use the word idiopathic. 
Species I.— Pyrexia Sthenica — Simple Inflammatory Fe- 
ver. — The Synochal grade of Idopathic Fever; Febris 
vasorum. 
This form of fever most generally seizes young persons in the flower of their age, and full of blood, those who are athletic and therefore fibrous and elastic, finally, those who constitute the first class, (page 20.) It may occur at any season of the year, but it is more liable to prevail during the spring and summer. 
It begins with a sense of lassitude, the body feeling as if bruised ; with weakness; cold and hot sensations which alternately succeed each other; with tremors and with pains all over the body, but particularly in the shoulders, back, knees, legs, and head. The bowels are constipated and the secretions are suspended. As this stage passes off the second is introduced with an intense and burning heat, an unquenchable thirst; a suffusion of the eyes, a redness and swelling of the face; nausea; vomiting; restlessness; anx- 


636 
FEBRILE FORMS OF DISEASE. 
iety ; a full, quick, and strong pulse; a dryness of the skin ; a scanty and high colored urine; a rough and dry tongue, frequently covered with a thick scurf; the respiration is difficult and labored. Delirium is not very common to this form of fever, but when it does supervene it is severe and threatening; the acuteness of the senses of seeing and hearing are much increased, and finally, the blood, when drawn, shows a buffy coat, cupped crassamentum and a deficiency of serum; but the introduction of this symptom is measurably useless to Eclectics as they never see it, except possibly, by some unexpected accident. 
It is not uncommon for the preceding symptoms to manifest remissions and exacerbations—the first appearing in the morning and the second in the evening, until terminated by some critical evacuation and a return to health; or by stupor, coma, tremors, twitchings of the muscles, hiccough and death. 
This form of fever, when its simple form is maintained, very seldom continues beyond the ninth day, but it may be extended to the fourteenth, and it may conclude on the fifth or seventh. When the symptoms have continued to increase in violence to the fourth or fifth, a crisis may be looked for on the seventh, and when its crisis is procrastinated to the fourteenth, it will be observed to increase in violence to the ninth or eleventh. 
Prof. Eberle, says that revolution in this form of fever, is almost invariably attended by general and free perspiration, urination etc. As this is one of nature's contrivances, he does not seem to think that the revolution is affected by secretion, of which perspiration and urination are now two of the most important. And here we would have the reader remark that he and most other authors inform us that a reddish or pale sediment in the urine, is a neverfailing concomitant in the crisis of this fever. Is the subtraction of this sediment from the blood a mere circumstance, and one of no particular importance? Did its retention in the blood have no agency in the production of the fever? 


637 
FEBRILE FORMS OF DISEASE. 
It should be remembered that in this form of fever the chilly sensations, during the forming stage, do not appear to be attended by any absolute reduction of temperature, at all events, if such be the fact, it is not ascertainable by the sense of others, or the thermometer. The only opinion we can suggest to account for it is, that the cold and hot sensations which are alternately produced, are occasioned by alternate contractions and relaxations of the capillary vessels; that in the former no caloric is evolved, and that in the latter it is. In support of this view, it should be remembered that the system is now struggling to remove all constriction, and finally succeeds. 
In many constitutions of even the firmer class, there is some part more feeble than the balance of the system, and hence, therefore, more liable to take on inflammatory action in the progress of this" fever, because of its inability to resist an excessive invasion of the febrile action. Hence it is that the simple and even tenor of this fever is frequently complicated with topical inflammation. 
Causes.—Of all the causes to this form of fever, an undue or unguarded exposure to cold is confessedly much the most frequent, and in a large majority of instances this exposure results from an incapacity to anticipate atmospherical vicisitudes or mutations, and hence its more frequent prevalence in the spring and fall months, more particularly in cold and variable climates. When we consider the fibrous and sensitive character of those who are most organically liable to this form of fever, we should reckon an electric condition of the atmosphere as a frequent cause, hence the reason why northwest and northeast winds so frequently occasion it. A sudden exposure to cold water is said to cause it when the the person is heated by exercise. This remark, standing as it does, unqualified, has been productive of mischief.* 
* The writer made it a rule of his life, never to take a cold bath until, by exercise, he had his surface in a perspiring condition—a condition that indicated an active and elevated condition of the vital forces—a condition the 


638 
FEBRILE FORMS OF DISEASE. 
An exposure to solar heat, by those of this class who have not been accustomed to it, frequently proves a successful cause. The use of highly stimulating food and drink, is also a frequent cause in old and affluent communities. But in all our reflections upon the etiology of fever, it should be remembered that the various grades and modifications of it depend more, much more upon the inherent organic conditions of the system, than upon either the remote or exciting cause. Hence we may safely assert that all the forms of fever which are incidental to any given section of country, at the same season of the year, are but so many varieties or modifications occasioned by the existing differences that organically exist between individuals. Thus, while the athletic—those having large organs of animal sensibility and muscular motion, will have pure synocha; another with less endowment of animal sensibility, synochus ; and in a third, in whom both of those vital forces are feeble, a typhoid, which, by neglect or improper treatment may degenerate into a proper typhous. 
best calculated to resist the constringing influence of a reduced temperature. The great matter to be avoided is an exposure to cold when the system is fatigued—when incapable of a prompt and efficient action. Furthermore, we have never known any one to suffer from drinking ice-water under a warm and perspiring condition of the skin, provided fatigue had not been induced, and provided, further, that the person was not in the habit of using ardent spirits. 
Under the false impression that now exists in society without qualification, that it is dangerous to go into cold water when the skin is heated, we see both men and boys go to the river in a heated condition, undress and fan themselves till the skin is cool and dry before entering it, the consequence is that the most feeble class of them come out with a contracted skin, and livid or purplish lips, which is sometimes followed by fever. 
In 1827 and on July the 5th, the writer and three other gentlemen, one of whom was athletic, another was less so, but in good health, the third possessed a fibrous constitution, but with impaired general health, and the fourth, the writer, had a constitution which at that time, though fibrous was considerably anaemic—the vital forces feeble—and who had never possessed good health, determined upon visiting a cave, near Bowling-green Kentucky, which was denominated the "Cold Cave." When they arrived at it, they were in a perspiring condition, and all of them, except the writer, refused to enter it until they should become cool, and to hasten this result they took off their coats and seated themselves under a shade. During 


FEBRILE FORMS OF DISEASE. 
639 
A sight of the patient, therefore, should generally determine the grade of the fever. 
Diagnosis.—It is distinguished from typhus fever by its strong, high, full pulse, dry tongue, intense thirst and heat and greater violence of the pains. The absence of clearly defined periodicity, will distinguish it from those forms which constitute the next genus, and from the succeeding species by the diagnosis which will there be given. 
Prognosis.—Such is the vital resistance in synochal fevers that the prognosis should not be considered as either uncertain or unfavorable. What the bleeding, purging, and mercurial practice may effect upon it, is altogether another question. This, so long as it has no complications to contend with, is the least dangerous of all the forms of continued fever, and for the simple reason that the vital powers are adequate to the removal of the disease. 
If the system though generally strong, should possess feeble parts, inflammation, in some one of them, may supervene, and in such case, the magnitude of the danger will depend upon the functional importance of the invaded part. If the breathing should become obstructed or painful, or attended with a cough, or with pain in the thorax; or if the abdomen be tense and tender upon pressure, we 
this time the writer employed himself, with his coat off, hunting fossils among the exposed rocks in the vicinity of the cave, and in the open blaze of a southern July sun. At length the three cooled gentlemen replaced their coats and announced that they were ready, and the writer, in a perspiring condition, replaced his coat and adjusted it closely about his person, and the party proceeded with their visit. 
It will now be perceived that when the party returned to the surface of the earth and into the presence of the sun, the writer was in about the same condition that the other gentlemen were in at the moment of their entrance into the cavern. Now for the consequences to this party individually. 
The first had simple catarrh which did not incommode him much ; the second was confined two or three days to his room, with a similar affection; the third had pneumonia, which apparently, came near costing him his life, and the fourth, the writer, suffered no conscious change of health. 
No one, and more especially a medical gentleman, can fail to understand the rationale of the facts involved in the preceding history. 


640 
FEBRILE FORMS OF DISEASE 
may apprehend danger. The presence of mere delirium should not be regarded as unfavorable, but should the existence of violent pain in the brain become indicated, encephalitis may be suspected to exist and to greatly increase the danger. 
Favorable Signs.—A slight hemorrhage from the nose, a general perspiration, urine pale when voided and turbid when cool; a reduction of the temperature and of the hardness, quickness, and frequency of the pulse. 
Species II. — Synochus Fever — Common Continued Syno- 
chus Fever — Enteric Fever — Typhoid Miteor — Typhoid 
Fever — Entero — Mesenteric Fever, etc. 
We have thought it best to regard this form as a distinct species, for the reason that it is confined to those regions of the country in which the bilious or so-called miasmatic forms of fever do not prevail. 
It is very probable the several names, at the head of this article, have been given to one and the same form of disease, modified probably by local and constitutional circumstances. The profession, it seems, have been brought to this conclusion by the labors of Louis, who designated it by the name of " typhoid fever," but its nomenclature is still unsettled, and consequently we have preferred to call it by a name which indicates a grade of action between the highest and the lowest that is known to the genus. Dr. Wood calls it " enteritic fever," and probably for the reason which we infer from the following remark of his: " The intestinal affection is as characteristic of this disease, as the eruption is of small-pox." We can not adopt this name, because it only designates a specific form, instead of a general one. We conceive that fifty individuals may have the same grade of continued fever, and yet no two of them will be attended by the same local or special phenomena. The multiplication of names to include or express local or incidental circumstances, has done much violence to the profession. 
We are disposed to suggest, in this place, that the present form represents the general character of this genus, 


641 
FEBRILE FORMS OF DISEASE. 
and that the synochal form is an upward departure from it, and that the typhous is a descending one ; and hence they should be regarded as being merely varieties, and this conclusion is sustained by a corresponding condition of the vital forces among men. Some men are much above the average of society in vital force, and others are much below it; the average then, is the legitimate sphere of the synochus grade of fever. Either of the ascending forms of constitution, may have typhous fever, because their vital force may be reduced to the typhous level by previously debilitating causes ; hence it is that every man, in a crowded and filthy ship or prison may, finally, die of typhous fever. But the reverse of this can not be effected —a man of a low grade of vital force will never have synochal fever. 
Now, in that mass of society which determines the average of the vital force, there necessarily exists many modifications, and each epidemic may result from a modified condition of the atmosphere. In one season, it may have a particular pulmonic, nervous, or gastro-enteritic tendency. Under these views, we think it best to generalize febrile forms of disease, to the full extent of practical advantage. 
This, or the synochus grade of fever, may have the usual forming stage or period of fever, but it frequently gives very little or no premonition of its approach, and abruptly announces itself by a chill, which may almost as abruptly terminate by the introduction of the fever; but most frequently it is imperceptibly merged or lost in the fever which so gradually increases as to leave the patient unconcious of the moment of beginning. 
In some instances, again, the patient is scarcely conscious of the existing chill, and the fever that succeeds is of a very mild grade; the tongue becomes white, the pulse more frequent and full, with a dry skin ; pain, more or less severe, over the eyes; urine diminished and highly colored; sleep disturbed, and bowels constipated. The appetite is not always arrested. When the affection is of this mild grade, it passes off in a few days by perspiration or diarrhea. 


642 
FEBRILE FORMS OF DISEASE. 
In our cold and variable climates, the ordinary continued forms of fever present various degrees of violence, from the mild form above described, to those of cerebral oppression and fatal collapse. Gastro-intestinal irritation may almost be regarded as a pathognomonic symptom of this form of fever, and it usually appears early in the seizure, by the manifestation of nausea, vomiting, unpleasant gastric sensations and foul tongue. 
In that form which is most usually denominated continued fever, the symptoms are, from the beginning, of a pretty high grade of violence. Beside a distressing degree of the symptoms of the forming stage, the exciting degree of the hot is pregnant with threatened danger. The skin is hot and covered with a pretty uniform, but slight, blush of red; the face is flushed, the pulse is active, full, and frequent; the patient is restless, and probably peevish and apparently incapable of fixing his attention upon anything, except a dull, heavy, or throbbing pain in his head. The urine is sometimes pale, but most frequently it is red and entirely destitute of sediment. The tongue, being white in the beginning of the fever, becomes, in its progress, dry, harsh, and dark-brown; the bowels, as usual in fever, become torpid, but the faeces continue soft, but frequently contra-indicate the presence of bile. 
For six or seven days, these symptoms, with slight intermissions and exacerbations, continue about the same ; but, in the further progress of the disease, cerebral symptoms are apt to supervene, more particularly delirium at night. If the vital energies are capable of effecting a favorable termination, it may be expected on the eighth or ninth day, otherwise it will pass, with more or less rapidity, into the typhous form or into collapse, when all the symptoms will become of a very threatening character—such as delirium', more or less stupor, dilated pupils, foul and dark-brown tongue, hurried breathing, picking at the bed clothes, subsultus tendinum, and a gradually sinking pulse to the close of life, which may happen on the fifteenth day, but it may be procrastinated two or three days longer. 


643 
FEBRILE FORMS OF DISEASE. 
When the cold stage has been protracted, and reaction established with difficulty, we may infer the existence of a feeble vital force, and therefore we should be prepared to expect a rapid declension of the disease into the typhous stage, attended with exhibitions of cerebral disorder of no ordinary grade—such as an aversion to light and sound, a disposition to watchfulness, contusion of ideas and delirium, which may become continuous and violent. The head is rolled from side to side; the arms and feet are kept in frequent motion ; all portions of the body are tender to the touch, and evanescent pains are felt in various parts of it. There is apt to exist, also, tenderness at the epigastrium, flatulence and irritability of the stomach. In this modification of the disease, the pulse never becomes remarkable for tenseness or fullness, and the typhous condition of the disease may be expected to supervene on the fourth or fifth day, and then we have a reduction of some symptoms, and an introduction of others of a less favorable import — the delirium passes into a low and muttering raving — great mental oppression, and a rapid destruction of the vital powers. 
When synochus fever occurs under circumstances of debility arising from poverty and depravity of living, such as may characterize life in a damp cellar, poorly ventilated and warmed, with food poorly calculated to produce health, then we have a fever in which the prodromal stage is much protracted, and the hot one extended indefinitely to five or six days, or probably to as many weeks. The pulse, in activity, frequently continues at very nearly the normal standard, but usually a little accelerated. The appetite is absent or greatly impaired, the thirst is very moderate, the eyes are dull and suffused, and the patient drowsy; the tongue is white and slimy, the urine is small in quantity and pale, containing, most generally, much mucus. This form does not necessarily run into the typhous state; but, as it progresses, the pulse becomes smaller, weaker, and more frequent. It may terminate favorably about the seventh or ninth day by a general diaphoresis 
41 


644 
FEBRILE FORMS OF DISEASE. 
with a slow convalescence. In the case of a fatal termination, the event will be preceded by muttering, subsultus tendinum, hiccough, and coma. 
When those persons who have been exposed so long to those influences which are called miasmatic, as to have the nervous system more or less enfeebled, and the secretions more or less impaired, become exposed to the influence of cold, a common cause of synochus, a modification of it will be induced which demands special notice. Beside the usual symptoms of the prodromal stage of fever in general, we are required to add a sense of distention and weight in the stomach, acid or bitter eructations, an icterode complexion of the face, pains in the abdomen, constipation or a bilious diarrhea, occasionally chilly sensations, and a silent and gloomy disposition of mind. In the hot stage, the pulse is but rarely over 112, during the first several days, and for the same time it is full, active, and compressible ; the skin rarely becomes very hot — the tunica albuginea and the whole surface of the body becomes of a jaundiced hue; some moisture may be frequently observed, during the course of the fever, about the region of the heart, but a general perspiration is but rarely, if ever, witnessed before the final resolution of the fever. The urine is small in quantity and charged with bile ; the tongue is bitter and covered with yellowish slime, which becomes brown as the disease advances, and, though moist in the beginning, it becomes dry, hard, and of a brown color. Nausea, vomiting, and a loathing of food always attend, with a desire of drinks, particularly of an acidulated character. In this modification there is an early tendency to pass into the typhous form, consequently the most prompt attention should never be withheld. The breathing is usually oppressed and attended with some cough; the remissions and exacerbations are quite apparent. If it shall reach the typhous stage, then delirium and all the other phenomena that usually characterize this form of fever will be apt to make their appearance by the fifth, seventh, or ninth day. 


645 
FEBRILE FORMS OF DISEASE. 
In the course of this malady there are certain symptoms, that occasionally arise, which so unavoidably affect its general character as to make it expedient that we should notice them. 
Diarrhea is a frequent attendant upon continued fever, but, whether present or not, such is the gastro-enteritic irritability that the bowels are much more easily operated upon by cathartic medicines than in other forms of fever; and where a doubt exists as to the character of the fever, this circumstance in the opinion of Dr. Wood, should have weight in determining our opinion. He says, that diarrhea sometimes precedes the fever, but more frequently comes on during the first twenty-four hours, and is often procrastinated to a later period. The evacuations may be only one or two per diem, and they may be extended to a dozen or more; and what is equally if not more remarkable, they have a normal or healthy appearance, except as to consistency. As this peculiarity attends throughout the disease, it becomes one among the best of the diagnostic symptoms, and, furthermore, the liquidity of this excretion being common to this form of fever, marks it as one of the most obstinate, and therefore, dangerous forms of fever we have to contend with. It prevents that concentration of the vital force which is indispensable to the re-establishment of depuration. The disease is sometimes attended, particularly in its advanced stages, by dark-colored or even black stools—sometimes by such as indicate the presence of inflammation, and abdominal pains are not unfrequent attendants. 
Tympanites. —Dr. Wood states that he has scarcely witnessed a case of this fever in which this symptom did not more or less prevail. It does not become very obvious until about the seventh day, but sometimes it obtains as early as the third. Its violence is usually proportioned to that of the disease. Sometimes the abdominal distention occasioned by it is very distressing—it greatly interferes with the respiratory function. It appears to be mostly confined to the large intestines. 


646 
FEBRILE FORMS OF DISEASE. 
Rose-colored eruption is said to be very characteristic of this form of fever. It occurs most frequently between the seventh and fifteenth day, and first appears on the abdomen, from which it extends to the breast and inferior extremities. It appears in small, red spots, either round or oval, and about a line in diameter, more or less, and possess a slight elevation which disappears upon pressure, and returns upon its removal. Their number is sometimes only two or three, but in many instances they are innumerable. By appearing in successive crops, they occupy a period ranging from three to fifteen days. They are said to be very rarely absent. They are easily distinguished from petecchiae, which consists of extravasated blood in the skin. 
Sudamina. —This consists of vesicles not larger than a pin's head, and in order of time their appearance is subsequent to that of the rose-colored eruption. They are more readily felt than seen, unless viewed obliquely. They may spread over the entire surface, except the face, but they are more usually confined to the neck and the superior portions of the chest. They have but little diagnostic weight, as they occur in other forms of fever, and by no means constant in any. 
Cough and bronchial rales. —Dr. Wood says, that " this is a very common complaint," and that the "cough is either dry or attended with a slight mucous expectoration, with very little or no soreness or sense of oppression in the chest. The dry, sonorous, and sibilant rales may be heard more or less extensively over the thorax, and are much greater in proportion to the amount of oppression or dyspnoea than in ordinary catarrhal affections. They thus afford an important diagnostic sign. They are not, however, present in all cases. Sometimes they begin with the disease, but more frequently not until the lapse of about a week. Occasionally they give place to a crepitant or sub-crepitant rale, indicating the occurrence of inflammation in the parenchyma of the lungs." 
Pulse. —This source of information to the vascular condition of all forms of disease betrays much variety in this 


647 
FEBRILE FORMS OF DISEASE. 
form of fever. It presents great diversity of character in different cases; sometimes, in the early stages, it is full and strong, and sometimes feeble from the outset, and always becomes so in the progress of the malady. But that average pulse, which is most characteristic of this fever, is one of frequency, smallness, and feebleness, and is indicative of nervous irritability and capillary congestion. Its general range of beat is from 110 to 160 ; the former marks the beginning and the latter its last stage. When the system passes into a prostrate condition, its frequency is reduced below the standard of health. 
Hemorrhage. —In the early stage of the disease epistaxis is not an unfrequent phenomenon—the result, perhaps, of an active determination to the head; it is generally slight, though sometimes requires attention. In the advanced periods of the disease, hemorrhage from the bowels is apt to supervene, and as it is passive it may be always accounted a dangerous indication. 
Dullness or hebetude. —In the early and probably most congested period of the disease, the countenance of the patient becomes, as it were, a blank —he is apathetic and lowspirited. This dullness may increase with the disease, until stupor and even coma may supervene. 
Delirium. —This usual attendant upon continued fever may appear early in the disease, but it is usually procrastinated until about the seventh day. The manifestations of this condition of the brain, embrace every possible conception of which the mind is capable. They constitute a field of much study and interest to the phrenological physician. The peculiarities of the delirium are always in harmony with the prevailing endowments of the brain. The strongest feelings or most governing trains of thought are pretty certain to be exhibited. When the vital and lower animal faculties are strong, the delirium may be furious; if caution be strong and hope small, it will be of a desponding character; if the social sentiments be well endowed, the patient will betray great pleasure in his vivid conceptions of the beautiful and the agreeable; and if he has 


648 
FEBRILE FORMS OF DISEASE. 
much language in connection therewith, he will probably write poetry on the wall, or recite it to his attendants. We once attended an unlettered but a very philosophical man— who was organically a philosopher. During his fever, he appeared to find exceeding pleasure in the solution of philosophical questions. 
But this state of mental exuberance is not of long continuance — it passes very frequently into a muttering of broken sentences, and thence into stupor, and finally coma. It is proper to add furthermore, that there are two varieties of delirium in this fever —one results from an active cerebral circulation in fibrous constitutions, and the other from cerebral irritation, resulting from an insufficient circulation—debility. It may be further remarked, that, with the remissions and exacerbations, these two forms of delirium may alternate each other. 
Sloughing of the skin. —The physician should be constantly on the watch to prevent this liability from running into serious mischief. Vesicated portions of the skin and those upon which the patient constantly reposes his weight, are very apt to slough. The knowledge of this tendency should greatly direct our indications of treatment —dimin- vitality, and consequently a feeble capillary circulation. 
Retention of urine. —The accumulation of urine in the bladder sometimes becomes very considerable—the distention occasioned in this way has sometimes been enormous. The possibility of this occurrence should keep the physician admonished of his duty in this respect. " M. Marten Solon," says Dr. Wood, " has paid special attention to the state of the urine in this disease. He has found it to be more scanty, higher colored, and denser than in health, equally acid, if not more so, much more abundant in urea, and occasionally alluminous, especially in severe cases, in which this character of secretion must be considered as an unfavorable sign." 
We have now passed over those symptoms which more or less frequently obtrude themselves upon this form of 


FEBRILE FORMS OF DISEASE. 
649 
disease, if not absolutely essential to it. As they are well calculated to keep up the vigilance of the physician, we could not consent to omit them. 
Causes. —Upon this subject there prevails much more speculation than knowledge. It is known that cities, prisons, hospitals, camps, and ships are, perhaps, more frequently visited by it than other situations; but it is by no means peculiar to them, for it has fatally prevailed, as an epidemic, in the healthiest regions of our country. It is known, furthermore, that those who are under the meridian of life are much more liable to it than those who are above it. Dr. "Wood says, that "of 255 cases observed by Louis and by Chomel, 78 were from fifteen to twenty ; 95, from twenty to twenty-five; 54, from twenty-five to thirty; 22, from thirty to forty ; 5, from forty to fifty, and only one above fifty." 
These statistics have induced the general opinion that the aged are less liable to it than the youthful; but as to the reason why this is the fact, no one seems ever to have ventured an opinion. Having pretty fully explained such facts in the second book, we will just remark here, for the purpose of calling attention to it, that the least viable are the most liable to be cut down first. No one ever died at twenty-five, who had the vitality of those who are now living at the age of eighty-five years. ' We are willing to admit, however, that the two extremes of life are less liable to it, than that period which is the most distinguished for animal sensibility and vascular action. 
It has been thought to be contagious, but the weight of professional opinion is now opposed to such a conclusion. Dr. Wood has advanced an opinion which gives direct support to those expressed by us, in defining the constitutional difference between this and other forms of continued fever; but the reader would scarcely notice the correspondence, without a special call of his attention to it, because there is no similitude in the modes, respectively, of reaching the same fact. He says: 
11 On the whole, the most rational view of the etiology of 


650 
FEBRILE FORMS OF DISEASE. 
enteric fever, in the present state of our knowledge, seems to be, that an inherent predisposition to this disease exists in many persons, analogous, in soine measure, to the tuberculous, the gouty, and the rheumatic predisposition, which is liable to be called into action by various exciting causes, perhaps by almost any cause capable of considerably disturbing the vital functions, but that all persons do not have the predisposition, and that it is generally exhausted by one attack of the disease." 
If, now, the word predisposition, in the preceding quotation, be replaced by the word liability, then the agreement between us becomes obvious; with this difference: we have exposed the organic conditions upon which the liability depends, while he has not and can not show upon what a predisposition depends. We have shown that a predisposition is, absolutely, disease — a conclusion which he would not grant, and yet it is one which he can not avoid. 
Nature.—Authors have given us nothing on this subject which we are willing to honor with the epithet of respectable nonsense. Many have labored to find some sort of inflammation in some sort of a place in which to found it; but, as yet, they have so utterly failed, as to cause Dr. Wood to conclude: "As to the real nature of the fever, we are in the dark, as we are, in fact, in relation to all the essential fevers." 
We are of opinion that fever is as easily understood as inflammation, and that it is as comprehensible as any other vital action; and as to the ultimate nature of any one, we neither know nor can know anything. Fever, in every instance, must hold a precise relation to the character of the disturbing obstruction and the organization it acts upon, and the mode of its action. 
Diagnosis.—It should always be remembered by the attending physician, that all febrile forms have, in the beginning, so strong a family likeness that it is exceedingly difficult, if not impossible, to distinguish one from another; consequently, no attempt should be made at diagnosis for 


651 
FEBRILE FORMS OF DISEASE. 
the first three or four days. If an epidemic prevail, he will be justified, in the beginning, in treating it as one of the same form. After the lapse of three or four days, the soft, or even the semi-fluid character of the faeces, the insidious character of the attack, the gloomy expression of the countenance, the cough, the rose-colored eruption, the tympanitic abdomen, the sudomina, the retention of urine, and the pulse will distinguish it from other forms of continued fever. From remittent fever, it may be distinguished by the less marked character of its remissions. When remittent fever assumes the typhoid character, the diagnosis will become obscure, and of but little importance if made. The diagnosis between it and typhous will be presented when we treat of the latter. 
Prognosis.—When this form of fever is allowed to run its course, without becoming complicated with local inflammation, it should never be accounted dangerous, but as one, particularly under a proper treatment, disposed to terminate favorably by diaphoresis at some time within the period of two weeks. But sometimes the constitutional infirmities do not permit of such a result, and then we find the pulse weak, small, and frequent, the muscular system greatly prostrated, and a constant disposition in the patient to lie upon his back, all of which denote a collapse, from which recovery is scarcely ever to be expected, and more particularly if complicated with inflammation, which is most generally the case. Under such circumstances, the prognosis is always unfavorable. 
Indications.—In this form of fever, nothing more appears to be required than to remove the constriction, to equalize the circulation, and to sustain these achievements when gained by a proper alterative course. 
Treatment. —At the commencement of this disease, we prefer the use of anti-periodics, anodyne, and diaphoretics, for the purpose of allaying nervous irritability, equalizing the circulation, and thereby removing constriction. If, however, diarrhea should be present, or an extreme susceptibility to such condition, it will be proper to commence 


652 
FEBRILE FORMS OF DISEASE 
the treatment with mild evacuants, such as the Compound Powder of Rhubarb and Potassa, or the syrup of the same, in doses of five or ten grains of the powder, or a fluid drachm of the syrup, to be repeated every two hours, and continued until the bowels are thoroughly evacuated, and the diarrheal disposition removed or lessened. Occasionally, when hepatic fever is present to a considerable extent, we prefer the following preparation : 
H. Podophyllin, grs. ij, 
Caulophyllin, 
Leptandrin, da grs. vi, 
Comp. Powder of Ipecac, and Opium, grs. xvi. Mix, Divide into four powders, and administer one every four hours, until catharsis of a bilious character is produced. This compound may likewise be used in cases where the diarrhea is accompanied with watery evacuations and much pain. 
After having accomplished the results to be desired from the above agents, it becomes necessary to administer the anti-periodic and diaphoretic agents at first referred to; the most efficacious combination we have found to be as follows: 
R. Sulphate of Quinine, grs. xx, Ferro-Cyanuret of Iron, grs. xv, 
Cornin, grs. xviii, 
Hydrastin, grs. xx. Mix, 
Divide into ten powders, and give one every four hours, in any convenient vehicle, and it may be continued throughout the disease, if not subsequently contra-indicated, even during the stage of convalescence. 
In connection with this powder, and for the purpose of promoting diaphoresis, the Compound Powder of Ipecac, and Opium must be given in doses of from three to five grains, three or four times a day; this, however, must be omitted should there be pain in the head or a determination thereto. 
In every case of this fever, throughout its whole course, especial attention must be bestowed upon the surface. It 


653 
FEBRILE FORMS OF DISEASE. 
should be bathed as often as two or three times a day with a cold alkaline wash, and even more frequently, should the heat obstinately continue. The patient may drink freely of cold water throughout the whole course of the disease, and if he desires it, a piece of ice may be given him. By a perseverance in this treatment, the disease will generally yield in from three to eight days. 
In the progress of this fever, many symptoms of a local character may present themselves, demanding the prompt interference of the practitioner. The diarrhea may not give way to the above treatment, but may continue with much severity, rapidly debilitating the patient; in this case, astringents must be given, and we prefer the addition of from five to eight grains of Geraniin to each dose of the above Rhubarb and Potassa preparations to any other agent with which we are acquainted. 
Tympanites is a common occurrence and must always be treated with warm fomentations, emollient cataplasms, and counter-irritants, together with the means heretofore named for this local difficulty. If it should obstinately continue, with constipation, the injections referred to in another part of this work, must be often repeated with laxative doses of Seidlitz Powders. 
Cough is sometimes present, and may be relieved by the use of equal parts of the Syrup of Squills, Syrup of Senega, and Camphorated Tincture of Opium, and of which one or two fluid drachms may be administered every three or four hours. If it proves severe and unyielding, Mustard Poultices must be applied over the chest. 
Hemorrhage frequently occurs in this disease; when moderate it is not alarming, but becomes so when excessive. It must be met by the continued use of tonics and astringents; and if it be excessive epistaxis, it may become necessary to plug the nostrils with sponge, moistened and dipped in powdered Tannin. 
Under the old depletive system of medicine, the condition of the blood and of the nervous power becomes so changed by the treatment, that this symptom is not an 


654 
FEBRILE FORMS OF DISEASE. 
unfrequent attendant; while, under Eclectic practice, in which the integrity of the system is maintained throughout the whole course of the disease, the corpuscles of the blood being increased, and the nervous system invigorated, it is seldom met with. 
Should there be excessive determination to the head, as manifested by pain, or delirium, or both, cold applications must be applied to the head, with counter-irritation to the back of the neck, as the application of Mustard Poultices; and the inferior extremities must be kept very warm by bathing in hot water, application of bottles of hot water, or other similar means. 
"When retention of urine occurs, warm fomentations of bitter herbs applied over the pubes, with diuretics internally, will generally prove sufficient. The diuretic preparation which we most commonly employ is Spirits of Nitre, given in half-drachm doses, every hour or two, in Spearmint tea, or decoctions of Marsh Mallows, or Uva Ursi. This treatment is recommended where sensibility exists, as evinced by pain; but as this symptom frequently occurs without pain, the practitioner must be watchful of it, and in such instances introduce the catheter. 
In the advanced stages of the disease, when there is debility, with stupor and delirium, stimulants must be given, and continued, until the solution of the disease, and until convalescence has ensued; wine whey, Longworth's Catawba wine, porter, and even brandy may be administered at intervals with excellent effect. Sulphuric Ether is often efficacious in cases of sudden and great prostration. The temperature of the system must also be regulated as much as possible, by the application of sinapisms, hot bricks, or bottles of hot water, etc., kept constantly to the feet and legs, and cold or cooling washes applied to the head. Excessive stimulation to the lower extremities must be avoided, lest sloughing should take place. If the coma or delirium be obstinate, the hair may be cut or shaved off, and the cooling washes continued. 
The diet of the patient, in the early part of the disease, 


655 
FEBRILE FORMS OF DISEASE. 
should be very light and usually of a liquid character, as toast-water, solution of Gum Arabic, rice-water, weak Indian-meal gruel, together with the juice of sweet grapes and oranges. 
As drinks, cold water, cold lemonade, or infusions of bitter herbs may be allowed. In the stage of prostration, animal broths, beef or mutton tea, milk punch, and other stimulating nutriment must be given to sustain the patient's strength. 
The room should be frequently ventilated, and the clothing changed at least as often as every other day. 
During convalescence, the diet should be mild, nutritious, and easy of digestion—care being taken that the patient does not indulge too freely, or use indigestible food, lest sudden dissolution should happen. 
Species III.— Typhous Fever — Typhus Gravior — Spotted Fever — Petecchial Fever — Putrid Fever — Camp Fe- 
ver — Ship Fever — Hospital Fever. In our treatment of febrile forms of disease, we shall observe the distinctions which have been made by Dr. "Wood. The words typhous and typhoid will be used as adjectives to express that resemblance of typhous fever, which other forms of fever sometimes assume; while typhus will be used as a substantive or as a name to designate a special form of fever—that which has been denominated typhus gravior, spotted fever, ship fever, etc. 
When treating of synochus or typhoid fever, we gave it as our opinion that synocha, synochus, and typhus were but three varieties, but the differences between them are such as to have caused them to be, by almost all writers, treated of as three pretty distinctly-marked forms of febrile disease. We have, therefore, arranged them as species, more especially as there exists many intermediate shades of difference between the three, which constitute varieties. This arrangement, as we have before remarked, has its parallel in the three grades of vital strength that distinguishes society. To the word predisposition, we can attach no 


656 
FEBRILE FORMS OF DISEASE. 
idea independently 'of an obvious organic condition—as an abstraction, it conveys no idea, except that of the fact—the patient has a fever or is liable to it; and of this liability it conveys no instruction. But the liability of one to a particular form of disease is indicated by an observable peculiarity of organization, and thus our idea is rendered intelligible and instructive. 
Dr. Wood says: " There are undoubtedly strong resemblances between certain cases of the enteritic (synochus) and typhous fevers ; and though in most cases easily distinguished by the obvious symptoms, they were often confounded, until the work of Louis placed us in possession of the means of a more accurate diagnosis." He continues: " But it is highly probable that the two diseases are sometimes combined, in consequence of the simultaneous character of their causes." 
This conclusion we very seriously doubt. It is very probable that the two causes could make two equally strong impressions upon the same system at the same time; and it is equally improbable that two forms of disease could possess the system at the same time ; but we can readily admit that two causes capable of producing, by their joint action, a modification of obstruction, might produce a modified form of fever. 
But, whatever may be the cause or causes of typhous fever, we exceedingly doubt their capacity to produce it in one of a vigorous vital force—a strongly-reactive force, unless it has the power to strike with death, as it were, the irritabitity of the nervous system. The history of the disease shows that persons in comparatively good health have been suddenly stricken with the disease; but of the condition of their vital force, normally, we have had no information. 
If, however, the cause has this power, then this form of fever is distinct, and also independent, in a great measure, of all vital conditions. It is probably well known that when a typhous epidemic prevails, all other forms of disease betray a tendency to fall into the same type, just as 


657 
FEBRILE FORMS OF DISEASE. 
we have recently known, under an Asiatic cholera atmosphere, all other forms of disease assumed more or less that of cholera. "With these speculations, which are always justifiable in the absence of knowledge, we proceed to the symptoms of typhous fever. 
Symptoms.—An intense, pungent, and remitting heat of the surface; a tense, low, quick, and unequal pulse; extreme weakness ; vast anxiety and dejection of mind, presaging everything that is bad ; nausea, and, in malignant cases, a vomiting of black bile; pain in the temples and over the brows, a deep-seated pain in the eyes, and a great injection of them ; a sort of smoke-dried complexion ; ringing in the ears; a laborious respiration, interrupted with sighs; pain in the stomach, limbs, and back; a difficulty in lying down; tremors; delirium; the tongue at first white, afterward black and dry; the lips and teeth are lined with a viscid sordes ; an unquenchable thirst; a bitter taste in the mouth; the urine, at first, pale, but, as the disease increases, extremely high-colored, and in some very putrid cases, it assumes a blackish color and deposits a stool-like sediment; fetid sweats, which are sometimes tinged with blood; stools, highly offensive, livid, black, or bloody; small, livid spots on the skin, like flea-bites, called petecchise, or, if more extended, vibices, hemorrhages, aphtha?, ulceration of the fauces, and hiccoughs. 
We have presented a dense group of fearful symptoms, and for the purpose of their elucidation a few words of comment and explanation will not be out of place. 
The initial stage greatly varies in both degree and duration ; it is in some instances so slight as scarcely to be observed, but in others it is severe and protracted; the skin is pale, cold, and shrunken; the expression is peculiarly anxious ; the pulse is very feeble; and so great is the prostration, that reaction does not become established; but this extreme prostration is by no means a general feature of the disease. The hot stage, in the beginning, manifests no considerable departure from what is common to other forms of fever. 


658 
FEBRILE FORMS OF DISEASE. 
We have named nausea and vomiting among the symptoms, nevertheless they are not common — frequently entirely absent, and the bowels are generally costive. This marks a diagnostic difference between this and the synochus fever, and we regard it as a more favorable symptom. The temperature of the skin ranges from 100° to 109°, and the pulse from 100 to 160 beats in a minute; the respiration is also very hurried, and an exacerbation usually becomes manifest toward night, with a remission in the morning. 
The disease having now been at its zenith for several days, its characteristic eruption then appears — that which originally gave to the disease the name of petecchial fever. This eruption is confined to no particular portion of the body—it may be quite local, and it may be so general as to impart to the surface a measled appearance. It may or may not be slightly elevated, and in color it may vary from red to black, as the disease progresses toward a malignant condition. The eruption appears usually from the fifth to the eighth day, but it may anticipate two or three days, or procrastinate four or five. Occasionally they disappear, and then reappear, and sometimes they are complicated with sudamina. 
The tongue takes on a brownish color, is more or less dry, particularly in the middle; in many cases a dark sordes collects on the teeth, gums, and lips. It happens sometimes, as in the typhous stage of other fevers, that the tongue is clean and glossy, and finally comes to resemble raw beef. The appetite, in many cases, is totally lost, but the loathing of food is less than it usually is in more active fevers. The color of the face becomes of a dark-red or of a livid hue; the eyes become turbid; some hemorrhage is apt to take place from the nose, and a peculiar odor exhales from the skin. 
As the disease advances its characteristic stupor increases, so that the patient ceases to notice anything that is going on about him, and not unfrequently delirium is complicated with the stupor. So powerless is the circulatory sys- 


FEBRILE FORMS OF DISEASE. 
659 
tem, that the slightest exertion is attended with syncope; great thoracic oppression not unfrequently attends this excessive debility. The malady has now obtained that stage in which a change must take place, and if it be toward recovery, the frequency of the pulse becomes diminished; the skin becomes relaxed; the tongue moist and cleaning; the eruption fades; stupor subsides, and consciousness returns. This change toward convalescence is sometimes distinguished, like synochus, by a copious perspiration or urination, and the patient falls asleep, to awake, comparatively, a new or different being. 
But should the change be for the worse, then the patient lies upon his back, eyes half closed, mouth open, delirium with subsultus tendinum, hiccough, picking at the bedclothes, difficult deglutition, involuntary discharge of urine, extremities cold, features collapsed, pulse, perhaps, absent at the wrist. The physician should not abandon the case yet; if he does, he may possibly learn on the next day, to his shame, that the system of the patient rallied through the night, and he is convalescent. When there is no necessarily fatal lesion of some very important part, it may be said, " where there is life, there is hope." 
Convalescence from this form of disease, as might be expected, is slow, but it generally advances to good health with very little liability to relapses. The time occupied by this disease is very variable or very fatal; it may, in mild cases, conclude in recovery in a week, and in other forms of violent cases it may consume four weeks; but, generally, one week is consumed in its advancement, one to its completed stage, and one to its decline. We should add, that in those cases in which reaction can not be established, death may supervene in twenty-four hours. 
Causes.—About these we have some facts, but no philosophy. The most common resort of this form of disease is in camps, prisons, ships, hospitals, and, in private life, the filthy abodes of the destitute and miserable. It is inferred, therefore, that- a poisonous effluvia is generated from the bodies and excrements of those who are thus confined 
42 


660 
FEBRILE FORMS OF DISEASE. 
together. Very many facts have been collected to render it very probable that the poison thus generated, may, through the medium ol the atmosphere, visit the disease upon those who have not had any part in the generation of the poison. It is, furthermore, pretty generally believed that the poison can be confined in clothing, etc., and thus transported beyond the region of its generation, and re-produce the disease. 
It is also believed to originate in epidemic influences. This, to us, is a puzzle, that the human body, under certain circumstances, and the atmosphere shall produce a cause, which, in its results, shall be the same. Dr. Wood states, that he has no doubt that the fatal epidemics that prevailed in our country between 1807 and 1820 were of typhous fever. Both sexes and all ages seem to be liable to it, and the winter season, rather than any other, the time for its most frequent appearance and greatest prevalence. 
Diagnosis.—This form of fever can, in a great measure, be distinguished from all others, by the sordes upon the teeth, gums, lips, and tongue; by the habitual stupor that attends it; the suffusion or injection of the eyes ; the dusky or dark-red hue of the countenance, and great prostration of strength. 
The typhoid fever is most frequently confounded with it, but from it, it may generally be distinguished by the difference in the condition of the bowels, respectively. In typhoid, they are very rarely habitually aperient; while, in typhous, they are habitually constipated. Again, alvine hemorrhage is common to the former, but very rare in the latter. The typhoid eruption differs from the typhous; tympanites is common to the former, but exceedingly rare in the latter, and the same is true of the bronchial rales, which generally attend the former. (See the article on Typhoid and Typhous Fever, by Dr. W. Jenner, at the end of this " Order.") 
Prognosis.—This should be always regarded as uncertain ; but the appearance of diarrhea or fetid perspiration, in the declension of the disease, and a change of the petec- 


FEBRILE FORMS OF DISEASE. 
661 
chias from a blackish aspect to a brignter color, may be regarded as favorable. 
Dr. Eberle says, that spontaneous vomiting during the first and second day of the disease, more especially when the unpleasant cephalic sensations are thereby abated; slight hemorrhage from the nose, about the sixth or seventh day of the stage of excitement, is a good indication, and so is a moderate diarrhea at an early period of the disease. 
The unfavorable signs are, a vast number of livid spots, a sudden disappearance of them, black aphthse, no thirst, inflamed fauces, laborious respiration alter the eruption of the petecchiae, a swelling of the abdomen, with a concomitant diarrhea, highly fetid and ichorous stools, coldness of the extremities, and convulsions. To these Dr. Eberle has added a still more certainly fatal class: as blindness, involuntary flow of tears, difficult deglutition, paralysis of the tongue, insensibility to active vesicatories, and involuntary colliquative stools and hemorrhages. After all, he adds, patients do sometimes recover from this disease after many of the most alarming of these symptoms have made their appearance. 
Indications. —The symptoms of this form of fever show that that chemico-vital action upon which the calorific function depends, is greatly arrested and deranged; that the vital laws show a constant tendency to yield to the chemical ; that there exists a morbid tonicity of the nervous and vascular systems; consequently the whol j system should be relaxed, heat should be applied, depuration should be promoted, and the putrescent tendency of the system should be counteracted. 
Treatment.—In this form of fever, we pursue a similar course of treatment to that recommended in typhoid fever, with the exception that counter-irritants must be more energetically applied to the extremities and the spinal column, together with the use of antiseptics, when putrid symptoms are present, as Vinegar, diluted Pyroligneous Acid, Elixir Vitriol, etc. 


662 
FEBRILE FORMS OF DISEASE. 
Treatment of Simple Inflammatory Fever.—"We will now proceed to lay down our treatment for this form of fever (see page 635), which, we would here remark, is frequently followed by typhoid symptoms, may occur independently of any other abnormal condition, and often attends as the early stage to several other forms of fever. 
The treatment of this form of disease is very simple, as a general rule, if there be no complication, as we before remarked ; but it is not always possible for the practitioner to determine immediately the existence of a complication, hence the safer course will always be to adopt an early treatment. 
The first indication is to remove morbid accumulations in the stomach and equalize the circulation and nervous action. 
To fulfill this, an emetic must be administered as early as possible, to be followed by a cathartic; after which, instead of the futile attempts frequently made to produce diaphoresis by vapor baths and internal sudorifics, refrigerant diuretics, as Spirits of Nitre with infusion of Marsh- Mallow, must be given internally, and the surface bathed frequently with cold or tepid water. The wet- sheet may here be used with advantage. 
As soon as the more active inflammatory symptoms have become subdued, tonic febrifuges must be given ; and here, we prefer our usual preparation of Sulphate of Quinine, and Prussiate of Iron, which will generally overcome this form of disease, except it be complicated, when a course of treatment must be pursued which is adapted to the complication. 
It will occasionally occur, however, that the inflammatory condition of the system will continue very severe and obstinate, not readily yielding to the above treatment; in such cases, the Tincture of Gelseminum must be employed in doses of ten or twenty drops every hour, to be given until the eyelids begin to feel heavy, with scarcely an ability on the part of the patient to control them, when its administration must be omitted, and no more should be given 


FEBRILE FORMS OF DISEASE. 
663 
until the effect has entirely subsided. It should always be used with care and caution, for the root possesses a resinous principle, which is extracted by pure alcohol, that is very poisonous, and doubtless would produce death, even if given in small doses — hence the alcoholic extract or tincture should never be used. The common tincture of the Eclectic Dispensatory will not produce any injurious effect. There is danger of producing too great a suspension of involuntary muscular action ; this must, in all cases, be particularly guarded against, to prevent a degree of relaxation which may not be overcome. If this should be produced, however, active diffusible stimulus, such as Ammonia, Spirits of Camphor, or good brandy, should at once be made use of. 
The symptoms will now be found completely removed, at least such has been the case in our practice, and Quinine may then be administered, as before, either with or without the Prussiate of Iron. 
The diet in this form of disease must be light, nutritious, and of easy digestion. 
During the fever, cold water or cold acidulated drinks may be freely used by the patient. 
It will be seen that we do not pursue nor recommend an active depletive treatment in fever, and especially in this form. Herein consists a great difference between Alio, pathic and Eclectic practice ; the former, considering fever to be an inflammatory disease, combat it with active depletion, which we conceive to be a principal cause of the subsequent typhoid symptoms or typhoid fever, and which, in their hands, is such a common result—for it is an admitted fact that all inflammatory fevers may be converted into typhoid, by too active and debilitating modes of treatment; while, on the other hand, the Eclectics, viewing fever as an effort of the system to remove morbid action and accumulations, adopt a course which assists nature in her efforts, invigorates the system, and prevents, as a general thing, any of the subsequent typhoid conditions. 


664 
FEBRILE FORMS OF DISEASE. 
Genus II.—Periodic Fever. 
Introduction.—This genus embraces those febrile forms which are usually attributed to miasmata; and though some of them are not strictly periodical, yet their remissions are more marked than those we have treated of as being continued. The opinion is pretty generally entertained that those of this genus are but varieties—essentially the same—modified by the intensity of the cause and the constitutional peculiarities of the assailed; nevertheless, as it is common to treat of them separately, and as they admit of well-defined differences, we shall treat of them as so many species, and then ample room will be left for any number of varieties. 
Species I.— Intermittent Fever — Fever and Ague 
The symptoms which we detailed under the general name of fever, as applicable to the forming stage of fever, applies very accurately to the same stage in this. We will add one symptom, and so far as the writer has observed the phenomena of this stage in himself, it precedes all others, and frequently by a week or ten days ; it consists of a sort of pungent or drawing pain, as though the epigastrium was being drawn to the spine, and for the purpose of relief he frequently took full inspirations. After he came to observe this symptom, in connection with this form of fever, he never failed to prevent its occurrence by the use of prophylactic measures. The pain is located immediately at the inferior extremity of the sternum. The writer has not found this symptom recorded by any one else, nor does he know whether it obtains generally or not; but if it does, its appearance will give ample time for prophylactic measures. We have before remarked, that a paroxysm consists of three distinct periods in this form of fever: the cold, the hot, and the sweating. 
Cold period. —This begins with yawning, listlessness, and a peculiar sensation in the back, or in the ends of the fingers, which are not easily described. The patient is 


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then visited by a sense of horror ; a tremor of the muscles, with a chattering of the teeth ; a sensation of extreme cold, which commences at the extremities and travels to the trunk; it appears sometimes to be deeply seated, even to the bones ; a pain in the joints, back and head ; difficulty of breathing; pellucid urine, and a quick, small, weak, contracted pulse, which can scarcely be numbered on account of the tremor. It lasts from a few minutes to three or four hours, and even longer, when reaction is not effected; death frequently happens in this stage. 
During the action of this period, the patient betrays a constant disposition to yawn; the skin becomes so powerfully contracted that the finger rings will drop from the hand ; the mind becomes unsteady, irritable, taciturn, and morose; the muscular tremor is sometimes so violent as to resemble a paroxysm of convulsions; these rigors, as they are usually called, when long continued, leave the patient greatly exhausted. A dry cough, deep sighing, and a feeling of stricture across the chest are usually present. 
Dr. Eberle says, that in debilitated persons a violent fit of rigors often induces a complete state of stupor or coma; but in the south, we have seen these symptoms in the athletic. In this period, the thirst is urgent, and although cold water is desired, the patient fears to take a second draught, because he found the first to increase the paroxysm. The chill is sometimes so slight as to escape the cognition of the patient; the finger nails, more than any other part, exposes the fact. 
As this period becomes merged in the next, a sensible and a very unpleasant mixture of heat and cold travels over the patient. About the time of this change, nausea and vomiting supervene, but sometimes earlier, and continue until the hot stage is formed. 
Hot period — Pyrexia. —As the last stage passes off, an intolerable heat succeeds. The arteries are dilated, and strike forcibly against the finger ; the respiration is strong and free. The head aches, and the patient frequently becomes delirious, or we should have said, perhaps, that when 


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the patient is of a dense fibrous constitution, he is very apt to become delirious. An intense thirst is complained of, and a frequent demand is made for cold water; the tongue is white ; the urine is high colored ; much heat is complained of about the praecordia, and sometimes there is a swelling of the epigastrium. The blood, when drawn, is more dense than usual, red on the surface but dark colored within, with only a small portion of serum, and less cohesive than in health. 
"When this stage is being introduced, a warm and pleasant glow is felt about the face and temples, and from this the whole surface becomes hot; nevertheless, at this early stage of the period, if a limb be moved, sudden sensations of cold will be felt running, as it were, in divided rays over the surface. But presently all traces of the former period have passed off; the skin becomes distended with blood, the cheeks are flushed, and the eyes become brilliant. Dr. Wood says that Fordyce found the temperature of the system to be 105° by the thermometer, and Mackintosh, he says, has known it to be as high as 110° in Great Britain, and 112° in warm climates. There is no desire for food, and sometimes nausea and vomiting are present. 
As to duration, this stage is as various as the preceding one, but it is generally more lengthened, extending sometimes to eighteen hours. The febrile action is frequently greater than in continued or remittent fever. The cerebral suffering in this period differs from that of the cold stage in this, it is more deeply seated and generally more severe. At the commencement of this period in children, convulsions not unfrequently occur. 
Sweating period. — The patient, at length, feeling as though he was scorched to a crisp, is relieved by a copious sweat all over his body. All the symptoms now remit, and the perspiration, after continuing three or four hours, but sometimes much longer, entirely disappear. The urine deposits a lateritious sediment; the patient falls to sleep, and an intermission succeeds. 
Apyrexia. —This period embraces that time which trans- 


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pires between the close of the sweating stage and the commencement of the forming one of the next paroxysm. During this period, the patient, though without fever, is not usually entirely free from some sensations of ill-health. He feels as though he had been sick; he moves about as though he suffered from languor, and possibly he has some obtuse pain in the back and loins ; his appetite is fastidious, and his complexion is more or less sallow. But, on the contrary, it frequently happens that he feels entirely clear of disease and has an appetite that is even less fastidious than in health. 
We shall now make an extract from Dr. Wood, for the purpose of showing how little is understood of the nature and modus operandi of fever. We select him, not because he is the most vulnerable, but because he is probably the most esteemed authority in this country. He says: 
" It has frequently been stated by writers that each stage of the paroxysm, subsequent to the chill, is the immediate effect of the preceding stage; in other words, that the cold stage produces the hot, and the hot the sweating; but this is scarcely probable, at least with regard to the first two stages, which bear no proportion to each other—a protracted and severe chill being frequently followed by less fever than a very slight one, and the fever sometimes occurring without any preceding chill whatever. The probability is, that while the depression attendant upon the cold stage is naturally followed by some degree of febrile reaction, as a necessary consequence, the morbific cause, whatever it may be, is capable of producing the hot stage by a direct influence." 
We would like to know what sort of action this "direct influence " is. We are utterly unable to conceive how any one can pursue a sound practice in fever, whose views of its pathology are so beclouded—the fact is, they do not, and can not. 
We do not expect to explain this matter to the satisfaction of the lovers of the mysterious, but we are of the opinion that it can be done for those who seek only for the truth, 


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and love it the more for its simplicity. Then, first, what is fever ? We have answered this question several times, but it will do no harm to do so again. It is vital action accumulated for the removal of obstructions from the system. Now, a proper application of the law contained in this answer, will enlighten the whole subject. 
When the vital force is great, and the obstruction is comparatively trifling, is it not obvious that the former may act upon the latter without the patient or his physician having any other cognizance of the fact than is rendered apparent by the sequence, which is fever ?* It is not characteristic of a great man to make much fuss over a little thing, then why should we expect such a vital force to make a great fuss —to shake the patient almost to pieces, to overcome a little obstruction? A little obstruction may occasion a more lasting fever than a great one, because the concentration of vital force will be less — its energies will not be thoroughly aroused. 
When the vital force is compared with the amount of the obstruction, if feeble, the chill will be thorough and protracted, and in the event that it is overcome, it has been effected by a thorough concentration of the force; and whenever successful, there will be no great excess to become manifested in the form of fever. 
In the former case, though the fever may be considerably protracted, the patient will recover without foreign aid; but, in the latter, two or three paroxysms may so exhaust the vital force that death may result in the next struggle— simply because it is overpowered by the obstruction. In the latter case, furthermore, when successful, almost as soon as the cold stage has passed, the sweating or secreting stage will be introduced, simply because the force did not and could not rise much above the secretory condition of the system. 
Upon this subject, we beg leave to refer Drs. Wood, 
*Such a fever as this is quite common, in some districts, among young people, under puberty, and it is usually called dumb ague to distinguish it from shaking ague. 


FEBRILE FORMS OF DISEASE. 
669 
Eberle, Cheyne, "Watson, and the whole Allopathic school, to the " Thesis," of Freeman Franklin, M. D., of the Eclectic Medical Institute, of Cincinnati, which will be found in the April number of the Eclectic Medical Journal of that school for 1853. We say unhesitatingly, and under a full sense of our responsibility, that he has conveyed, in four or five pages, more sound and correct views of the pathology of fever, than can now be found in every Old-School book extant. The young gentleman merits this compliment, and the Old School the rebuke. 
As a difference of latitude, of topographical condition, of constitution, and of modes of life, produce great departures from the general history we have given of this form of fever, it becomes proper that we should notice a few of them. The principal of these peculiarities Dr. Eberle has reduced to the following: 1, the inflammatory; 2, the congestive; 3, the gastric; 4, the malignant; to which we add: 5, the masked intermittents. 
1. Inflammatory intermittents. —According to the same author, Bichter is of the opinion that this form of intermittent fever occurs most frequently during the winter and spring, and that it occurs more frequently in quotidians than in tertians, and in the latter more than quartans. Those who constitute our first class are the most frequent subjects of it.* 
It is usually introduced with rigors, and in the hot stage the temperature of the surface rises high and the pulse 
*Why should this form of fever assail the strong rather than the feeble? 
The writer in his winter travels, in the colder regions of this country, observed that stout and athletic men suffered more — complained more, than females and feeble men. For this fact, he was unable to assign a reason, until he discovered the origin of animal sensibility. He now knows it to be a fact that with this class the skin more readily becomes constricted under the influence of cold, and consequently, in such a state, it can not depurate, and thus such obstructions are generated as to cause that struggle and reaction which constitute the paroxysm. The writer, having a feeble organ of animal sensibility, has, in very many instances, witnessed his superior power in brooking exposure to cold air and water and the usual trials of a camp life, in comparison with those of a contrary organization; and now, as to the accuracy of his conclusion, he has not a doubt. 


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beats with fullness and strength. But the diagnostic symptom of this form is the fact, that no matter how thoroughly marked the sweating stage may have been, a state of pyrexia will still continue to the next paroxysm. Much of the violence of the hot stage, to be sure, has subsided—the pulse has lost its fullness, but much of its quickness and tenseness remains; the thirst, too, is reduced, but still the patient demands drink, and still complains of some pain in the extremities and back. The discontented and fretful condition of the patient indicates the existence of much irritability in the system. Richter, says Dr. Eberle. teaches that this variety of intermittents is but seldom attended with gastric disturbances. 
2. Congestive intermittents. —This form of the disease does not occur often in this climate, nor very frequently even in the south. Those who become the subjects of it are of the third class, and who, in the north, would probably die of phthisis pulmonalis. 
For the reason that we have before given, the cold stage is greatly protracted, and all the symptoms indicate a highly congested condition of all the viscera, such as pain in the head, a sense of weight and oppression in the chest, fainting, vertigo, a feeble pulse; beside these symptoms of the cold stage, the hot is never clearly developed—it does not present a single feature of this period as it usually obtains. It develops itself very slowly — the skin scarcely becomes warm, the respiratory function continues oppressed, the countenance continues to appear anxious, and the pulse, though frequent, is small and tense —and probably the only heat complained of appears to be internal, and but seldom demanding drink. 
3. Gastric intermittents. —This variety, as might be inferred from its name, is attended by much gastro-enteritic irritation, from the redundancy of bile, a hyper-secretion of which is going on in the liver; the skin wears a jaundiced complexion ; the urine is charged with bilious matter ; nausea and vomiting of bilious matter is common; the tongue appears to the taste to be bitter; much pain is complained 


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of in the forehead. As the sequela? of this form of disease, we may anticipate much visceral derangement, as a cachectic condition of the system, and induration of the liver and spleen. 
This form of the disease usually appears in the fall, and has, in the opinion of the writer, no necessary connection with the, so-called, miasmata. He has witnessed it only in those who had been exposed to the preceding summer's sun, whereby the cutaneous system became, not only deranged, but greatly debilitated, and through a failure of its function, the disease resulted. 
4. Malignant intermittent — Congestive cliill. —Dr. Eberle says, that, according to Alibert, this form is of frequent occurrence in the south, and is always of a dangerous character. It is characterized, he says, " by a copious and fetid perspiration in the third stage, together with colliquative hemorrhages from various parts of the body, sometimes petecchiee and other marks of malignity. They run their course with great rapidity, death usually taking place in the third paroxysm." 
The writer has seen, and has had to contend with, many cases of this form of disease, and he has never known it to occur except in the first class of persons—the strong and more or less athletic. The first and second paroxysms are, so far as he has observed, uniformily mild, and the patient, during the intervals, will employ himself as usual; but the third paroxysm is characterized by the above-narrated symptoms. Alibert says that death takes place in the third paroxysm; —to this remark we will add, and it always happens in the cold stage. 
It is thought to be, and if neglected or inefficiently treated it certainly is, a dangerous disease. The writer thinks it hardly probable that one per cent, of unaided patients recover; nor has he ever known one to recover in the Old School practice—and yet, in the main, its practice was founded upon correct indications, but it wanted energy. He is decidedly of the opinion that there is no form of disease more manageable than this; and this opinion he 


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founds upon his own uniform success. And why should it not he ? It never assails the feeble, nor those of a brokendown constitution; but those who are otherwise sound, and so strong as to require only proper and prompt aid to effect a reaction.* 
*As the writer, from his many years' residence in the south, has seen much more of this form of disease than his co-laborer, the author of the practice* he thinks it proper to add, in this place, his own uniformly successful treatment of it. As his first case was the most malignant one he ever saw, he will simply introduce it and his treatment. 
In the valley of the Arkansas river, his person being generally known, he was called from the road to render what assistance he could to save a young man who was, as stated by the messenger, dying. The patient was so far gone that his eyes had the fixed position of death, and the globes were covered with its gloss; his lips were contracted tightly over his teeth; his body was covered with a cold and clammy sweat; his skin was insensible to almost any violence; his mind was unconscious; his pulse had left his wrist, and a copious but passive cero-sanguineous hemorrhage was going on from his bowels. Such was his condition. 
The only medicine the writer had was Quinine, which he always carried for his own personal use; and the family had none of any kind, except the common red pepper of their gardens. He ordered a strong decoction to be made of it—a good fire to be made and covered with stone, and a large kettle of water to be hung over it to heat. All this was accomplished in a short time. A tub was placed by the bedside; a few pieces of brush-wood were placed about the patient to raise the blanket from his body, and the tub and he were covered with the same. A few hot rocks placed in the already boiling water, soon produced a scalding vapor or steam, which was so managed as to envelop the body. He was too unconscious for voluntary deglutition, but when his mouth was filled with the pepper decoction, and his nose closed, he swallowed. At first, and for some time, he made no complaint of the scalding steam; but at length he complained—still its continuance and the use of the tea were persisted in, until his eyes and lips assumed a normal appearance and the hemorrhage ceased. Injections of the tea would have been administered, but no means of doing so could be had. While the preparations were making, four persons were kept rubbing him with hot cloths. 
Having pretty well equalized the circulation, twenty-grain doses of S. Quina were administered every three hours, until he had taken a drachm, and then smaller portions, until it was deemed unnecessary to give more. This was done with a view of maintaining that equality of the circulation which had been achieved. This was in the afternoon, and by the same time the subsequent day, he was well, but not strong. 
This practice succeeded so well, in so threatening a case, that, in his subsequent practice, the writer has resorted to no other. On the day after the 


FEBRILE FORMS OF DISEASE. 
673 
5. Masked intermittents. —Under this head, it is useless for us to do more than to apprise the young physician that among those forms of disease which, in the normal mode of manifesting themselves, are familiar to every practi tioner, do frequently obtrude themselves upon our notice in a masked form; and what is still more important to be known, is the fact that they will yield to no other means of cure than those which are applicable to the regularly-formed intermittent fever. In other words, it appears that the disease or obstruction which generally results in what is known as intermittent, does, in consequence of local or some general variety of infirmity, appear in that form of disease in which the said infirmity would most likely manifest itself. As an illustration of our meaning, we remark that a tooth is so decayed as to expose its nerve, which by aching indicates the usual morbid actions of the system; hence the system, laboring under the usual cause of intermittent fever, the reactive power expends itself in the form of odontalgia. This, we opine, is the true explanation of the fact, just as gastric derangement is manifested in the same manner, and for the other reason, that masked intermittents can be cured only as pure intermittent is. 
Of the masked forms of intermittent fever, Dr. Brown (En. Prac. Med.) has given a catalogue, from which the following are extracted —but without his appended authorities: Pleuritis, carditis, peritonitis, ophthalmia, swelling of the head, urticaria, scarlatina, rheumatism, gout, epistaxis, odontalgia, cephalalgy, encephalitis, meningitis, gastroenteritis, dysentery, asthma, hysteria, epilepsy, convulsions, blindness, dumbness, sneezing, eructation, leucorrhea; but neuralgia, in some form, is the most frequent that appears in this disguise. 
Prognosis.—Simple or uncomplicated intermittent fever can not, directly, be regarded as a dangerous form of dis- 
paroxysm, his skin had very much the color of a boiled lobster—as red as it could have been made without vesication. Such has been the writer's success in this practice, that he believes ninety-nine per cent of cases may be saved by it. 


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ease, but when loug continued it is apt to lay the foundation of a premature death. The feet and legs become edematous, the spleen enlarged, the digestive function greatly impaired, and finally dropsy terminates the case. But the practice of irregular habits, and the use of trashy and innutritious food, have as much to do in these results as the disease—indeed, we have seen but few who possessed a good constitution, and lived obediently to the organic laws, who ever had the disease. 
When the disease assails those who possess a highly encephalic constitution, passive congestion of the brain, or apoplexy, may be so far anticipated, as to place us on our guard. Prof. Eberle says: " In general much less danger is to be apprehended from this disease in the young and vigorous, than in persons of feeble, nervous, and depraved habits of body." We should think so, as we have never seen the disease, except in the malignant form, in persons of that character. He further states : " Delirium seldom occurs in intermittents, and when it does happen, it must be viewed as unfavorable; and even more so than mere coma." We do not believe one word of this. Dense and fibrous constitutions very rarely have febrile action without delirium; and yet they have the least danger from this disease. The writer, during five years, had more than twenty paroxysms, and delirium attended them all; and yet he never had a threatening one. We have seen much of the disease, and would greatly prefer to see delirium than coma. 
Before closing, it is proper to remark, that tertians are more manageable than quotidians, and they again much more so than quartans. It is our opinion that simple intermittent fever is always founded on debility—and hence remittents are converted into intermittents by bleeding and purging. 
Causes.—In treating of the causes of fever in general, that which pertained to this particular form was so far discussed, as to leave us but little to say at present. Our readers have, no doubt, learned by this time, that we have 


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no more faith in the doctrine of haino-miasmata or malaria, than a man of common sense might be supposed to have in the so-called " spirit rappings." It is, we believe, a settled principle in philosophy, that like causes will produce like results—hence like results should be referred to like causes. Bear this in mind, while we attend to Prof. Eberle. He says: "I have seen one instance, in a delicate child, where a distinctly-formed ague was manifestly produced by intestinal irritation, from too free an indulgence in irritating articles of food. An interesting case is related by Mr. Earle, in which a regular intermittent was produced by the irritation of a small piece of dead bone in an old wourfd, and which was at once arrested on removing the irritating substance." He further states, "Richter observes, that worms and other causes of intestinal irritation have been known to produce intermitting fever." 
What a wonderful similitude there must be between irritating articles of food, worms, and a small piece of dead bone, and Jcaino-miasmata I 
Let us notice him a little further. " Intermittents are never more prevalent than when the days are very warm, and the evenings and mornings are cool and damp." 
We are disposed to think that such mornings and evenings, acting upon a skin that had become exhausted from previous long exposure to a hot sun, would be sufficient to produce an adequate obstruction to call forth an action of the system. 
Proximate Cause. — Upon this subject, we have had nothing but speculation, and hence a little more can do no great mischief —therefore, we claim a brief indulgence. 
Periodicity is a law of the animal economy, and therefore we shall attempt no explanation of it, but we may elucidate it. A man sleeps to-day at a given hour, and therefore, on the morrow he will desire to sleep again, unless his mind shall have been pre-excited. This is our experience. Application: A man has a febrile paroxysm to-day, why, therefore, should not his system require one at the same hour on the following day ? 
43 


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FEBRILE FORMS OF DISEASE. 
But there is another view that may be taken of this subject. Obstruction to the performance of some essential function has been produced; vital force accumulates and acts for its removal; but the force accumulated in the viscera and large vessels was at the expense of the surface and extremities, and consequently, in them, the calorific function is greatly weakened for a time, or suspended, and a chill is the result. Next, the force acts, and the action is called fe er, and in this action it is expended, and depuration is the result; but the obstruction is not all removed, and therefore, as soon as preparation can be effected for another paroxysm, it returns; and thus a habit is finally established which, sooner or later, under favorable circumstances, will spontaneously leave the system. Connected with the subject there are many minor phenomena, for which we have no explanation. 
Indications. —As intermittent fever results from obstructions in debilitated constitutions, the indications must be to assist the vital force to remove the former and to strengthen the latter. 
Treatment.—At the commencement of this disease, an emetic must be administered, if possible, just previous to the return of the cold stage, which may be followed by a purgative, if the patient's strength will admit; and in very severe attacks, this course must be continued daily for several days in succession. After the action of the first emetic, anti-periodics must be given, and continued through the whole course of the disease, without regard to any of its particular stages. The anti-periodics which have proved most efficacious in our hands, are Quinia, Prussiate of Iron, Hydrastin, and Cornin, in the following combination: 
H. Sulphate of Quinia, 
Fero-cyanuret of Iron, 
Hydrastin, 
Cornin, da xv grs. Mix. 
Divide this into ten powders, of which one may be given every hour, until the disease is arrested. If much influence upon the head should ensue, the dose of Quinine may 


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be lessened or altogether omitted. If catharsis is required during the treatment, a combination of Podophyllin and Leptandrin, or the Compound Pill of Podophyllin, will be preferable to all other cathartics, as they act both by freeing the bowels and unloading the congested liver. 
In cases where there is much gastric irritability, accompanied with nausea and vomiting, and an inability to retain anything upon the stomach, sinapisms applied to the epigastric region, hot applications to the feet, with Lupulin or small portions of Opium carefully administered, will, if persevered in, overcome the difficulty; when the curative treatment may be pursued. 
The Extract of Leptandrin Yirginica and Salicaceae have been employed by one of the authors with much success in this disease (Eclec. Med. Jour., 1852, vol. iv, p. 295). We extract his remarks upon the use of the latter: 
"Of the Salicacece. —We make no pretensions to botany, and therefore, we can not designate the two varieties of the tree of which we shall treat. They are, beyond doubt, indigenous. Our acquaintance with them was contracted in Arkansas: one is common to the Arkansas and Mississippi rivers, and probably to many other streams ; it grows into a very tall tree, and, in some instances, obtains a diameter of two feet. Its twigs or small branches are very brittle at their junction with the stalk, of a darkish yellow, not bright, like a foreign variety, which is common about Cincinnati. The tree is straight, and grows near the edge of the river, and frequently forms dense groves of small growth on the sand beaches. 
"The other variety, in Arkansas, grows scrubby, about the size of a peach tree, on stony branches, where, in the summer season, there is scarecly any moisture. 
"Knowing that some varieties of the willow had been used as an anti-periodic, we were, during our first season in the State, forced, for the want of a better, to use the extract of the bark of the tall willow first above described. The result was so satisfactory that we sought no other agent while in the vicinage of the river. 


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"During our third summer in the State, we attended a very large political gathering of the people of the valley o* the Arkansas river, upon which occasion we were called upon for a political speech ; but as the opportunity did not suit our politics, we gave them one upon the cure of intermittent fever, which prevailed very extensively among them. 
"We instructed them to fill a ten-gallon kettle with the twigs and bark of the Arkansas willow, and boil them about thirty minutes, then re-fill the kettle with fresh material, and thus proceed until they shall have a kettle full of a strong decoction; then strain it and boil it down to a syrup; and then, to avoid burning "t, evaporate in the sun to a proper consistence to make into from four to eightgrain pills. 
"In the use of these pills, we instructed them to resort to no variety of preparatory medication, but to commence six or seven hours before an expected paroxysm, and give two of these pills every hour, until the chill came, or its time for appearing should have passed. 
"In the following winter, we again visited that portion of the State, when a Mr. Barnets informed us that the pills he made cured seventy-four or five cases ; that another gentleman, a few miles from him, had cured more than fifty; and that, in all, he supposed one hundred and sixty cases, in his acquaintance, had been cured by our address. 
"In our practice, we never knew the chill to follow these instructions, when thoroughly carried out. 
"It is not our opinion that this willow has much, if any, of the astringent principle; these pills had, more frequently than otherwise, an aperient effect. 
"Being, upon another occasion, in the southern and mountainous portion of the State, we were called to an obstinate case of intermittent fever, and had no medicine to combat it with. The Leptandrin was not known to exist about there, nor did the tall willow, but the scrubby willow abounded. Supposing, as others have stated, that all the willows possessed similar qualities, we had an extract made 


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of it, and administered it as above taught. It produced no observable tonic or anti-periodic virtue, but so obstinately locked up the bowels as to do more mischief than could have been compensated by a destruction of the chill. It is a powerful astringent, and appears to be as destitute of tonic power as the other is of astringent. 
"There is, in this vicinity (Cincinnati), a willow precisely resembling the Arkansas, except in size; that their virtues are the same, we can not answer. Among the forest timber, there is another similitude equally striking: the buckeye of this country is a tree, in that, it is a shrub; in all other respects the resemblance is perfect, even to the effects upon the cattle which eat it." 
The Tincture of Gelseminum is extensively used in this disease by many of our physicians, and, as far as we can learn, with much success; our use of it, however, has been limited, yet, as far as tested, we are much pleased with its effect. 
Although we have stated that an emetic will be advisable at the commencement of an attack of intermittent fever, yet it will rarely be required after the first week of its existence. 
Notwithstanding the immense amount of matter from time to time presented to the profession for the treatment of this disease, we have found the above simple plan fully sufficient to meet the most obstinate and severe cases generally met with. 
Species II. — Remittent Fever — Bilious Fever — Bilious Remittent Fever. 
In order that the reader may not be misled by names when reading other works on fever, we deem it proper to state, that this form has received many, in consideration of the locations in which it has fatally prevailed, or from the local circumstances which are supposed to give origin to it, viz: miasmatic fever ; marsh fever; country fever; river fever; lake fever; Bengal fever; African fever; Walcheren fever; Mediterranean fever ; but it is, by the American 


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readers, most generally understood by the names of bilious fever, bilious remittent fever, and remittent fever; yet, even these names are objectionable, because all of them are sometimes just as applicable to other varieties of febrile action. Nevertheless, the term remittent conveys more nearly the idea we wish to convey than any other by which it has been designated, inasmuch as it really holds somewhat of an intermediate position between the continued and intermittent forms of the disease ; and it may be taken to represent, in respect to violence or grade, a mean degree between intermittent and yellow fever. 
Prof. Caldwell used to maintain that the principal difference between these three forms of disease consisted, mainly or altogether, in the violence or concentration of the cause; and this opinion, we believe, is considerably prevalent in the profession. To those who have not studied closely the differences in human constitutions, this doctrine may appear almost or quite unexceptionable; but our long acquaintance with the latter subject causes us to entertain some doubt, more especially as it affects the intermittent and remittent forms. "We are much disposed to regard these forms as such varieties only as may result from differences of constitution. 
Under the head of remittent fever, writers embrace two widely-differing varieties: the sthenic and the asthenic. In the former, all the vital functions are vigorously performed; while, in the latter, the vital system was either organically feeble or had become so by previous disease or debilitating habits. When treating of intermittent fever, we found that the malignant variety never obtained with those of a feeble constitution. In this form, then, the sthenic and asthenic can only be reconciled as members of the same form, upon the principle that intermittent and remittent forms of fever are one and the same, modified by telluric, atmospheric, and constitutional differences. 
So far as our observation has extended, and it has not been very limited, intermittent fever is produced by the action of a humid atmosphere upon feeble constitutions —the 


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humidity preventing a proper cutaneous action ; and remittent fever results from a less humid and a highly-heated state of the atmosphere acting upon highly-vital constitutions ; hence, in new countries, as we have seen, remittent fever may prevail in the towns, and intermittent in the country where forest and marsh abound. This explains also, why it is that intermittent fever prevails in the south at the river's edge, and remittent on the top of the bluff, where ponds and marshes do not exist. 
In the preceding book, we taught that narrow and damp streets were fatal to children, and broad and hot ones to men. From such facts as we have here introduced, it would seem that strong vital force is best adapted to an unexciting atmosphere, and that a feeble one does best in an exciting or electric one. We may further add, that we have always found malignant intermittent to obtain under remittent influences.* 
Dr. Joseph Brown (Cy. Prae. Med.), treating of this subject, says: "Remittent is the endemial of warm climates, especially of those of which the soil is marshy; but it is to be met with in the more temperate regions of the earth, and is not unfrequently observed in our own country, especially in seasons of universal heat, and in those parts of it where under ordinary temperatures agues are prevalent." This observation, as far as it goes, supports directly the opinions we have advanced. 
Dr. Wood says: " Remittent fever has the same types aa the intermittent. The most frequent is the quotidian, with 
* The writer was early induced to observe closely the relations of autumnal forms of disease to their causes, beeause he rejected the doctrine of malarious poison when a student of medicine, and under the voice, too, of its champion advocates, Professors Caldwell, Chapman, and Hossack. He will not assert that the doctrine of malaria is false, but that he believes it to be, and expresses this conviction for the purpose of inducing his readers to observe and investigate the matter for themselves. He would have them, as he has endeavored to da, to take nothing for granted that has not been demonstrated, unless it be self-evident. This course is indispensable, if we would escape imposition, for the most flagrant errors have received the sanction of truth, by the universal consent of mankind. Illustration : Mineral coal is of vegetable origin! 


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a paroxysm occurring at about the same time every day. The tertian, with its every-other-day paroxysm, is not uncommon. The quartan is very rare. Next, perhaps, to the quotidian, is the double tertian, having a daily paroxysm, but that of one day differing from the next, and the alternate paroxysms resembling each other both in character and in time of occurrence." 
The phenomena of the forming stage in this form of fever are, in general, such as we have before detailed under the head of "Order I;" but sometimes this period is remarkably brief, for the second or cold stage, as indicated by slight chills, is frequently the first manifestation of the disease. For a time more or less definite, these chills alternate with flashes of heat, until finally the latter acquires an entire ascendency—the febrile action is fully established, and with a highly-increased condition of many of the usual prodromal symptoms ; such as, pain in the back, head, and extremities. The pain of acute rheumatism is not more severe than that of the extremities frequently is. The tongue is covered with fur; a jaundiced complexion spreads over the eyes ; nausea, which is sometimes attended with a vomiting of bilious matter; the right hypochondriac and epigastric regions labor under a sensation of weight or tension ; the urine is scanty and charged with bile ; the skin is generally dry and hot; the respiration is oppressed • the pulse is but seldom hard or tense, but generally full and frequent, although not to such an extent as to exceed 116 or 120 beats per minute; the appetite is not gone, but there is usually a loathing of food ; thirst is not a constant though a frequent symptom. It is common for the eyes to be suffused and the face flushed. 
These symptoms, from having continued from six to eight or ten hours, relax, and the stage of remission commences. About the neck and face some moisture appears, which may or may not extend itself over the whole surface—giving so much relief that the patient soon becomes lost in a quiet and refreshing sleep. All of the febrile symptoms have abated, but a state of apyrexia does not supervene. The 


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683 
duration of the abatement or remission is very indefinite — extending from two to twenty hours, depending upon the existing quotidian or tertian type, as the case may be, when another febrile paroxysm supervenes, commencing in many instances as the previous one did, with chilly sensations, and subsiding in perspiration. This alternation of exacerbation and remission continues, with a gradual increase of the former and diminution of the latter, until the zenith of the disease is attained. But it is proper to remark, that the remission, instead of being attended with perspiration, will frequently give no other evidence of its existence than some abatement of the symptoms. 
In mild cases, the tongue is disposed to be moist throughout the disease ; but, with the usual violence of the disease, it becomes dry and frequently brown, or even blackish, particularly about the surface. In most cases, the epigastrium becomes particularly tender to pressure; in some instances, gastric oppression is complained of, and in others, a sensation of burning pain which is very distressing. During these symptoms there is apt to be much gastric irritability. 
One of the distinguishing symptoms of this form of disease is yellowishness of the skin and of the white of the eyes, and though not always present in the beginning of the malady, it rarely refuses to make its appearance by the fifth day; its tint of color sometimes becomes very intense, even simulating that of yellow fever, and not unfrequently quite uniform over the system; —it has even been known, in some instances, to be so secreted upon the surface as to stain white articles coming in contact with it. If bilious diarrhea supervenes, this peculiar secretion of the skin will not be produced. 
At the beginning of the disease, nausea and possibly vomiting may be among the symptoms; they are rarely absent, however, when at its height. The ejections are, generally, in the latter case of a yellowish, greenish, grass-green, bluish, or brownish color, and of a bitter taste. The force of the symptoms are not unfrequently reduced by nausea. 


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The bowels are not always constipated, but that they are, may be assumed as a general fact; and the fecal excretions though sometimes anti-bilious, are generally the contrary and probably mixed with some shade of green or black. In the advanced stage, a bilious diarrhea sometimes supervenes, and occasionally it is present at the beginning, and when nausea happens to be present, also, the introduction of the disease has somewhat the appearance of a cholera morbus. As most generally obtains in fever, the urine is small in quantity, high colored and turbid, and in an advanced condition of the disease, it is usually of a brownish color. As might be expected, there is some increase of it during the remissions. 
There is, perhaps, no symptom that is more uniformly present than headache, and along with it there is generally one or more of the following symptoms: vertigo, intolerance of light or sound, roaring or singing in the ears, redness of the conjunctiva, flushing of the face, delirium, drowsiness, tetanic spasms, paralytic symptoms, wakefulness, hiccough, etc. 
Finally, the reader is not expected to meet, in observations upon this form of disease, with all the symptoms we have enumerated in any case; and he should remember, furthermore, that there is perhaps no other form of fever that presents so many modifications of type, grade, and variety. We have therefore, only attempted to represent that character which may be drawn by generalizing a majority of its visitations. 
Dr. Joseph Brown says: " Recovery may be expected if the pulse becomes more full and expansive, the heat more equalized over the surface, the pain of the head and epigastrium less distressing, and if the countenance, though still flushed, loses the purple hue which it previously possessed. A favorable inference may be drawn, too, from the remissions becoming more distinct, the conjunctiva? being less vascular, the bowels more obedient to the action of purgatives, the restoration of a more abundant urinary secretion, and the appearance of bile in the matters vom- 


FEBRILE FORMS OF DISEASE. 
685 
ited. The mean duration of the disease, in cases of recovery, is about fourteen days." 
Dr. Wood makes the average duration to be about the same period, but very properly adds, that it sometimes terminates as early as the fifth or seventh, and often about the ninth or eleventh; but sometimes it is protracted to twentyeight days. 
The writer never had a case to extend beyond nine days, and frequently they terminated on the seventh ; yet, in the practice of his neighbors, he has known cases to continue twenty-seven days and never less than twenty. He alludes to those cases only to which he was called in consultation that had passed into the typhoid character — which never happened in his practice. He does not believe that the disease has a prescribed course to run. An energetic and proper practice will never suffer a case to run fourteen days. 
Remittent fever is considerably modified by the season of the year in which it may appear. When it appears in the spring, it is apt to produce thoracic symptoms of a dangerous character; when in the summer, the brain and the nervous system become the most vulnerable, and in the autumn, the abdominal viscera will suffer the most. 
Dr. J. Brown treats of one symptom which, it seems, has been noticed only by Dr. R. Jackson and himself; it is what we would denominate a suicidal monomania, instead of general delirium. It seems to have puzzled him very much, more particularly as post-mortem examinations revealed nothing! If, in such cases, he had examined the parietal ridge, immediately behind the coronal suture, he would have found that part largely developed. Monomania of any kind, in all febrile cases, depends upon special mental powers in a high state of endowment or excitement. He speaks also of some who, while in the fever, predicted that they would die — and die they always did, but the secret cause and fulfillment of the prediction he could not divine. If he had phrenologically examined them, he would have found a large endowment of caution, and a small one of hope. Even in cases of general delirium, it 


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is not uncommen for some particular idea to predominate. As to the circumstance of their dying, there is nothing strange —but it would be strange for men to recover from under a constantly-abiding impression of fear, so common and natural to such an organization, more especially when submitted to, as an inevitable doom. 
In the course of this fever, those of its subjects who possess a part so feeble that it can not resist invasion, inflammation is apt to be induced, and upon this circumstance, rather than upon the inherent character of the fever, does its fatality depend. The most vulnerable parts are usually the stomach, the spleen, the lungs, and the brain. When inflammation thus supervenes, the treatment will be found under the head of inflammation of these organs, respectively. 
It sometimes happens that this fever presents only a typhous character from the beginning. This may depend upon an inherently-feeble constitution, but we are of the opinion that it originates more frequently in those who have become enfeebled by previous disease or vicious habits. Bilious fever of the ordinary character frequently degenerates into the typhous through neglect, but more frequently through mal-practice — the very common antiphlogistic. When the disease is of this character, the treatment will be found under the head of typhous fever. 
It frequently happens that individual parts share a greater portion of the diseased action than others, and that, too, without the existence of inflammation ; but it is proper to add, that such local manifestations of disease should render us vigilant lest inflammation should supervene. Upon these local determinations, varieties of this fever have been established; hence we have gastric-bilious fever, hepaticbilious fever, and upon the same principle we have as many as there are important parts in the system —nevertheless, these local modifications should always command our earliest attention. 
Convalescence. —We have but rarely witnessed a case of convalescence which was not more retarded by the mal- 


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practice tbat had been instituted, than by any pre-existing peculiarity of the fever or of the constitution, and the principal difficulty we always found to be referable to mercury or the lancet. We have known the latter to be used to reduce the fever to an intermitting form — one that essentially depends upon debility. Such practitioners must act upon the principle that it is more easy to remove the system from the disease, than it is to remove the disease from it. In consequence of the use of the lancet and of mercury, the convalescence is not only greatly protracted, but attended with much suffering. 
When the case is of a mild grade, the convalescence is rapid and altogether favorable, and such is the case in almost all of its modifications when the treatment has been judicious. The troubles that are usually classed under this head consist frequently of the manifestations of that disease which was instituted to remove the pre-existing one. In originally frail constitutions, this stage may be attended more or less with copious night-sweats, imperfect digestion, constipation, enlarged spleen, and perverted action of the liver. 
Causes. — Upon this subject, we have perhaps said enough, unless we had something more certainly true than has yet been divulged. The profession generally attribute it to miasma, but many think it may be produced by heat and moisture. In answer to this hypothesis, Dr. Wood inquires why it does not occur among sailors at sea, and in our cities. We answer: At sea, the temperature is never so afflicting, and in our cities, in consequence of its hard, paved, and shaded condition, there is comparatively but little moisture. But, in this matter, all have overlooked an important feature—the electricity evolved by evaporation. One square foot of black, moist, and heated soil will throw off more vapor and evolve more electricity than a square rod at sea or in the city. Here, we are satisfied, lies concealed the secret. Under the head of intermittent fever, we delivered our opinion as to the cause of that and also of this form of fever. 


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Diagnosis.—When we shall have treated of the two following species, the reader will have but little use for a special treatise on the distinguishing differences between this and other forms; and yet, there is, perhaps, no single symptom, taken separately, that may not occur in other forms of fever. To judge of it at all, we must view it as a whole. The most marked symptoms of this form are: 1st, its paroxysmal character—but this is even more perfectly possessed by the intermittent; 2d, gastric irritability—this symptom attends this form more habitually than it usually does others, but others sometimes equally manifest it; 3d, constant pain in the head—this is like the preceding ; 4th, bilious phenomena—although these are more generally present, yet the same is true occasionally in other forms; hence all effort to divide febrile forms of disease into welldefined species, must fail. Fever, therefore, is essentially the same in all of its modifications. 
Prognosis.—Under this head, we have the same difficulties to contend with. In taking a general view of bilious fever, we are prepared to declare it to be favorable. Under a prompt and judicious treatment, we consider it (all circumstances considered) a less fatal and a more manageable form than the intermittent, simply for the reason, that, in it, there is more vital force, generally, to contend with the disease. It should never be considered as dangerous, except when it invades a diseased or broken-down constitution. 
Indications. —In this form of fever, these are very simple, but require an energy which shall be in harmony with the vital force ; they consist in equalizing the circulation and the nervous irritability of the system, to remove obstructions and all sources of irritation, and to promote depuration. 
Treatment.—At the commencement of the febrile stage of this form of fever, or during the first day or two of its attack, one of the best agents that can be given is an emetic, which not only removes the morbid matters accumulated in the stomach, but, by giving a shock to the 


FEBRILE FORMS OF DISASE. 
689 
nervous system generally, causes more or less profuse diaphoresis, mitigating the subsequent severity of the disease, and not unfrequently breaking it up at once. 
The emetic operation should be followed by a cathartic, for the purpose of removing congestion of the portal circle, augmenting the secretory action of the liver, and unloading the bowels of fecal and bilious accumulations. To effect this, we know of no better agent than the Compound Powder of Jalap of the U. S. Eclectic Dispensatory, which in ordinary cases may be repeated every other day. In cases where this agent can not be given, as well as in instances where there is excessive congestion of the portal circle, combinations of Podophyllin and Leptandrin, may be given in doses and at intervals suited to the urgency of the case. 
After the action of the cathartic has ceased, should there still remain pain in various parts of the system, nausea, or vomiting, or rapid pulse and high fever, active diaphoresis must be produced and maintained for a few hours. To effect this, the spirit vapor-bath is the best method; and may be given while the patient is in bed ; or the Compound Tincture of Yirginia Snakeroot may be administered in suitable doses, and repeated at short intervals until the patient perspires freely. 
If these symptoms, however, should not be present, or only slightly exist, the practitioner may commence at once with anti-periodics, and continue them through the whole course of the disease. The agents of this class and combinations which we prefer, have already been given under the treatment of the preceding forms of fever. 
For the determination to the head, which is almost always present in this disease, the same course must be pursued as already named in the treatment of continued fever. 
Hiccough may be relieved by Aqua Ammonia, Compound Spirits of Lavender, Musk, or other anti-spasmodics. Restlessness, wakefulness, and similar symptoms may be relieved by Compound Powder of Ipecac, and Opium, Sul- 


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FEBRILE FORMS OF DISEASE. 
phuric Ether, or infusions of Valerian, Skullcap, or Black Cohosh. 
Convulsions, which usually take place with children, may be treated by the warm bath, sinapisms to the extremities, and the internal exhibition of a dose or two of the Tincture of Lobelia and Capsicum. 
The patient may drink freely of cold water, and the diet should be light and fluid, with proper ventilation of the room and changing of linen. If acidulous draughts are craved, such as lemonade, tamarind water, or currant jelly, apple-sauce, and similar digestible preparations of acid fruits, they should be permitted. During convalescence, the diet must be more nourishing, but strictly of a digestible character. 
Species III.— Congestive Fever — Pernicious Fever — Pernicious Remittent — Pernicious Intermittent. 
Dr. Wood thinks the name " pernicious fever " to be less exceptionable than any other that has been selected to represent this form of fever. This, in the abstract, may be true, but the one we have adopted has become so familiar from long use, particularly to our western and south-western people, to whom this work will be measurably confined, that we prefer it. 
If congestive fever was not so signally distinguished in the popular mind from all others, we should have treated of it as a mere variety of the preceding, which, in truth, is the fact. Indeed, we may say that all the forms comprised in this genus are but varieties — modifications, and they should be so considered. 
Dr. Wood says, that he does not apply the epithet pernicious to all fatal or dangerous cases of either intermittent or remittent fever, but to those " in which there is great and sudden prostration or depravation of the nervous power, or to use a customary phrase, in which the innervation is extremely and most dangerously defective or deranged." 
This manner of defining his meaning amounts to about 


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691 
nothing, because it applies with as much justice to those forms of fever which are malignant or pernicious in consequence of a depraved constitution. In such cases, there is prostration—a want of innervation. Our idea of what he intended to define is about this: A pernicious fever is one in which the obstruction exceeds the resisting power of the vital force—one which will readily recover when the force is so aided as to overcome or remove the obstructions. By this state of the system is commonly understood a congestion from the magnitude of the invasion, and not from any previous depravity of the constitution; and one that is entirely independent of any local inflammation. 
The importance of this distinction is very considerable, because, in the first, though the present congestion may be relieved, the patient will probably die by reason of constitutional depravity; but, in the second, if it be overcome— if reaction be established, the patient is saved—dissolution and recovery depend, respectively, upon the turning of a single point and this point, to a malignant extent, rarely recurs. 
Between this form and the one of malignant fever, there is one striking similitude, it never cccurs in a depraved or feeble constitution—but in the strong; and there is also an equally striking difference: the congestive chill is confined to the usually miasmatic season of the year; but this has been known to commence in the spring and to prevail through the winter, though it generally obtains in the same season with the preceding. 
It is found to be difficult to state what the type of this fever will be, until after two or three days • — the period of doubt and uncertainty to both the patient and physician— that of congestion, or struggle or effort to overcome the obstruction. If this period be survived the type may be intermittent, remittent, or continued. But if the congestive period be procrastinated for two or three days, it may for this time appear as an intermittent or a remittent; and subsequently, instead of either of these types, it may appear, as before stated, in the continued form. 
44 


692 
FEBRILE FORMS OF DISEASE. 
Observations from various parts of the country seem to have determined, beyond doubt, that there are two leading modifications or varieties of this malady: in one the cerebro-spinal or animal system seems to be almost exclusively invaded ; and in the other, the ganglionic. Whatever may be the character of the disease as subsequently developed, it usually begins, as do the miasmatic fevers in general, and betrays no pernicious phenomena until the arrival of the second or third paroxysm ; or, as before intimated, at the close of the prodromal stage a highly-congested condition of the system may become manifest. 
If the fever is to be of that modification which more especially invades the cerebro-spinal system, the first indication will probably be drowsiness, which will be followed by more or less of stupor. The patient's attention becomes greatly impaired and his memory unfaithful. When asked a question, he may be so far aroused by it as to attempt an answer, but will probably stop before he has concluded, and possibly in the middle of a word. 
This cerebral condition may, and not unfrequently does, pass into a complete coma, and from an impossibility to arouse him, he will die in it. The circulation appears labored, and though the pulse indicates fullness, the rapidity is frequently even less than the normal standard; the respiration is stertorous. It is said that epileptic convulsions do sometimes attend this fever, and also tetanic spasms and difficult deglutition. 
These symptoms sometimes occur in the first paroxysm, but more frequently they are procrastinated to the second, or even the third. This form is consistent from the start, for though the first paroxysm may be light, yet comatose symptoms will prevail more or less. If the patient shall rally from the first severe paroxysm, which is generally the second, the following intermission will be attended by its usual symptoms; indeed, he may be exempt from all symptoms of disease, and thus go on to recovery ; but it is unsafe to indulge, without the greatest precautionary means, such a hope, for most frequently he will continue drowsy 


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and stupid until the next paroxysm, which usually proves fatal. 
The Medical and Surgical Journal of New Orleans, vol. iii, p. 733, contains an article from Dr. Bowling, of Montgomery, Ala., upon the subject of this fever, as he observed it. He states, that the approach of the paroxysm, after a few febrile exacerbations, was attended by spasms which closely resembled an attack of tetanus, that, with exacerbations and remissions of fever, continued with a corresponding degree of violence. He further states, that after the occurrence of the spasm, the patient in no instance lived longer than five days, and most frequently, if not arrested, death supervened at an earlier period. But the disease, as he saw it, differed from its usual character in this: it was attended with some intellectual capacity. 
When it invades the ganglionic system, the sight of one patient, in the forming stage, will so impress his general pathognomy upon the memory of the physician that he will never forget it. Language can convey no adequate idea of it. His expression is one of alarm, of horror, and impending dissolution ; his features are shrunk, shriveled, and apparently reduced within two-thirds of their former compass; his eyes are sunken in their sockets, and the skin is of a bloodless paleness. The extremities and the whole surface are cold, but the patient does not appear to be conscious of it, and a clammy perspiration covers the surface. Sometimes, as an exception to this general coldness, the chest and abdomen are much heated. The tongue is occasionally pale and cold, and the stomach greatly oppressed; and yet, with these symptoms, the patient complains of an intense internal heat, and of unquenchable thirst. 
In many instances, the stomach is particularly irritable, and all ingesta are rejected, and with it sometimes a little bile or muco-serous fluid, and possibly a little blood ; and, as in the case of congestive chill, the bowels may labor under a sero-sanguineous hemorrhage, the discharges being frequent and greatly prostrating. The respiration is difficult or labored, being quick and panting; the pulse is fee- 


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ble, or it may be corded, and so frequent as to number 160 beats per minute. Those who have practiced in the cholera, but have not seen this form of fever, would, upon seeing it, suppose it to be the former—it resembles it in very many particulars. The preceding symptoms, with modifications, may continue two or three days, and unless relieved will terminate in death ; or, if not too oppressive, they may be followed by a remission, or even an intermission, when the same symptoms will be repeated with increased and fatal violence when the proper hour is brought about by the revolution of its type. 
In a majority of cases, however, these dreadful symptoms may continue but a few hours, before they are replaced by a more favorable set, as returning warmth to the surface and extremities—by a stronger and fuller pulse; in fine, by a regularly-formed hot stage, which as to mildness will be in the ratio of the preceding severity. 
Cause.—About this we absolutely know nothing ; but a few facts have been observed in relation to it. It has been observed in some places, that when bilious fever prevailed on the table-lands, this form took place or was produced in still lower situations near the river's edge. It has been further observed, that when remittents and intermittents have prevailed, this variety did not. 
Dr. "Wood is of the opinion that it is a miasmatic fever, but it appears to us rather difficult to reconcile this idea with the prevalence of the disease through the winter, as is sometimes the case. » 
Nature.—Dr. Wood asks: "What is it that imparts its peculiar character to the pernicious fever ? Can it be inflammation ?" He appears to come to the conclusion that it is not — and we think this conclusion is very correct. He then asks: "Is congestion the source of danger? I can not think so." 
When we consider the cold and shriveled condition of the extremities and surface generally, we can not doubt the presence of congestion even to an alarming extent. We Care not whether the danger be attributed to congestion, or 


FEBRILE FORMS OF DISEASE. 
695 
to the obstruction, for the removal of which the congestion was the first preparatory step, because, if we equalize the circulation, and thereby re-establish depuration, we shall remove the disease.* 
Treatment.— The most reliable treatment is artificial heat, together with counter-irritation, most energetically applied. The most active and powerful means must be adopted to procure a determination to the surface, and thereby relieve the oppressed condition of the nervous system, as well as the congestion of the internal viscera ; for instance, if possible, the warm or vapor-bath may be used, hot foot-bath, sinapisms to the whole surface of the inferior extremities and spinal column, having previously applied powerful, stimulating liniments with considerable friction. 
As to internal treatment, Quinine may be administered in very large doses, as soon as possible, without regard to any particular stage or period of the disease; and its admin- 
* In the treatment of this disease, the indications are, very generally, by the Allopathic faculty, properly judged of, but their therapeutics are defective in energy The writer has witnessed the death of many patients from this and other congestive forms of disease, simply through a want of energy. To melt a pig of iron it is necessary to apply heat, but to expect to melt it in a pile of shavings or straw, would betray a remarkable degree of folly— not more, however, than most physicians manifest with regard to congestive forms of disease. To place around or about the patient a few bottles of hot water, and to administer to him a little toddy and a little Ammonia, is equivalent to melting a pig of iron with straw. 
Through a similar want of energy, he has known death to result from coma. Through a fear of public opinion, physicians frequently omit to discharge their own convictions of duty—such men should not practice medicine. An illustration of this may not be out of place. A professional acquaintance of the writer had a case of coma, and after having, with commendable zeal, tried all the means to arouse his patient that had been recommended by authorities, but to no effect, he sent for counsel. The consulting physician suggested actual cautery to several inches square of the surface on the lumbar region of the spine. The attending physician refused to accede to it, on the ground that the patient would die anyhow, and if such a measure were used, the people would say that they had killed him. The consulting physician then requested the privilege, upon his own responsibility, which, after consultation with the mother, was granted. Hence the cautery, in the shape of a hot shovel, was applied—and the patient saved. In this instance, but for the energy and decision which every physician should possess, the patient would have been lost. 


696 
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istration should be continued, at short intervals, until a decidedly normal impression is effected. 
We have found the tincture of Gelseminum given in connection with Quinine, in these cases, to be without a parallel in efficacy ; it must be given, however, until its peculiar effects are induced, which may be known by an inability of the patient to raise his eyelids, or muscles generally, although perfectly conscious of all around him ; together with a sense of increased temperature of the surface, a return of the skin to its normal condition, and a greater degree of regularity and softness of the pulse. 
In many instances, diarrhea is present, and the discharges are sometimes hemorrhagic, for which Geranin may be given in large doses in conjunction with the above remedies; but if, on the contrary, there should be constipation, active doses of Podophyllin must be given ; and, in either case, as soon as the condition of the patient will permit, a combination of Podophyllin and Leptandrin should be administered, at short intervals, for the purpose of restoring the bilious secretions to their normal standard. 
When stupor or coma is present, ice-cold applications must be made to the head, in connection with the above counter-irritating means to the spine and extremities, and stimulating enema may be frequently employed, together with active doses of Podophyllin, if the patient can be made to swallow them. 
Cold water may be drank freely by the patient, and even in large quantities if craved. We have used it with much benefit in this disease. The patient is stripped of all clothing, and cold water is poured upon him, until a slight chill is produced, or a sensation of coldness; then dry the surface with considerable friction, and place the patient in bed well covered up; reaction soon takes place, the surface becomes warm and moist, congestion is overcome, and the patient's life is saved. This plan is recommended, however, more especially where the patient complains of a peculiar burning heat in the skin. 
After the disease has been subdued, the treatment dur- 


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FEBRILE FORMS OF DISEASE. 
ing convalescense must be similar to that already recommended in other forms of fever. 
Species IV. — Yelloio Fever — Typhus Icterodes — Remit- 
ting Yellow Fever — Bulam Fever. 
This is another form of fever which seems to be produced by a longer continuance or some modification of that cause from which the other forms of this genus result. In its individual character it presents many and considerable extremes of variety; so much is this the case, that a physician introduced to it for the first time would be strongly induced to suspect, in a number of hospital cases, that he had almost as many independent forms of fever to contend with. Although the several patients may have been assailed at the same time, yet no two of them will have the same symptoms, in the same order, or manifested in the same manner. Much of this variety must be referred to inherent differences of constitution ; and some of it, no doubt, is referable to the magnitude of the cause of the lesion inflicted. 
The prodromal stage or period partakes largely of those peculiarities which attend the other forms of fever. In the period of chill, rigors very rarely obtain, and in some instances, there is not even an appreciable sensation of cold or chill—the hot stage being gradually merged out of the incipient, which is greatly distinguished by the severity of the pain in the back and extremities. The stage of excitement is characterized by a dry and hot skin, frequent pulse, a flushed face, red and suffused eyes, and a hurried respiration. The stomach is disturbed by nausea, and possibly by some vomiting, as both are not unfrequent attendants. Deglutition is frequently rendered difficult by the soreness of the fauces, and the tongue wears a white fur in conjunction with considerable moisture. Gastric disturbance is often present from the beginning, but generally it does not appear until after the lapse of twelve or eighteen hours, when it becomes exceedingly troublesome—attended with a sense of burning pain, tension, oppression, and soreness 


698 
FEBRILE FORMS OF DISEASE. 
upon pressure—all ingesta is retained, while, singular to remark, its own morbid contents are retained. The bowels, as is common to febrile action, are constipated ; flatulence is often troublesome, and the desire for cold drinks is very imperious. 
"Writers generally inform us that the tongue usually, if not always, wears a pasty coat, but Dr. Gillkrist says, that a perfectly clean tongue is not an unfrequent attendant upon very severe cases. From our acquaintance with fever, in general, we are disposed to regard the latter as a more unfavorable symptom than the former. He adds, that the most characteristic symptom of this fever is a pasty tongue, with the tip and edges red. In young and vigorous subjects, the skin may, and often does, have a pungent heat, but we are not to suppose that this is a more dangerous symptom than even a much lower temperature. In the latter case, the skin has a peculiar condition—one that can best be represented by the idea of compression or impaction, which is by no means to be regarded as favorable. The patient is apt to suffer much from his incapacity to obtain rest—he is restless—incessantly tossing his head and limbs about—unable to sleep — he is deeply distressed— draws deep inspirations; in fine, all of his manifestations indicate a state of congestion—one of imperfect reaction. 
The nervous symptoms provoked by this fever are surpassed by no other class, in relation to the suffering they produce. The severe pains in the back and extremities with which the affection was introduced, increase and continue even through the stage of excitement; pains in the head and eyes usually attend, are generally severe, and, like the former, continue through this stage, and with it, all of them so increase in violence as to cause the patient to moan and even to scream. The mental functions are frequently deranged ; sometimes it amounts only to confusion, but at other times it is manifested by maniacal violence. 
As the disease advances, the irritability of the stomach becomes so excessive that it is perfectly useless to attempt to do anything, through it, in the way of medication. Dr. 


699 
FEBRILE FORMS OF DISEASE. 
Gillkrist (Cyc. Prac. Med.) says: " Our experience during two epidemics, one in the West Indies, and of 1828 at Gibralter, by no means bears out the statement of others as to the bilious appearance of what is vomited in the progress of this fever; after having paid the closest attention possible to this point, we must, on the contrary, state, that with the exception of the black-vomit stage, and at the very commencement of the attack, what is thrown up consists of the ingesta and a glairy fluid. Bile is also usually absent on an inspection of the stools and urine." But he goes on to remark, that it should be remembered that we are treating of a disease which is so much like spasmodic cholera as to furnish exceptions to almost every rule that can be drawn from its diversified manifestations. 
Dr. Eberle says, that after the first ejections, bile in abundance is frequently brought up, which varies in color from yellow to dark-green, and often of so acid a quality as to excoriate the fauces. 
The stage of excitement, with occasional rigors, may vary, says Gillkrist, in its duration from forty-eight to seventy-two hours ; the pulse begins to give way, after having, up to this time, been full, rapid, and firm ; the eyes lose their brilliancy, and the patient, in most instances, becomes exceedingly feeble—too much so to sit up without aid. The skin becomes cooler and moister, the respiration calm, and the stomach measurably easy ; the severity of the headache and other pains have departed, and the patient believes himself to be convalescent, and such may even be the fact; but in the majority of cases the struggle is yet to be encountered. 
During this calm, however, we are not without indications of the existing probability. If the worst is yet to be expected, the epigastric tenderness, upon pressure, will be found to have increased, and instead of the flushed face and red conjunctiva, we will find an orange-yellow extending from the face to the chest, and possibly it may invade the entire surface ; the urine has also a yellowish tinge, though in a deep quantity it may appear brown, and the pulse has 


700 
FEBRILE FORMS OF DISEASE. 
fallen below the normal standard. This intermission or remission, as the case may be, may continue only a few hours, or it may continue twenty-four. But, be it long or short, it is succeeded by pain in the stomach and a burning sensation, and to these succeed a most distressing vomiting—the ejections are flocculent, and the desire of cool drinks urgent, and which, as soon as swallowed, are rejected with a force that leaves no doubt as to the extreme irritability of the stomach. These symptoms, having continued from twelve to thirty-six hours, introduce the last or third stage. 
The vomiting now becomes almost incessant, and the matter thrown up resembles coffee-grounds suspended in a glairy liquid, which is both dark and ropy ; the pulse sinks in force, volume, and frequency ; the tongue is dark, approaching black in color ; the burning sensation in the stomach is extremely distressing; the extremities are cold and clammy; green or black discharges from the bowels now ensue; and then follow hiccough, hemorrhages, delirium, coma, convulsions, and death. 
This is perhaps the most general course of this fever, when fatal; but it must be remembered, that it is frequently still more overwhelming—the patient sometimes falls at the seizure as though felled by a blow; and in some it commences with furious delirium. In such cases, it is common for the disease to terminate fatally at the close of the third day ; but even in these cases, dissolution is preceded by an acrid or burning sensation in the stomach and extending to the esophagus. The temperature of the surface and extremities falls rapidly; the features shrink; the urine is absent; distressing singultus comes on, and finally black vomit. 
But it is much more common for the disease to be protracted to the fifth, sixth, or seventh day, and sometimes fatal cases are continued to the twelfth or even the fifteenth day. The yellowishness of the skin frequently appears as early as the third day, but more frequently it does not appear until a more advanced period, and in a few instances, 


701 
FEBRILE FORMS OF DISEASE. 
not at all. Hemorrhages from the nose, gums, decayed teeth, and every other orifice of the body are apt to appear about the fourth day. 
The profession are generally of the opinion at this time that the matter of black vomit consists of coagulated particles of blood suspended in gastric mucus — it is insipid, whereas the black vomit of bilious or typhous fever, when it occurs, is bitter. 
Causes.—The time has been when this subject was much discussed, but it has measurably passed. During the studentship of the writer, it was strenuously maintained by some to be contagious. Prof. Hossack told the writer, that if he would hear him through his course on the subject, he would convince him that it was contagious ; he did so attend—but was not convinced. Prof. Caldwell maintained that it was not contagious—and in this we are disposed to believe that he was coriect —but he also maintained that it was produced by a peculiar poison, which he denominated malarious or miasmatic. This may be true, but the writer has never believed it. It is, and has been, his opinion that the various forms of fever embraced by this genus result from various combinations of heat, humidity, and electricity ; but, however this may be, the weight of the profession has concurred in the opinion that yellow fever is not contagious, and in this we think an important point has been gained. 
We do not intend to enter into any discussion of the subject in this place, but will introduce some facts which may possibly aid others to think for themselves upon the subject: 
1. Yellow fever does not prevail in the cold season. 
2. It does not require a higher temperature than 79° or 80° of Fahrenheit. 
3. It is arrested by cold, heavy rains and storms. 
4. It appears simultaneously, and is intermixed with bilious remittents.— Eberle. 
5. Dr. Ramsey states, that during the prevalence of the yellow fever at Charleston, in South Carolina, in the 


702 
FEBRILE FORMS OF DISEASE. 
year 1804, " neglected intermittents frequently terminated in yellow fever."— Eberle. 
6. Dr. Bush also states, in relation to the yellow fever, at Philadelphia, in 1802, " Intermittents, the mild remittent, the inflammatory, bilious, and the malignant fever, have, in many instances, all run into each other."— Eberle. 
7. Dr. Caldwell, in speaking of the yellow fever of Philadelphia, in 1803, states: " As the fever receded from the low ground and malignant atmosphere of Water street, it became more and more manageable, until its evanescent shades in Second street were, in many instances, much lighter than the common remittent of the country." 
8. In the city of Baltimore, " the bilious or vomiting fever, in its ordinary form, prevailed in that town and continued until it was gradually lost in the severer form of yellow fever as the season advanced."— (Danage) Eberle. 
9. " In some epidemics, females have remained wonderfully exempt; this was the case during a terrific epidemic at Dominique and Martinique, in 1801."— Gillkrist. 
10. In 1811, at Xeres, females "suffered in a particular manner."— Gillkrist. 
11. Negroes are known to be, generally, very insusceptible to the cause of this disease. 
We have in another place shown why it is that women and children are measurably exempt from any form of fever to which the other sex is peculiarly liable. This fact can not be explained by assuming any modification of the poison, if such it be. We have also explained why it is that negroes are but little liable to the southern fevers. 
Yellow fever is sometimes produced under circumstances entirely incompatible with the idea of a malarious poison. Dr. Gillkrist, upon this subject, says: "In fairness, we can not think that, like many other places which may be mentioned where yellow fever is known from time to time to appear, it can not be admitted that Gibralter furnishes sources from which malaria, in the usual sense of that word, arise3, sufficient to account for the appearance of a malignant 


FEBRILE FORMS OF DISEASE. 
703 
fever; neither can we concede to authorities of great respectability, that either there or in various other places the solution of the question is to be found in a crowded population, the filth of the town, or the state of the sewers. 
"If we consider the soil and elevation, it must be admitted that here, too, no satisfactory conclusion can be drawn; for if we find evidence, especially in the West Indies, and on the American continent, of the influence of a marshy soil, on several occasions, this does not hold good in other instances; and in those countries, as well as in Spain, many places might be mentioned, where elevation, soil, etc., would seem to guarantee immunity, but where, nevertheless, the disease occasionally prevails to a devastating extent." 
If we had space to enter fully into this subject, it would be discovered that all the facts which favor the doctrine of malarious poison, equally favor our own views, and that those which are fatal to that hypothesis, are entirely compatible with ours. 
If yellow fever be caused by miasm, it is supposed that it must in some way be associated with the decomposition of animal matter, because the disease is confined to cities, armies, ships, etc. The disease is never known in New Orleans when the river keeps full during the hot season ; and when it becomes low, there is exposed an immense mud-bar through the whole extent of the city's front, in which was deposited, during the business season, an immense quantity of animal matter. Under such circumstances, is it not possible that the atmosphere may generate a species of animalculse which may be inhaled, and thus produce the disease ? Or, in lieu of this, may it not cause their generation in the human system ? Dr. Rhees, of Philadelphia, states : "When the matters fresh thrown from the stomach were examined, the animalculae were alive and in constant motion ; but that no such phenomena could be detected in autumnal or bilious fevers." This circumstance demonstrates the existence of a very great difference between the two varieties of fever. 


704 
FEBRILE FORMS OF DISEASE. 
Diagnosis.—All fevers, in their initiatory stage, have so many features in common, that it is difficult to distinguish this from other febrile forms under two or three days, and yet there are signs which may guide to a very probable conclusion, such as the turbid conjunctiva, the great severity of the pain in the loins and inferior extremities, and, when the malady has further advanced, the great epigastric tenderness and the gastric irritability, the regular continuance of the fever for two or three days, and then succeeded by an abatement—intermission or remission, the yellowishness of the eyes and skin, and finally the appearance of the black vomit. If yellow fever prevails at the time, or if the other usually attending circumstances of the disease be present, the preceding symptoms can scarcely leave a reasonable doubt as to the character of the disease. 
Prognosis.—This has hitherto most generally proved to be a very fatal form of disease, having its fatality sometimes to run as high as ninety-five per centum. We feel quite sure that such a fatality is, in a great measure, due to the prevailing ignorance of its pathology and requisite therapeutics. 
It is now a well-settled fact, that the disease is attended with a much more extensive mortality when it first appears than at any subsequent period—that its fatality declines from the beginning of the epidemic to its close ; and from this circumstance it appears to be generally inferred, that the cause, whatever it may be, is more concentrated or capable of inflicting disease than it becomes to be at a later period. We regard this inference as being true only to a small extent, if at all. Our conclusion is, that the cause, when it becomes first introduced, cuts down all of the most vulnerable to its influence, and as the vulnerability diminishes, so does its fatality and the number of its victims. Dr. Wood says: " Perhaps the general average of deaths from yellow fever, prevailing epidemically, may be stated at one-third." 
Among the unfavorable symptoms, Dr. Wood cites the following: Excrutiating pains in the forehead, back, and 


FEBRILE FORMS OF DISEASE. 
705 
limbs; great frequency and fullness of the pulse, a gaseous state of it, or its entire absence at the wrist; a blood-shot appearance of the conjunctiva, and a bronzed or mahoganycolor of the skin; a short and violent febrile stage; coma or convulsions; a slow respiration with deep sighs; hiccough ; excessive restlessness, and a disposition to get out of bed and walk; an unnatural apathy, or an expression of dogged indifference in the advanced stages; a voracious appetite ; suppression of urine; an universal hemorrhagic tendency, with peteechiae; and finally, the occurrence of black vomit. This last symptom is regarded as almost necessarily fatal, but occasional recoveries are mentioned by authorities as having taken place after its appearance. 
Indications.—Whatever the cause may be can matter but little when we know the absolute condition of the system, and that this is one of a high order of congestion there can be entertained no reasonable doubt. The indications then, must be to overcome all cutaneous stricture and stimulate its surface, and by revulsives to produce a centrifugal action in the circulation —in other words, our duty is to equalize the circulation, and to establish and maintain depuration. 
Treatment.—In the early stage of the disease, should there be no irritability of the stomach, an emetic must be given, to be followed by an active cathartic, for which the Compound Powder of Jalap is admirably adapted; after the operation of the cathartic, the Compound Powder of Ipecacuanha and Opium, combined with equal parts of Quinine, may be given every hour or two in three or fourgrain doses; and the bowels must be kept open daily, in every case, by small portions of Podophyllin and Leptandrin, frequently administered; but in cases of irritability of the stomach, in which everything is rejected from it, Mustard must be applied over the epigastric region, and energetic counter-irritation to the spinal column and inferior extremities, together with active cathartic injections, combined with pulverized Lobelia or a portion of Tincture of Lobelia and Capsicum. The patient may also eat ice 


706 
FEBRILE FORMS OF DISEASE. 
in proper quantities, which will usually be found to assist in overcoming the gastric irritability. 
The surface of the body, in all instances of this disease, and especially when gastric irritability is present, should be closely attended to ; the whole surface should very frequently be bathed with a cold alkaline wash, which should be continued until the temperature is much diminished and renewed whenever there is an increase of fever. In other respects, pursue the same course as laid down for congestive fever. Cold water may be allowed whenever the patient craves it, but should it be almost immediately rejected, small portions of ice should be substituted. 
Species Y.— Infantile Remittent Fever. 
After having decided to publish a fourth book, we concluded not to separate this form of fever from the general subject—that nothing could be gained by so doing. 
This species has been divided into three varieties: the acute, slow, and low—and the differences between them are sufficiently considerable to justify the distinction. 
Variety I.— Acute Infantile Remittent. 
This form is distinguished by pain in the head and abdomen, slimy stools, little thirst, loss of appetite, drowsy exacerbations, and wakeful remissions ; it begins, usually by several days, with marked symptoms of indisposition ; the patient's color is changed; its expression contra-indicates health; its breath is offensive; it picks its nose and lips; has a dry cough, anorexia, swollen abdomen, and flatulence ; it grates its teeth, moans and starts in its sleep ; its urine is turbid, and upon cooling it deposits a whitish sediment ; and its bowels may be either loose or costive. In the midst of these symptoms a chill is produced, which is soon followed by fever; but sometimes its beginning is sudden, and no introductory stage becomes apparent. 
Of the paroxysms there are frequently three in twentyfour hours—one in the forenoon, one in the afternoon, and one at night, which is usually the most intense. It is hot 


707 
FEBRILE FORMS OF DISEASE. 
and of course restless at night, and the diurnal exacerbations soon succeed. When the fever is severe, the remissions are short and frequently not more than observable ; it is attended by troublesome flatulence, an increased cough, a horrid respiration, and occasionally by nausea and vomiting. As the fever progresses, the exacerbations increase and all of its attendant symptoms become aggravated, so that the pulse runs from 140 to 160. 
At length, all the symptoms during the remissions abate; it begins to rest composedly ; the pulse is reduced to 120 or 130 per minute ; it is more wakeful, gives more attention to passing events, and is not unfrequently playful. In the exacerbations and remissions the skin is usually dry, and when an exception occurs the moisture is usually confined to the head, breast, or palms of the hands. As yet, neither food nor drink is desired, and when either is taken it is usually rejected as soon as swallowed. The urine has become limpid and of a high color, and the stools never have a normal appearance in smell, cqlor, or consistence; worms are sometimes found in the stools and vomitings, and they spontaneously appear through the anus or the mouth ; the exacerbations become milder and more abridged as the pyrexia declines; moisture generally appears upon the surface ; the pulse falls; the appetite and refreshing sleep return; a copious sediment deposits from the urine, and the alvine excretions have become more healthy. The complaint continues from one to three weeks and occasionally longer. 
Variety II.— Slow Infantile Remittent. 
There is a variety of infantile remittent which makes its assault more insidiously and imperceptibly, and by way of distinction it is called the slow variety. In this form the breath is offensive, the appetite is fastidious, the abdomen frequently enlarged, and the flesh is gradually wasted ; it has but one exacerbation, which comes on in the evening, continues until morning, and is then succeeded by a profuse perspiration; hectic flushings are frequent through the 
45 


708 
FEBRILE FORMS OF DISEASE. 
day, the skin is dry and harsh, the pulse about 140 in the exacerbation and about 100 in the remission. The patient is rarely so much indisposed as to be confined to bed, nevertheless, it is not inclined to be active or playful, but is indolent, listless, and complains of an aching of the limbs when motion is attempted. It is often considerably disposed to doze both day and night; to pick its nose; the urine is of a deep orange color ; the thirst is but little ; the appetite is absent; the tongue is white and moist, and the stools, as in the former, or acute variety, are unnatural. At the commencement of a favorable termination, all the symptoms abate, and health and cheerfulness return. The continuance of this form of disease may be of two or three months. 
Variety III.— Low Infantile Remittent. 
This form resembles very closely, for the first week, the acute variety, except that it begins, pretty uniformly, in a sudden manner, and afflicts the brain more severely, often to the production of delirium. Its peculiar character now commences by an exhibition of indifference to all that surrounds it; it calls for nothing, and yet refuses neither food nor drink when presented to it; the superior extremities are usually, during its waking hours, kept in constant motion, while its inferior continue in a fixed posture. "When the disease has attained to its most oppressive stage, such is the debility that the patient loses the power of speech, and its jaws occasionally become fixed and immovable. During the exacerbations it slumbers much; the eyes are dull, inattentive, and flushed when the stage begins; the tongue, teeth, and lips are covered with a blackish fur; the facial expression betrays much distress, and during the remissions much restlessness becomes apparent by the constant motion of its arms. Before a discharge of faeces or flatus, it becomes restless, and, though sensible, the cystic and alvine excretions are passed involuntarily. In the remission, the pulse is about 100, but in the exacerbation it rises to 120. When the exacerbations become shorter and 


FEBRILE FORMS OF DISEASE. 
709 
milder, a favorable turn is supposed to have commenced, and if so, the drowsiness will be reduced, the eyes will become clearer, the expression more placid, the pulse more calm, the tongue more clean, and the appetite improved; it gradually becomes to betray some fretfulness, the speech and voice return, but the urine is still passed involuntarily—weakness is the only matter of complaint, and this is finally overcome. This form may continue six weeks, or even longer. 
Causes. —Upon this subject there has existed considerable contrariety of opinion. At one time it was attributed by many to the presence of worms ; so much so was this the opinion that Hoffman was greatly surprised when he did not find worms in connection with this disease. At that day the disease was familiarly called " worm fever." Something like a hundred years since, an Edinburgh physician questioned the doctrine, and showed that worms were not always the cause of this fever. Dr. Butter, in 1782, in his work on this fever, attributed the disease to debility, derangement, etc., of the digestive organs. He was of the opinion, however, that worms were of advantage to the system —and even Dr. Bush was much inclined to the same view of the subject. At the present time, the profession is generally of the opinion that Butter's views, in the main, are correct. In France, it is considered as a species of gastro-enteritis. It occurs both spasmodically and epidemically. In the latter form, it is produced, probably, in organically liable constitutions, by some of the usual causes of fever. Dr. Sims reports one epidemic of it as prevailing simultaneously with a low grade of nervous fever among adults (Cy. Prac. Med.). 
Diagnosis.—Dr. Sims, above cited, was of the opinion that it was impossible to distinguish this fever from hydrocephalus in patients under five years of age ; but Pemberton is of a contrary opinion. He thinks, that the screaming of the patient during sleep, strabismus, tossing of the hands over the head, intolerance of light, and the disturbed condition of the intellectual faculties, which characterize 


710 
FEBRILE FORMS OF DISEASE. 
hydrocephalus, will distinguish it from this form of fever, in which there is no strabismus, no derangement of the intellectual faculties, and but very seldom any screaming during sleep or any intolerance of light. Furthermore, says Dr. Gblis, hydrocephalus is attended by no distinct stages, its pulse never falls below the normal standard, and never extends from three to six weeks. 
Prognosis.—Although this is a troublesome and tedious disease, it can not be thought very liable to any unfavorable termination, more particularly under a judicious practice. In fatal cases the intestines have been found greatly distended and the mesenteric glands somewhat enlarged, but neither inflammation nor effusion has been detected in the abdominal cavity. The fact that this fever is somewhat liable to pass into hydrocephalus, constitutes its most dangerous feature. When such a tendency exists, it is usually indicated by sickness and vomiting in the beginning. 
Treatment. —At the commencement of the disease, when the stomach is loaded with undigested food, or before gastric irritation has taken place, a light emetic will usually be found advantageous. This should be followed by an active purgative, as the Compound Powder of Jalap, which is probably the best agent that can be used, often exerting a beneficial influence over the disease sufficient either to put an end to it at once, or greatly mitigate its subsequent severity. 
After the bowels have been freely acted upon, should the fever continue, small doses of Leptandrin, with or without Podophyllin, or if there be gastric acidity, Leptandrin combined with the Compound Powder of Rhubarb, or Syrup of Rhubarb and Potassa, should be administered in doses sufficient to cause one, but not to exceed two daily evacuations from the bowels ; and in cases of excessive irritability of the stomach, in which these agents are rejected, active cathartic injections must be used. 
Gastric irritability may be overcome by mild mucilaginous draughts of a diuretic nature, as Marsh-Mallows, to be aided by external applications, as sinapisms to the epigas- 


FEBRILE FORMS OF DISEASE- 
711 
trie region and spinal column. Spasmodic action will usually yield to the Tincture of Lobelia and Capsicum, aided by warm baths, especially if it amounts to actual convulsions. Probably the Tincture of Gelseminum might be of service when these symptoms are present. When great determination to the head is manifest, cooling lotions must be frequently applied, together with warmth and counter-irritation to the inferior extremities and spinal column. 
As soon as the stomach can retain medicine, antiperiodics must be given continuously every few hours, until the solution of the disease; the following is perhaps equal, if not superior, to any other for this purpose : 
R. Powder of Ipecac, and Opium, 9ss, S. Quinine, 9j. Mix, 
Divide into ten powders, and, to a child two years old, give one powder every four or five hours. 
As soon as convalescence takes place, the mild bittertonics, as Hydrastin, Cornin, etc., must be given, and their use continued, until the strength and appetite are restored. The diet must be very light and increased as the restoration to health advances. Oftentimes, when this disease is very obstinate, a removal to the country or change of climate will effect an immediate beneficial result. 
TYPHOID AND TYPHOUS FEVERS. 
We here present to our readers the investigations of Dr. W. Jenner, in relation to these two febrile forms of disease, which we regard as an excellent analysis, and of much value to the practitioner: 
On Typhoid and Typhous Fevers. An attempt to Determine the Question of the Identity or Non-Identity, by . an Analysis of the Symptoms, and of the Appearances found after Death, in Sixty-Six Fatal Cases of Continued Fever, observed at the London Fever Hospital, from January, 1847, to February, 1849. By W. Jenner, M. D., Professor of Pathological Anatomy in University College, London. —This is the title of an extremely interesting paper 


712 
FEBRILE FORMS OF DISEASE. 
which has been published in successive numbers of the Monthly Journal of Medical Science, commencing in the number for April of last year, and concluded in the number for April of the present year. It constitutes one of the most important contributions to the history of continued fever that has yet been made, presenting, as it does, the carefully-recorded histories of a very large number of cases, admirably arranged and analyzed, by a highly-competent and reliable observer.— Amer. Jour. Med. Sci., for 1850. 
"Age. —Typhoid fever was limited, in the cases here considered, to persons under 40 years of age; nearly onethird of the forty-three cases of typhous were more than 50 years of age. 
"Mode of attack. — As a general rule, the attack of typhoid fever commenced more insidiously than that of typhous fever. This observation, like all others in this paper, applies, of course, only to fatal cases. 
"Duration. —The average duration of the fatal cases of typhoid fever was 22 days. Of the fatal cases of typhous fever, 14 days. Half the cases of typhoid fever survived to the 20th day of the disease. Not a single case of typhous fever survived the 20th day of disease. 
"Eruption. — The difference in the appearance of the eruption in the two diseases was as great as it well could be, considering that both were of a reddish hue. 
"Miliary vesicles and sudamina. —These vesicles were present in an equal proportion of the cases of both diseases under 40 years of age. But in no cases of typhous fever, more than 40 years of age, were they detected. 
"Subsequent experience leads me to believe that miliary vesicles are rarely seen on individuals more than 40 years of age; and very rarely, indeed, if ever, on patients more than 50 years old. I have, during the last year— i. <?., since my attention was directed to this point—seen these bodies on no one of the many patients more than 50 years of age, laboring under various diseases, that have come under my observation. 
"Expression, manner, hue of face, etc. —As the rule, in 


FEBRILE FORMS OF DISEASE. 
713 
the cases of typhoid fever here analyzed, the expression was much less indicative of prostration, and more anxious, than in cases of the typhous fever. In the former disease, the complexion was tolerably clear, and the flush, when present, was of bright-pinkish color, limited to one or both cheeks, and often distinctly circumscribed. In typhous fever, on the contrary, the complexion was thick and muddy, the flush of the face uniform, and of a dusky-red color. 
"Headache was a constant symptom in all the cases of typhoid and typhous fevers; but it disappeared about the 10th or 12th day in the latter, and not until the termination of the second, or the middle of the third week, in the former. 
"Delirium commenced in three only of ten cases of typhoid fever before the 14th day; while it began in fourteen out of fifteen cases of typhous fever before the 14th day. As a rule, the delirium was decidedly more active in typhoid than in typhous. 
"Somnolence. —In eight out of nine cases of typhoid fever, somnolence commenced after the 14th day of disease. In seventeen out of eighteen cases of typhous, before the termination of the second week. 
"Coma-vigil. —One-fifth of the cases of typhous fever experienced coma-vigil; not a single case of typhoid fever experienced that condition. 
"Spasmodic movements were nearly equally frequent in the two diseases. 
"Retention of urine and involuntary discharge of urine and stools occurred with equal frequency in the two diseases ; but at a much earlier date in typhous than in typhoid fever. 
"Loss of muscular power. —Little more than a fourth of the patients attacked with typhoid fever kept their beds entirely before the seventh day of disease. All the patients affected with typhous, whose cases are here considered, took altogether to their beds before the seventh day of the disease. 
"The prostration was rarely so extreme in the cases of 


714 
FEBRILE FORMS OF DISEASE. 
typhoid fever as in those of typhous fever. Extreme prostration, when it did occur in typhoid fever, was not observed until from the 14th to the 30th day, while in a large majority of the cases of typhous fever it was marked between the 9th and 12th day of disease. 
"Epistaxis was present in five of fifteen cases of typhoid fever—in not one of twenty-three cases of typhous fever. 
"Hearing was equally and similarly affected in the two diseases. 
"Eyes. —The conjunctivae were very much more constantly and intensely injected in the cases of typhous than in those of typhoid fever; the pupils were absolutely larger than natural in a majority of the cases of the latter disease, while these were abnormally contracted in a large majority of the cases of the former affection. 
"Tongue. —Although individual cases of the two forms of disease may have closely resembled each other in the appearance of the tongue, yet, taking the whole of either group of cases, this organ presented a singularly-different aspect in the one from what it did in the other. It was much more frequently moist throughout the disease in typhoid than in typhous fever. When dry, it was often red, glazed, and fissured, in the former; but rarely so in the latter. 
"Again, in typhoid fever, when the tongue was brown, its Jine was much less deep—it was of a yellowish, instead of a blackish brown. The small, dry tongue, with red tip and edges, smooth, pale, brownish-yellow fur, fissured— the surface seen between the fissures being red—may be considered differentially as a diagnostic sign of typhoid fever. One only of the twenty patients affected with the typhoid fever, but eight of the forty patients laboring under typhous fever, were unable to obtrude the tongue when bidden.* 
"Intestinal hemorrhage occurred in one-third of the 
" * This clearly indicates the difference in the amount of prostration in the two diseases. 


FEBRILE FORMS OF DISEASE. 
715 
patients laboring under typhoid fever —in none of those suffering from typhous fever.* 
"The other abdominal symptoms and signs need no recapitulation. 
"Appetite and thirst. —No difference in the two diseases. 
"Pulse. —The frequency of the pulse fluctuated much more, from day to day, in the cases of typhoid than in those of typhous fever. 
"Cough and physical chest-signs. —Sonorous rale was very much more frequently present in the cases of typhoid than in those of typhous fever— i. e., it was present in eleven out of twelve cases of the former, and in seven only of twenty-one cases of the latter. Dullness of the most depending part of the chest, from intense congesting of the lung, was observed in nine cases of typhous fever—in no case of typhoid fever. 
"Sloughing appeared to be nearly equally frequent in the two diseases. 
"Erysipelas occurred in seven of the twenty-three— i. e., in nearly a third of the cases of typhoid fever; and in two only of the forty-three cases of typhous fever— i. e., less than one-twentieth of them. 
"Discoloration of the walls of the abdomen, and of the skin covering the larger veins, was much more frequently present in those dead from typhous than typhoid fever. 
"Emaciation had made greater progress in the typhoid than in the typhous subjects. 
"Spots. —The spots observed during the progress of the cases of typhous fever continued after death; no trace of the spots visible during life could be detected after death from typhoid fever. 
"Head. —After typhoid fever, the pia mater and arachnoid separated from the convolutions with abnormal facility 
" • I may here remark, that in one case only of typhous fever, received into the London Fever Hospital during the last three years, has blood passed from the bowels. The case referred to was that of an old man who had hemorrhoids, which occasionally bled when he was in health. During the time specified, notes of near two thousand cases have been taken. 


716 
FEBRILE FORMS OF DISEASE. 
in one only of nine cases examined with reference to the point. The vessels of the pia mater were abnormally filled with blood in one-third of the cases, but intensely congested in one only of fifteen cases. After typhous fever, the pia mater and arachnoid separated with abnormal facility in nine of eleven cases of which notes on this point were made. The vessels of the pia mater were congested in nearly half, and intensely congested in one-fifth, of the whole of the cases ; while the cerebral substance itself was abnormally congested in half. 
"Hemorrhage into the cavity of the arachnoid, which was not found in a single case of typhoid fever, had occurred before death in one-eighth of the cases of typhous fever. 
"The amount of serosity found within the cranial cavity was decidedly greater after typhous than typhoid fever. 
"Pharynx. —After typhoid fever, this organ was found ulcerated in one-third of the cases. After typhous fever, ulceration of the pharynx was not to be detected in a single case. 
"Larynx. —Ulceration of the larynx was found in one of fifteen subjects dead from typhoid fever—in one of twentysix from typhous fever. 
"Esophagus. —After typhoid fever, ulcerated in one of fifteen cases in which it was examined. After typhous fever, the esophagus was free from ulceration in all the twenty-four cases in which it was examined. 
"The epithelium separated from the esophagus spontaneously at an earlier period after death from the latter than the former disease. 
"Stomach. —In none of the fifteen cases examined after death from typhoid fever was the mucous membrane of the stomach softened throughout its whole extent; in no case did the softening of the cardiac extremity approach perforation. 
"In four of thirty-seven cases of typhous fever, the whole mucous membrane of the stomach was softened; and in four others, there was such extreme softening of the whole 


FEBRILE FORMS OF DISEASE. 
717 
of the coats of the great cul-de-sac that they were perforated by the slightest violence. 
"Small intestines and mesenteric glands. —The presence or absence of lesion of these organs was the ground on which the cases of typhoid and typhous fever here analyzed were divided from each other — consequently they were invariably diseased in the one and normal in the other. 
"Large intestines. —After death from typhoid fever, the mucous membrane of the large intestines was found ulcerated in rather more than a third of twenty cases. In no instance after death from typhous fever. 
"Peritoneum. — As peritonitis was in typhoid fever secondary to, and dependent on, the entero-mesenteric disease, it may here be excluded from consideration. 
"Spleen. —This organ was enlarged in all the cases of typhoid fever — softened in one-third of the cases only. Before the age of 50, it was as large after typhous as typhoid fever; after that age, it was decidedly smaller in the former than in the latter affection. After the age of 50, it was as soft in typhous as in typhoid fever; before that age, it was less frequently softened. 
"Gall-bladder. —There was ulceration of the lining membrane of the gall-bladder in one of fourteen cases of typhoid fever; in none of thirty-one cases of typhous fever. In the latter disease, the bile was much thicker and of a darker-green color than in the former.* 
"Liver, pancreas, kidneys. — These organs were more flabby in the cases of typhous than in those of typhoid fever. 
" Urinary-bladder. —This viscus was ulcerated in one of the cases of typhoid fever—in none of the cases of typhous fever. 
"Pericardium. —This cavity contained a small amount of yellowish, transparent serosity in all the cases of typhoid fever examined. The corltained serosity was red, from 
«« *The condition of the bile, as found after death in these two diseases, is worthy of more careful investigation. The difference in appearance is, in a large majority of cases, well marked. 


718 
FEBRILE FORMS OF DISEASE. 
transudation of a solution of hsematosin, in five of thirtyone cases of typhous fever, in which the pericardium was examined before the termination of the fever. 
"Heart. —The muscular tissue of this organ was much more frequently and decidedly flabby, and its lining membrane was much more frequently and deeply stained of a dark-red color, in the cases of typhous fever than in those of typhoid fever. 
"Lungs. —Granular and non-granular lobular consolidation were very frequent in the subjects dead from typhoid fever; rare in those dead from typhous fever. The reverse was the fact with reference to consolidation from congestion of the most depending part of the lung. 
"Pleura. —Recent lymph or turbid serosity was found in six of fifteen cases of typhoid fever— i. e., between onehalf and one-third, or in the proportion of forty per cent. The same lesions, but much less in amount, were found in two only of thirty-six cases of typhous fever— i. e., oneeighteenth, or in the proportion of 5.5 per cent. 
" The particulars here briefly recapitulated, appear to me to prove indisputably that the symptoms, course, duration, anatomico-pathological lesions, and the tendency to cadaveric changes, are different in typhoid fever to what they are in typhous fever. 
" To account for the differences in symptoms which exist in continued fever, with or without entero-mesenteric disease, the following assertions have been put forward: 
"1. That typhoid fever is merely typhous fever complicated with lesions of a particular organ ; and, therefore, it is to be expected that certain symptoms referable to, and dependent on that lesion, will be present, and so far modify the symptoms of the disease. If the symptoms and signs referable to the intestinal disease as a cause— i. e., the condition of the tongue, the diarrhea, increased resonance, and fullness of the abdomen, gurgling in the iliac fossa, pain and tenderness in the same region from the fluctuation of the contents of the bowel — were the only symptoms by which typhoid fever was separated from typhous fever, 


719 
FEBRILE FORMS OF D1SASE. 
although the idea might cross the mind that they were two diseases, no sufficient ground for their separation would be present, unless the specific cause of the one was proved to be different from that of the other. But, putting aside the symptoms strictly referable to the abdominal lesion, the general symptoms of the two diseases, in the cases here analyzed, differed widely; such differences having no apparent connection with the local affection, but being probably, like it, dependent on some common cause acting on the whole system simultaneously. 
" Thus the remarkable differences in the kind, not simply amount, of the rash in the two diseases; and the tendency to local inflammations, to erysipelas, and to ulceration, observed in the cases of typhoid fever here analyzed, can not, with any show of reason, be considered to have been dependent on the disease of Peyer's patches— i, e., in the same way as the abdominal signs undoubtedly were; and it is to be carefully borne in mind that the external, the hygienic conditions of either group of cases were precisely the same in all respects. They occupied the same wards, partook of the same diet, slept on the same beds, under the same amount of clothing, and had the same physicians to attend them, and the same nurses to wait on them. 
"Moreover, of the symptoms ,common to the two, the headache continued longer, and the delirium and somnolence came on, as we have seen, much later, in typhoid than in typhous fever; and the delirium, too, possessed a more active character. These differences, also, can not be explained by the presence of intestinal disease in the former, and its absence in the latter affection. 
" The short comparative duration of the cases of typhous fever here considered, is another remarkable point of difference, totally inexplicable by the hypothesis that typhoid fever is typhous fever with intestinal ulceration. Had the cases eventually recovered, it might have been said that the intestinal lesion prolonged the disease in the cases of typhoid fever ; but that all the fatal cases of fever, with a 


720 
FEBRILE FORMS OF DISEASE 
local lesion of so severe a nature as that recorded to have been present in the cases of typhoid fever, should have had a much longer course than all those other fatal cases of fever in which no organic change of structure could be detected after death, appears to me inexplicable, on the supposition that the former is simply the latter disease, with this serious lesion superadded. Let me repeat, by this hypothesis we are asked to imagine that death is retarded in fever by extensive ulceration of the small intestines, and enlargement, softening, and even suppuration of the mesenteric glands. Surely, it behooves the supporters of such a statement to bring forward cogent proofs of the identity of the specific cause of the two affections ere they ask us to admit its truth. 
u The same mode of reasoning appears to me equally conclusive, when we consider the comparatively early period of the disease at which the patients suffering from fever lost the ability to make muscular exertion. For, to suppose that the presence of abdominal complication in fever invariably prevented the extremely early supervention of debility is, a priori, still more absurd than to suppose such lesions to have retarded death. How, again, are we to explain, if we regard typhoid as typhous with abdominal complication, the differences observed in the ages of the patients; in their general manner; the muddy hue of the skin and uniform flush of the face, the injected conjunctivas and contracted pupils, in typhous fever ; and the comparatively clear complexion, the pink flush limited to the cheeks, the pale conjunctivas, and the large pupils, in typhoid fever ? 
" In what way, also, are we to account for the differences observed in the physical breath-signs, on the supposition that the one is merely the other with abdominal complication % 
"Death itself, moreover, adds new proof to the non-identity of the general affection in the two diseases. The comparatively rapid loss of muscular rigidity, the discoloration of the surface, the more flabby condition of the heart, 


721 
FEBRILE FORMS OF DISEASE. 
liver, and kidneys, the extreme softening of the stomach, and the early separation of the epithelium, after typhous fever, are all cadaveric changes, by which death makes us cognizant of a condition of the system at large, which condition must have existed anterior to the cessation of life from that disease; and which condition could not have been present in the cases of typhoid fever, or death would have made it manifest. 
" I need not here more than advert to the differences observed in the lesions which death simply enabled us to lay bare. The almost constantly-congested brain and membranes in typhous fever; the frequent presence of the signs of pre-existing serous inflammation in typhoid fever ; the difference in the nature of the pulmonary lesions in the two —are inexplicable on the supposition that the one disease is the same as the other, excepting so far as concerns the abdominal affection. 
" Thus tried by facts— i. e., by recorded symptoms and lesions—the assertion that typhoid fever is merely typhous with abdominal complication, is completely refuted. 
"2d. But another mode of explaining the differences which exist between the two diseases have been given— i, e., that the differences observed depend on variations in the epidemic constitution. These cases afford a complete answer to this assertion. For a majority of the cases here analyzed of both diseases were observed during the same epidemic constitution. If the reader will refer to vol. xix, p. 668 Amer. Jour. Med. Sci., he will find that nineteen of the cases of typhous fever I have used were collected between May and November, 1848; and that thirteen of the cases of typhoid fever were collected during the same months of the same year. For such as prefer broad, general assertions to the details of particular but more-limited facts, I may remark, that during the three years' attentive watching of nearly all the cases admitted to the London Fever Hospital, in which time there have been epidemics of relapsing fever, typhous fever, and cholera —and, consequently, according to those whose opinions I am here exam- 


722 
FEBRILE FORMS OF DISEASE. 
ing, as many changes in epidemic constitution — I have seen no alteration in the general or particular symptoms of either typhous or typhoid fevers, or the lesions observed after death from either — i. e., from November, 1846, to November, 1849. The cases of typhoid fever—which disease is rarely absent for a fortnight from the wards of the hospital—preserved their symptoms unchanged, and presented the same lesions, whatever the epidemic constitution that prevailed; the same is true of typhous fever. Cases of the latter disease are also rarely absent from the wards of the same institution. It is there common to see patients occupying beds side by side, and presenting respectively the well-marked characters of either disease. 
"But to return to the particular cases here analyzed. Allowing to epidemic constitution all the power of modifying disease claimed for it by certain writers, it must be granted that whatever influence this epidemic constitution exercised over the group of cases without intestinal lesion, it ought to have exercised over the group of cases with intestinal lesion, because the cases of the two groups were scattered indiscriminately over the space of two years only. If, I repeat, the two affections were really the same disease, then the same epidemic constitution ought to have impressed on both the same general features, implanted in both the same local lesions, and given to both the same tendency to cadaveric changes, and this allowing for all the modifying influence which the accidental presence of the abdominal lesion in the one and its absence from the other group might have occasioned. The analysis of every symptom, and every lesion, shows that the two affections were not thus assimilated by the prevalence of any particular epidemic constitution. But if this epidemic constitution, by any stretch of the imagination, could be supposed to change from week to week, to cause the case attacked to-day to have typhous fever, the individual who takes the disease to-morrow to have typhoid fever, still, it could not account for the fact—as well established as any fact in medicine —that typhoid fever rarely, if ever, affects per- 


FEBRILE FORMS OF DISEASE. 
723 
sons more than fifty years of age ; while age exerts little influence in determining the occurrence of typhous fever. 
" Thus, then, the assertion that typhoid fever is merely typhous fever modified by the prevailing epidemic constitution is as irreconcilable with facts as that the former disease is simply the latter with abdominal complication. 
" To conclude —In a former paper, I proposed to examine whether typhoid fever and typhous fever differed from each other in the same way as small-pox and scarlet fever differed from each other; and for the purpose of comparison, I laid down certain grounds, as those on which we founded our belief in the non-identity of the two last-named diseases. Those grounds were: 
"1st. In the vast majority of cases the general symptoms differ— i. e., of small-pox and scarlet fever. 
"[This holds equally true with respect to the general symptoms of typhoid and typhous fevers.] 
" 2d. The eruptions, the diagnostic characters, if present, are never identical — i. <?., in small-pox and scarlet fever. 
"[The particulars detailed in the foregoing papers prove that this is true of the eruptions of typhoid and typhous fever as of those of small-pox and scarlet fever.] 
" 3d. The anatomical character of small-pox is never seen in scarlet fever. 
" [Just in the same way, the anatomical character of typhoid fever — i. e., lesion of Peyer's patches and the mesenteric glands—is never seen in typhous fever.] 
" 4th. Both— i. <?., small-pox and scarlet fever—being contagious diseases, the one by no combination of individual peculiarities, atmospheric variations, epidemic constitutions, or hygienic conditions, can give rise to the other disease. 
" [In this paper, I have not attempted to determine how far this holds true with respect to the diseases here treated; but I have considered it in a paper read before the Medico- Chirurgical Society of London, December, 1849 [Amer. Jour. Med. Sci., vol. xx, p. 384], the contents of which I 
40 


724 
FEBRILE FORMS OF DISEASE. 
may anticipate so far as to state that, to my mind, the origin of the two diseases from distinct specific causes is as clearly proved as that scarlet fever and small-pox arise from distinct specific causes.] 
"5th. The epidemic constitution favorable to the origin, spread, or peculiarity in form or severity of either — i. <?., small-pox and scarlet fever — has no influence over the other excepting that which it exerts over disease in general. 
" [The facts detailed in this paper prove that this holds as true of typhoid as typhous fevers as of small-pox and scarlet fever.] 
" If, then, the above are the grounds—and, after mature deliberation, I am able to assign no others—for the separation of small-pox from scarlet fever, I think it is indisputably proved that typhoid fever and typhous fever are equally distinct diseases ; not mere varieties of each other, but specifically distinct — specific distinction being shown in typhoid and typhous fevers, as in small-pox and scarlet fever, by the difference of their symptoms, course, duration, lesions, and cause. 
" Before closing this paper, I ought to observe that, with respect to some secondary points— e. g., the chronological relation between the laryngeal and pharyngeal affections— it may be considered that I have drawn general conclusions from a too limited number of facts. But a few facts, impartially observed, minutely recorded, and carefully analyzed, are, I believe, more likely to give correct results than a multitude of general observations; and moreover, I believe most men would be astonished, if they had in numbers all the cases of any given disease they had ever seen, yet concerning which they have generalized. The method I have adopted, however prolix it may be, however difficult to conform to, however tedious the details into which it leads, has this advantage, that, if the observer be honest and capable of noting what is before him, thinking men may judge of the value of his facts, the force of his reasoning, and the correctness of his conclusion; whereas, general observations, while they are incapable of prov- 


FEBRILE FORMS OF DISEASE. 
725 
ing anything, are exposed to all the fallacies of definite statements, because the one, like the other, rests ultimately on the accuracy of the facts observed. If the observations, on which any reasoning is founded, be erroneous, no cloaking of those observations, in general terms, can render the conclusions correct. It has been objected to definite numerical statements, that they mislead the reader by an appearance of accuracy, in cases where there has been great inaccuracy in observation. This objection appears to me to lie against the condition of the reader's mind, and not against the method. For if the reader fails to examine, 1st, the trustworthiness of the author, and 2dly, the legitimacy of his conclusions, the fault is, obviously, mentally his own, and in noway to be ascribed to the method. Because chemists have, by the imperfection of their analysis, arrived at incorrect conclusions as to the ultimate constitution of various organic bodies, we surely would not have them henceforth confine themselves to the general impressions produced on their minds by a series of experiments or observations. The more complicated the problem to be solved, the more careful ought we to be that every step in its solution is made correctly. How complex questions, such as arise in medicine, are to be determined mentally— i. e., without the aid of figures—by ordinary men, I am at a loss to conceive. Yet physicians think to solve, by mental reveries, problems in comparison with which the most difficult that the most renowned mental calculators ever answered were child's play ; and not only do they think to solve these problems, but to carry in their minds for years the complicated materials by which they are to be solved. 
" Who can tell what general statements are worth, without knowing on what evidence they rest ? One man's many is another's few. Last month (Oct.) I saw thirty cases of fever—to me these were few; to men with smaller opportunities of observing that disease, they would have been many. One man's frequent is another's seldom." 


726 
INFLAMMATORY FORMS OF DISEASE. 
ORDER II. 
INFLAMMATORY FORMS OF DISEASE, OR THOSE WHICH ARE REMOVED BY INFLAMMATION. 
General Remarks.—Professor Eberle calls inflammation a vascular form of disease. Our definition has already been given. It is said to be characterized by pain, redness, swelling, and increased heat; and yet, it is conceded that neither of these phenomena is essential to its existence. It is said to terminate by resolution, suppuration, and gangrene. We deny the two latter; they are chemical processes, and the last frequently happens without having been preceded by inflammation. 
Inflammation, therefore, when properly considered, has but one termination, and that is by resolution or the reestablishment of health; under some circumstances, no accumulation of vital force can effect this, and suppuration is the result—the only means by which, under the circumstances, depuration can be effected. Gangrene is a chemical process which results from deficient vital power. 
Genus I.—Cerebritis— 
Softening of the Brain — Bamollissement du Cerveau — Inflammation of the Substance of the Brain. 
In the early records of medicine but little can be found upon this subject as an independent form of disease. We are indebted, almost entirely, to modern investigation for all that is now known with reference to it. 
Its introductory stage is indicated by uneasiness and restlessness, a sense of weight and fullness in the head, with occasional attacks of pain in it, drowsiness and vertigo, flushing of the face and increased heat of the head, acuteness of the external senses, optical illusions, contractions of the pupils, intolerance of light, strabismus, imperfect 


727 
CEREBRITIS. 
vision, tinnitus aurium, confusion of thought, an obvious departure from the previously-established character of mental action in some respect, imperfection of the memory, pains in the limbs, lassitude, muscular debility, disturbed sleep, paroxysms of chilliness and flnshings of heat or feverishness, and sometimes obstinate vomiting. Many of these symptoms, particularly those which pertain to the head, may continue for several months. 
At length, in what some have denominated the second period, paralysis of some part or parts supervene; and such is the injury that has already fallen upon his nominative faculties, that he resorts to pantomime to make known his wants. Occasionally coma and convulsions supervene. In many instances convulsions first announce the existing danger—sometimes they recur at short intervals, at other times they continue for many hours, and occasionally are succeeded by a contracted state of the flexor muscles and coma. From this condition the patient may recover and appear well for several days, and then, without the least premonition, the convulsions return and pass into fatal coma. 
In some instances, the convulsive paroxysms entirely subside, the muscular system becomes relaxed, and paralysis, more or less complete, succeeds ; the eyes become sunk, pale, and dim; the pupils become dilated and motionless ; the pulse is rapid, small, and unequal; rigors become frequent; the skin becomes cold and loaded with a clammy sweat; the respiration is slow and stertorous; the face is sunk and cadaverous; the patient lies senseless on his back; deglutition is difficult, and a fatal issue is close at hand. Paroxysms of excitement and collapse may recur several times, or until in this way he finally sinks into coma and death. 
The symptoms, in no one case, can fairly represent any other one case, because of the numerous modifications that result from the difference in the extent of the invasion, and the part in which it may be particularly located; this will become obvious when we reflect that different portions of 


728 
INFLAMMATORY FORMS OF DISEASE. 
the brain perform different functions. Post-mortem examinations of the brain in this form of disease discover a softening of some of its parts —it consists, when complete, of an entire disorganization, and of various shades of color. This ramollissement may exist in distinct and comparatively-distant portions of the organ. 
The nature of this disorganization continues a subject of doubt in the profession. Some regard it as a result of inflammation, while others entertain the opinion that it results in a manner similar to that which is effected in tuberculous matter in the lungs. We are of the former opinion. 
Dr. Abercombie (Eberle) thinks it most probable that there are two modifications of this affection ; one he thinks is inflammation, and the other a cerebral gangrene, from deficient circulation. If cerebritis was confined to the third class of constitutions—the organically ensemic—we might feel disposed to take this view of the subject; nevertheless, there are some circumstances that yield countenance to the opinion—its existence in those who had exhausted their vital force by an immoderate use of ardent spirits. 
Causes. —Depressing mental emotions ; drunken habits; blows on the head ; suppression of accustomed evacuations. 
Diagnosis. — There exists a possibility of confounding this form of disease with tuberculous meningitis, apoplexy, and some varieties of hysteria. When the case is attended by frequent pulse, headache, delirium, general convulsions, and ultimately coma, without rigid spasm or local paralysis, we may presume the presence of meningitis (Wood) - y but so intermingled are the symptoms of these two forms of disease, that no certain diagnosis can be given, and fortunately no great mischief can result from the mistake if made. 
Prognosis.—This must always be esteemed a dangerous form of disease, and it is probably safe to conclude that all severe cases prove fatal. 


729 
PLEURITIS 
Treatment.—The treatment must be similar to that laid down for meningitis, in a preceding part of the work, remembering, however, to employ it more actively and energetically in the case of adults. 
While most authors recommend depletion in this disease, probably for the purpose of subduing inflammation, and which must greatly diminish the normality and number of the blood corpuscules, we consider it a much better mode of treatment, and more properly adapted to this disease, to employ agents which will enrich and invigorate the blood, thereby furnishing the brain with healthy corpuscules, and assisting nature to overcome or retard the progress of the lesion; for this purpose, chalybeate preparations, and alterative tonics, with generous but not too-stimulating diet, will be proper. 
Genus II.—Pleuritis— 
Pleurisy. 
This name was used, in an early age of the profession, to designate a pain in the side, without any reference to its precise location ; but the idea it now conveys is that of inflammation of the pleura—the serous membrane that invests t'ie lungs and lines the cavity of the thorax. Inasmuch as it is not known that adhesions are ever effected without inflammation, and as they are very frequently found in some portion of this membrane, we may reasonably conclude that pleurisy is a very frequent disease—and frequently we know it to be a fatal one. 
So intimate is the connection between this membrane and the lungs, that it was at one time supposed to be impossible for one to be invaded by inflammation without involving the other ; but the contrary is now known to be the fact, which was beautifully illustrated when treating of this affection in children. Nevertheless, it is true that the complication is frequent. 
This form of disease presents so many varieties as to render it impossible, or at most, obscurely possible, to obtain a general view of it from any one position. As Dr. Law justly remarks, " It may be acute or chronic ; it may affect 


730 
INFLAMMATORY FORMS OF DISEASE. 
one side of the chest or both sides; it may be general, involving the whole of one side, or partial, only involving a part of one side ; it may be simple or complicated; the complication may be either accidental or essential, and in the latter case the pleurisy and its complication stand to each other in the relation of effect and cause." 
The right pleura is more frequently the seat of the disease than the left, and it is not unfrequently influenced by modifying causes ; hence it may be combined with bilious or typhoid fever, and then the disease is known as bilious pleurisy, typhoid pleurisy, etc. It may also be complicated with pneumonia, in which case it is known as pleuro-pneumonia. 
Species I.— Acute Pleuritis. 
This is an acute pain in the side, accompanied with an inflammatory fever, difficult and painful respiration. 
It begins with rigor and shivering, followed by heat, thirst, inquietude, and an acute, pricking pain in the side, verging toward the spine or clavicles; the pulse is hard and tense, like the vibrations of a cord; the patient lies without difficulty on the affected side, and has a dry cough which increases the pain; the urine is high-colored ; the blcod drawn by venesection coheres very strongly together, and is covered with a tenacious, whitish coat, resembling matted tallow; the head aches; respiration is performed with much difficulty, and an expectoration of a thin, sanious, and often bloody matter comes on after the third day from the first attack. 
The pain may be the first symptom, or it may come with the chill, or not until it has passed off. Most generally the pain is in the mammary region, and yet it is often felt elsewhere, depending measurably upon its location in the pleura. It will be felt, for instance, in the inferior margin of the chest, when the diaphragmatic pleura is the location of the inflammation. When it is located in the lining pleura of the chest the pain is increased by intercostal pressure. Sometimes it is extensively diffused, and then the pain is less acute. Internal pressure, as suspended respi- 


ACUTE PLEUR1T1S. 
731 
ration, stops the pain. The violence of it is modified with the exacerbations and remissions of the fever. The pain, in some cases, is scarcely felt, except upon a full inspiration, coughing, or pressure. 
With reference to the breathing, the dyspnoea increases as the disease advances, but it becomes to result from pressure on the lung by the serous effusion which has diminished both the inflammation and the pain. In consequence of the constricted condition of the lungs, the patient feels a distressing want of breath all the time; but this is much increased by a sudden and copious effusion, which now arises rather from pressure than constriction. It is proper to add, however, that this symptom, in some cases, never supervenes, although all the conditions that usually produce it are present. 
Dr. Watson says : "In some patients the dyspnoea never ceases to be urgent from first to last; and these are apt to prove fatal cases. In others the respiration is very much impeded at first; then the difficulty of breathing diminishes ; and at length it ceases long before the fluid is reabsorbed. In others again, by some unaccountable idiosyncrasy, the respiration remains at all times very facile, both at the outset and during the progress of the disease." 
The attending cough is short and dry, and will measurably continue so, unless some bronchial irritation or inflammation should supervene, and then it may be attended with a mucous or frothy expectoration, which in a few instances is streaked with blood. In some cases, not only the pain, as we have remarked, but also the cough is absent—such forms of the disease have been denominated latent pleurisy. The fever undergoes a daily exacerbation and remission; the latter occurs in the morning, and the former toward evening; the pulse is usually full and tense in the hot stage, but, it is worthy of note, that when the pain is very great, there is some reduction of the pulse. Delirium is sometimes present in the course of the inflammatory stage. 
Among the physical signs by which we are to determine the presence of pleurisy, most reliance should be placed, 


732 
INFLAMMATORY FORMS OF DISEASE. 
perhaps, upon the results of auscultation. In the beginning of the disease, before effusion has taken place, the percussion is clear—giving no other auscultory sign than a diminished respiratory murmer—a result of a less pulmonary expansion ; but after the effusion has commenced, a comparison of the results of percussion upon the two sides can leave no doubt. Instead of a healthy resonance upon the diseased side, there is an unmistakable dullness, which increases with the effusion until a complete flatness is produced. 
Post-mortem appearances.—A thickened condition of the pleura is but seldom a result of this inflammation; but, in fatal cases, an extravasation upon its interior surface, of a pseudo-membranous substance, is an uniform result; and it usually contains filaments of coagulable lymph or concrete pus, which may be nearly transparent, reddish, or of a light-yellow color. Through the interposition of the pseudo-membranous matter, adhesions between the costal and pulmonary portions of the pleura are usually effected. 
Causes.—This form of disease most frequently attacks persons of the first class—the feeble are but little liable to it, except perhaps from metastasis. Of external causes, cold, acting upon the body in a state of perspiration from exercise, is the most common. It is not unfrequently occasioned by metastasis of rheumatism, erysipelas, and gout— affections, which are emphatically of the same class. A modification of this form of disease not unfrequently results from surgical operations. 
Prognosis.—Easy respiration and purulent expectoration indicate a favorable termination ; but a great difficulty of respiration, a sense of imminent suffocation, a plentiful discharge of aqueous urine, and a dry cough, after the close of the third day, portend a fatal termination. A sudden cessation of the expectoration, without sediment in the urine, a violent diarrhea, and a hippocratic countenance indicates a speedy dissolution. A relapse generally proves fatal. 
Although this is a very dangerous form of disease, yet it 


733 
ACUTE PLEURITIS. 
is not, under a careful and judicious treatment, a frequently fatal one. 
Treatment.—This is one of the most unyielding forms of disease to Allopathic practice, and its history and treatment have afforded a text for writers to consume pages upon ; nevertheless it is perfectly tractable to a mild but thorough and active course of medication. Ordinarily, we are in the habit of producing copious perspiration by means of the spirit vapor-bath, if the strength and condition of the patient will admit. If, however, this can not be done, we give the Compound Tincture of Virginia Snakeroot in two or three-drachm doses, and repeat it at short intervals until the patient perspires very freely, when instant relief is afforded. 
After the patient has been relieved, and can breathe without pain, or at all events with but little pain, an emetic should be administered, which is more especially indicated in that form termed bilious pleurisy , and which should be followed by an active cathartic. Should more or less pain still continue, the Compound Tincture of Virginia Snakeroot may be given in half-drachm doses every two or three hours for the purpose of keeping up a moisture of the surface ; and to relieve cough and assist expectoration, some nauseant-expectorant must be given, as the Compound Tincture of Lobelia. 
In cases where, from the condition of the patient, it was impossible to use the spirit vapor-bath, and where the employment of the above tincture was forbidden—likewise in instances where the disease has presented itself as a complication with some other disease, Prof. J. King has met with excellent success by covering the whole of the affected chest with a fomentation of bitter-herbs, as hot as could be borne, and which should be renewed every five minutes ; in many instances relief was given in five minutes, and in fifteen minutes from the first application the patient was free from pain. 
We have adopted this plan in similar cases, and with debilitated patients, and found it to be efficacious, affording 


734 
INFLAMMATORY FORMS OF DISEASE. 
prompt and immediate relief; and in very severe cases we have conjoined it with the internal use of the Compound Tincture of Virginia Snakeroot. 
Occasionally, the practitioner will meet with cases which do not so readily yield to treatment; that is, although the pain is removed, yet it returns, or continues with less severity than at first; in such instances the use of the hot foot-bath and counter-irritation over the chest and between the shoulders by means of sinapisms, with draughts of a warm infusion of the roots of Asclepias Tuberosa and Althaea Officinalis, and the Compound Powder of Ipecacuanha and Opium, will be found to be very valuable auxiliaries. 
After the above treatment, should the pulse continue full and hard, with no mitigation of the symptoms, hemastasis may be performed, and continued until approaching syncope ; the ligatures must be applied with caution, being careful not to check the arterial circulation, nor confine the the venous circulation too long, lest mortification ensue. However, under the treatment just given, such cases will be very rare. 
The diet should be low, consisting in the early stage of mucilaginous liquids, with acidulated drinks if craved, and during convalescence, toast-bread, stewed fruit, oranges, etc. The temperature of the room should be kept uniform; the patient may lie with his head and chest elevated somewhat, and should avoid speaking and coughing as much as possible. 
Species II. — Chronic Pleuritis. 
By the chronic form of disease we usually understand not only one in which the symptoms proceed slowly, but one that was preceded by its antithesis — the acute. By chronic pleurisy, therefore, we are to understand that there occur two distinct varieties: one is a continuation of the disease from its acute stage or form, and the other is chronic from the beginning. 
In treating of the acute form, we remarked that it was mostly confined to persons of a full, strong, and athletic 


735 
CHRONIC PLEURITIS. 
habit, and now we have to state that the organically chronic form obtains in those who constitute the most feeble of the third class—those of a cachectic habit of body—those, possibly, in whom the vital force is incapable of manifesting the acute form. It may also occur in those of the first class whose constitutional vigor has been exhausted by previous disease or long-protracted habits of intemperance. These two varieties, though very different in their origin and in their respective subjects, will nevertheless be treated of as one form, as no therapeutical advantage can be obtained by a separate consideration of them. 
In this form of the disease there is but little acceleration of the pulse or of the cutaneous temperature, and the pain in the side does not usually amount to more than a mere soreness. The respiratory difficulty is but rarely such as to attract the patient's attention; yet his pallid and unhealthy appearance is such as to arrest the attention of every observer—to declare that mischief is progressing. His appetite is gone, much languor is present, also a dry cough, which may be attended with a scanty mucous expectoration and some febrile movement toward evening. When we find the cough, without any indications of crude tubercles in the lungs, or any gastro-intestinal irritation, we can have but little reason to doubt the existence of chronic inflammation of the pleura. 
The anatomical peculiarities of this form do not differ much from those of the acute, except in magnitude ; the pseudo-membranes are generally more developed, and when this form is but a continuance of the acute, this membrane appears to consist of recently-deposited laminae upon those of the acute stage —the latter being more firm and adherent to the pleura. The effused fluid is generally more turbid— containing fibrinous flocculi, or it is purulent and of a disagreeable odor, or it has the consistence of jelly. Sometimes the quantity is so enormous as to produce an enlargement of the chest and an equal compression of the lung. When the disease has been of long continuance, the spine is apt to become deformed—so curved that its concavity is 


736 
INFLAMMATORY FORMS OF DISEASE. 
directed toward the disease, and if it be on the left side the heart becomes also displaced. 
Diagnosis.—This form of disease is usually so insidious that it is apt to have made considerable progress before the patient becomes admonished to seek medical aid ; hence at this time it will generally be found that the diseased side is rounder, and the intercostal spaces possess more than a normal dilation and elevation ; possibly some flatulence may be felt, and it is also possible that the integuments may be oedematous, and it is further possible that some displacement of the spine may exist. 
Prognosis. — This is generally unfavorable —when uncomplicated a hectic fever usually supervenes which rapidly destroys the patient. In some instances a cure is spontaneously effected by absorption ; or when the fluid is purulent, by making a passage through the pulmonary tissue into the bronchial tube, when it is coughed up; or through the parietes of the thorax, when it is discharged externally. 
Treatment.—Chronic pleurisy is often the termination of the acute form, and though generally not so immediately dangerous, yet it is as certainly fatal in its results, if not arrested. 
The treatment, which we have pursued and found the most successful, is the application of the Compound Tar Plaster over the affected side, the use of which must be continued until a free discharge of purulent matter takes place; after which, remove the plaster and dress the ulcerated surface with the Compound Lead Ointment, continuing its use, until the irritability of the part subsides, and the soreness of the ulcer is somewhat removed. If, however, the pain in the chest should still continue, the irritating plaster should be re-applied, and the same process continued alternately and intermittently until the pain is completely dissipated. 
In connection with this, should there be any febrile symptoms, quick pulse, increased temperature of the surface, or irritability of the nervous system, the Compound Powder of Ipecac, and Opium should be given in doses of 


737 
PULM0N1TIS. 
atyrat five grains every three or four hours, and continued until such symptoms are alleviated. 
In the absence of any symptoms of the above character, the Compound Syrup of Stillingia and the Iodide of Potassium, in the proportion of one drachm of the salt to six fluid ounces of the syrup, must be given in doses of a fluid drachm every three or four hours, to act as an alterative in arresting organic changes which so frequently take place in this disease, as well as to promote the absorption of effused serum. 
For the dry cough which usually accompanies this form of pleurisy, nauseant-expectorants may be given with advantage, as the Compound Tincture of Lobelia, or the preparation of Senega, Squills, and Paregoric, equal parts of each, as heretofore referred to. 
The diet should be of a nutritious and easily-digestible character, consisting of farinaceous articles, cooked fruits, and fresh vegetables, together with the addition of eggs, oysters, boiled meats, etc., in cases of great debility. 
Active exercise should be prohibited, and sudden changes of temperature, or exposures to damp air, night air, or noxious atmospheres, should be avoided. The surface of the body should be often bathed, and the various excretory functions properly attended to. 
Genus III.—Pulmonitis — 
Pneumonia — Peripneumonia — Pneumonitis — Inflammation of the Lungs. 
This affection is defined by Dr. C. J. B. "Williams (Cyc. Prac. Med.) to be, " fever, with more or less pain in some part of the chest; accelerated and sometimes oppressed breathing; cough, with viscid and rust-colored expectoration ; at first the crepitant rhonchus, afterward bronchial respiration, and bronchophony, with dullness of sound on percussion in some part of the thorax." 
We may remark, in so many words, that this form of disease consists of an inflammation of the parenchyma of the lungs. It may, or it may not involve the pleura, but 


738 
INFLAMMATORY FORMS OF DISEASE. 
when it does, the complication is denominated pleuropneumonia, or pleuro-pulmonitis. 
The disease is divided by writers into two species—the common or lobar, and the lobular. The latter, though not entirely confined to children, we treated of in the preceding Book, and the former will now engage our attention. 
It begins with a sense of coldness, which sometimes amounts to a decided chill, succeeded by heat or fever; a full and strong pulse, which is sometimes considerably accelerated ; laborious, quick, and hot respiration ; an oppressive, heavy, but not acute pain; redness of the face and eyes; anxiety; inquietude and weakness ; sometimes vomiting ; a dry cough; dryness of the mouth and tongue; pain in the shoulders; high-colored urine, which becomes turbid after cooling ; watchings, and sometimes delirium. At length respiration is performed with a hissing noise; the pulse grows trembling and weak; the sight becomes dim ; the extremities cold ; a moisture appears on the superior parts of the body, and death ensues. 
These are briefly the usual symptoms of pneumonia or pulmonitis, but as they are attended with many modifications, a few remarks by way of explanation are demanded. 
Although it is common for the chill and fever to precede the other symptoms, yet it sometimes happens that the pain and dyspncea have precedence ; and, in those cases where pneumonia supervenes upon bronchitis, the chill does not happen at all; and, in some cases where it is present, it is preceded by a sense of depression and languor, a disordered condition of the stomach and bowels, and pains in the back and limbs. To these symptoms a shivering fit and intense pyrexia may succeed, and yet precede any local symptom even by a day or two. 
When acute pain is present, it is probably occasioned by some invasion of the pleura; but it frequently happens that there is no acute pain in the whole course of the disease, and in a few instances no pain is complained of in any stage. But most frequently pain is present, and its character is one of stricture, soreness, oppression, or weight, and 


PULMONITIS. 
739 
it may be referred to the region of the sternum, epigastrium, side, or even both sides. In some instances, when the pain appears to be absent, it can be elicited by a full inspiration, coughing, or pressure between the ribs. 
The cough, though sometimes very severe, is in many instances entirely absent to a late period of the disease. Before or until some pulmonary secretion has been effected, it will be dry, but at length it becomes viscid, of a rusty color, or it may become yellow or green, or more or less stained with blood. The rusty and viscid character of the matter expectorated is perhaps the most diagnostic symptom that attends the disease. The expectoration is never very copious in pure pulmonitis, yet it does become so when complicated with catarrhal symptoms. Toward the close of the disease the expectoration, as in the beginning, becomes scanty, and passes into a purulent form. In the protracted stage of threatening cases the pulmonic secretion becomes quite liquid, sometimes tinged with blood, and finally of a very dark color, which observation has discovered to be a very dangerous symptom. 
In this form of disease the breathing becomes exceedingly rapid—passing from the normal standard to as many respirations in some cases as sixty per minute, and so difficult is it, sometimes, that the patient has to assume, more or less, a vertical position. The dyspnoea is sometimes so exceedingly urgent as to render it almost impossible for the patient to speak, and when it becomes so violent as to produce a livid color of the face, the danger becomes extreme. 
The fever is scarcely ever absent in this inflammation, and in many instances it constitutes almost the only symptom. For some days, in many cases, the headache it induces constitutes almost the only trouble of which the patient complains—being often so severe as to run into delirium, and when thus severe it is an unfavorable symptom. In most instances the pulse is only moderately accelerated, but it is always full and strong. When it becomes very frequent, some complication may be suspected. The skin is generally hot and dry, and the cheeks flushed ; the 
47 


740 
INFLAMMATORY FORMS OF DISEASE. 
urine scanty and high-colored. In some instances the prostration is extreme from the beginning—indicating perhaps a high state of congestion and more or less of constitutional debility. 
The application of percussion and auscultation have been brought to such an accuracy, that they now furnish the most certain means of obtaining a knowledge of thoracic conditions that the experienced physician can command; and hence their use should never be neglected when accurate information is desired with reference to this form of disease. 
Dr. Williams says, that in the beginning of the inflammation there is, in the respiratory function, "a crackling or crepitating sound, like that produced when kitchen salt is thrown on a heated iron," or like the sound emitted by rubbing hair between the fingers near to the ear. He adds, that Laennec regarded this sound as " pathognomonic of the first stage of pneumonia." He continues: " The parts where it is most commonly heard are below the inferior margin of the scapula, below the axilla, or about the lower margin of the pectoral muscle, points corresponding with the lower lobes of the lungs, which, as we have before noticed, are the most frequent seats of the inflammation ; but it is occasionally to be met with in other parts of the chest." 
In the second stage of the disease, percussion over the hepatized portion of the lung yields a sound as dull as if it was made over the liver—neither the respiratory murmur nor the crepitant rhonchus of the first stage is heard. When the hepatization reaches or approaches the middle parts and root of the lobes, and extends to the surface, a whiffling sound is heard, amounting sometimes to a whistle, called, by Andral, the bronchial respiration. With these sounds there is often mixed a mucous gurgling, but it is circumscribed and obscure. 
When the third stage arrives there is, with the dull sound of the second stage, heard at the root of the lungs, in many instances, a coarse mucous rhonchus; but the 


PULM0N1TIS. 
741 
bronchial respiration and resonance continue, in some instances, and then we have no proof that the third or suppurative stage has supervened. 
In the event an abscess shall form in any part of the lungs, we obtain no evidence of its existence until an expectoration of matter shall have taken place, and then a cavernous rhonchus will be heard at the corresponding point. 
Causes. —This form of disease is most generally confined to those who constitute the first class, and more particularly those in whom the organ of animal sensibility is highly developed—for it is usually occasioned by atmospheric causes. Dr. Wood says : " Of the predisposing causes, cold may be ranked among the most efficient. Hence the disease prevails most in cold countries." In this opinion we agree with him. Animal sensibility is more generally developed in cold than warm latitudes, and this provision was indispensable as an admonition against too much exposure. The surface being very sensitive to the impression of cold, it becomes constricted under an exposure to it, forcing the fluids upon the internal organs. But this is not ordinarily the cause of the disease; it usually results from a sudden exposure to cold when the surface is in a perspiring condition, and more especially when the reactive energies of the system have become fatigued by previous exercise. The depuration that was going on became suddenly arrested, and the whole cutaneous system has, consequently, become obstructed and pneumonia may be the result. 
When those of feeble vital forces become similarly operated upon, the most frequent result is catarrh or bronchitis, which may develop a pre-existing tubercular liability, and consumption may be the result. We have somewhere else remarked how much gross men suffer under the influence of cold more than lean men or spare women, and how much more the latter can endure exposure to cold and wet than the former, without provoking disease. 
Some persons of the same class are much more liable to this disease than others, the organ of animal sensibility 


742 
INFLAMMATORY FORMS OF DISEASE. 
being the same, which must be attributed to some local condition, or to a difference of temperament; and those which partake most of the sanguine are, costeris paribus, the most liable, and this constitution prevails more in the north than in the south. 
Beside the influence of cold, there are many other causes, as poisonous inhalations, mechanical violence, very unusual exertions of the muscles, violent emotions of the mind, the retrocession of cutaneous eruptions, of gout, or rheumatism. To all of these causes, except mechanical violence, the first class of persons is the most liable, and the most sanguineous period of their existence is more liable than any other—as between twenty and thirty-five years. Females are less liable than males, not because of their less frequent exposure, as Dr. "Wood thinks, but because of their less-endowed animal sensibility. If men were generally as thinly clad as women, they would have the disease more frequently than they do. Women can go to parties with naked arms, neck, and breast, and with very thin shoes, with comparative impunity ; but if men were to do it, they would pay dearly for their enjoyment. 
Diagnosis.—Those forms of disease, with which this is most liable to be confounded, are bronchitis, pulmonary oedema, pleurisy, and certain states of phthisis. In bronchitis, the pain is located in the anterior and superior portion of the chest and posterior to the sternum ; the pain, so called, is rather a feeling of soreness than the acute pain which attends pulmonitis; the expectoration in the latter is viscid and of a rusty color, which is not the case in the former; but when the two are combined, as they sometimes are, then it is difficult to diagnose them. In oedema of the lungs, the discharge, when copious, is thin, colorless, and frothy; the face or the extremities are oedematous in most cases, and frequently general anasarca prevails. None of these symptoms attend pneumonitis. 
In pleurisy, the pain is usually sharp, severe, and generally concentrated ; but iu uncomplicated pneumonia it is dull and moderate. In the former, the expectoration is 


743 
PULMONITIS. 
mucous and transparent or whitish, or possibly streaked with blood; it the latter, it is viscid and rusty. Percussion produces no distinctive sound in pneumonia in its early stage ; but in pleuritis it is obviously dull. In phthisis the symptoms are so indefinite at first, and so various that it can scarcely be said to possess a clearly-defined diagnostic symptom; but the viscid and rusty sputa of pneumonia will be generally sufficient to distinguish the one from the other. 
Prognosis.—The indispensable necessity of the lungs to the great function of life, renders pulmonitis a dangerous disease. If the obstruction be small, and the fever only of moderate violence, then a resolution of the disease may be expected. A creaking noise of the lungs, and dimness of sight, indicate much danger. When both lungs have been invaded, death is almost certain to ensue; and pleuropneumonia is not much less dangerous. If the sputa shall become white, yellowish, mixed with streaks of blood, and expectorated without difficulty, a recovery may be hoped for; if it be of florid blood, frothy, livid, and porous, like a sponge, the most imminent danger exists. If the urine becomes aqueous, or if diarrhea supervenes and arrests the expectoration, a speedy dissolution may be looked for. 
When the disease assails those who are organically liable to tubercle, tuberculous deposition may ensue, and necessarily produce a fatal termination. If the inflammatory symptoms continue to the fourth day, without abatement, its termination by suppuration may be expected. 
Treatment.—At the commencement of this disease, we administer an emetic, as the Compound Powder of Lobelia, to an adult, or the Compound Tincture of Lobelia, to a child, and as soon as possible after emesis has ceased, follow it with the spirit vapor-bath, if the circumstances of the patient will permit. 
If the pain be very severe after this course has been pursued, fomentations of bitter-herbs must be placed over the chest, as hot as can be borne; and, internally, administer nauseant-expectorants, as a combination of Senega, 


744 
INFLAMMATORY FORMS OF DISEASE 
Squills, and Lobelia, in tincture, of each equal parts, which must be administered in sufficient doses to keep up nausea and free expectoration. 
In some instances, where the pulse keeps full, and there is no cessation of pain, with a dry skin, the Compound Tincture of Virginia Snakeroot may be added to the above, or it may be given in connection with the Compound Powder of Ipecac, and Opium. Ligatures may likewise be placed around the extremities, as heretofore recommended in other forms of disease, thereby retarding a too free return of the venous blood into the trunk, and consequently diminishing the pain and active condition of the inflammation. 
The surface of the body should be often bathed with a weak alkaline-solution, and sinapisms applied to the feet, legs, and along the spinal column, employing them intermittingly, but avoiding, as far as may be, the production of vesication. 
In many instances, where the pain remains obstinately severe, immediate relief will follow the cathartic effect of a dose of Compound Powder of Jalap, and this should generally be given at an early period of the disease; and subsequently the bowels should be kept in an open condition by small doses of Podophyllin and Leptandrin. 
During the whole course of the disease, from its commencement through to convalescence, mucilaginous drinks must be used freely, as an infusion of Elm-bark, Flaxseed, or Marsh-Mallow root; and during the inflammatory stage, Sweet Spirits of Nitre may be occasionally added to the draught, as often as the circumstances of the case and the condition of the patient may require. 
As the inflammatory symptoms subside, the practitioner will, according to their indications, gradually omit all other means, and rely principally on the expectorants and mucilaginous draughts, which at this time will most generally be found very useful. 
Should debility ensue as the disease advances, tonics and stimulants will be necessary—wine-whey, Quinine, cold 


745 
PULMONITIS. 
infusion of Virginia Snakeroot, and in some instances even milk-punch, may be used, more or less freely, until a restoration to strength has taken place ; among those who have been addicted to the use of alcoholic stimulus, it is better to employ other stimulants, among which the Carbonate of Ammonia will be found a superior remedy. 
In the early part of our practice, we treated pneumonia by bleeding, a method taught by our Allopathic professors and our various text-books; but observing the evil results produced by this course, we speedily abandoned it for what we consider a more rational practice—that which is recommended in the preceding pages. 
The following statistics, by Dr. Deitl (Eel. Med. Jour., vol. iii, p. 114) present a fair illustration of the failure and evil consequences attending bloodletting in this form of disease. He gives us the results of 380 cases of pneumonia, of which 85 were treated by bloodletting, 100 by large doses of Tartar Emetic, and 189 by diet and rest alone. He says: 
" Of those treated by bloodletting, 17, or 20.4 per cent., died ; of those treated by large doses of Tartar Emetic, 22, or 20.7 per cent.; while of those treated by diet and rest only, 15, or 7.4 per cent., terminated fatally. 
" The fever continued from 5 to 9 days in 41 cases that were bled, and from 14 to 21 days in 27. In those treated with Tartar Emetic, it continued from 5 to 9 days in 66, and from 14 to 21 days in 18; and in those treated by diet alone, in 140 it continued from 5 to 9 days, and in 35 from 14 to 21 days. 
" The period of convalescence was from 5 to 21 days in 30 of the cases that were bled, and from 22 to 60 days in 38. In those treated by Tartar Emetic, it lasted from 5 to 21 days in 62, and from 22 to 60 days in 22; while in those treated by diet alone, it lasted from 5 to 21 days in 133, and from 22 to 60 days in 42. Thus, the medium duration of convalescence, in the first set of cases, was 28.9; in the second, 20.3, and in the third, 19.7. 
*' The entire duration of the disease, from the first 


746 
INFLAMMATORY FORMS OF DISEASE. 
appearance of fever to the complete restoration of the patient, was, in 27 of the cases treated by bloodletting, from 10 to 30 days, and in 41 from 30 to 60 days ; in 54 of those treated by large doses of Tartar Emetic, it was from 10 to 30 days, and in 30 from 30 to 60 days ; in those treated by diet alone, it was from 10 to 30 days in 119, and from 30 to 60 days in 66 —showing that the medium duration of the disease, in the first set of cases, was 35 days; in the second, 28.9, and in the third, 28 days. 
'* In 27 of the cases, the inflammation was seated in both lungs. Of these, 10 were bled, and 4 died ; 6 treated with Tartar Emetic, and 1 died ; and 11 treated by diet alone, and 2 died. 
"In 142 of the cases, the inflammation was confined to the right lung, and n 211 it was confined to the left lung— making, in all 353 cases in which the inflammation was of one lung only. Of these 75 were bled, and 13 died, or 17.4 per cent.; 100 were treated by Tartar Emetic, and 21 died, or 21 per cent.; and 178 were treated by diet alone, and 12 died, or 5.1 per cent. 
" In the stage of red hepatization, 23 died, namely, of those who were bled, 5; those treated with Tartar Emetic 11, and by diet, 7. 
" In the stage of gray hepatization, 17 died, namely, of those who were bled, 7; treated by Tartar Emetic, 7, and by diet, 3. 
" In the stage of purulent softening, 13 died, namely, of those who were bled, 5; treated by Tartar Emetic, 4, and by diet, 4. 
" Of pueumonia, without complication of any kind, 9 patients died, namely, of those who were bled, 7, and those treated by Tartar Emetic, 2. 
"Of pneumonia, with complication, 44 died, namely, of those who were bled, 10 ; treated with Tartar Emetic, 20, and by diet alone, 14. 
" So far as the evidence based upon the results of these 380 cases goes, it is decidedly in favor of a purely expectorant treatment of pneumonia. It would seem to prove that 


PHTHISIS—CONSUMPTION. 
747 
inflammation of the lungs is a self-limited disease, and all that is necessary to insure its passing favorably through its several stages, is the withdrawal of those influences calculated to interfere with its regular course, all active treatment being avoided as useless, if not injurious." 
Genus IV.—Phthisis— 
Tubercular Phthisis — Phthisis Pulmonalis — Consumption. 
The term phthisis, at one time, was employed to designate every variety of consumption, as well of the liver and mesentery, as of the lungs—indeed, it was a sort of baptismal name for all forms of disease—as, phthisis scorbutica, phthisis syphilitica, phthisis rheumatica, etc.; but since the investigations of Lsennec into the true character of pulmonary forms of disease, it has become to be used exclusively to designate that form of disease which consists of tubercles in the lungs—and in this restricted sense we shall use it. 
We have placed phthisis, more through a regard for fashion than for truth, under the general head of phlegmasia or inflammation, when, in reality, it consisted of tubercles in the lungs, which were present before the inflammation commenced ; and yet we may contend for the absolute accuracy of the place we have assigned it, upon the truth of our general principle, that inflammation exists only in consideration of previous disease —that it is a mere result of disease—an accumulation of vital force to expel disease. Upon this view of the subject, phthisis is as much a member of the phlegmasia as pulmonitis—because both have their origin in obstruction. 
The difficulty in the subject before us, is not as to the cause of the inflammation—for this we know to be tubercles in the lungs—but whence the tubercles ? In answer to this question, there have been expressed, perhaps, as many conflicting opinions as there have been writers ; and as to the nature of the affection, professional opinion has not been less divided. 


748 
INFLAMMATORY FORMS OF DISEASE. 
Dr. James Clark, in treating of this subject (Cyc. Prac. Med ), says, that his principal object in so doing is that of taking a " comprehensive view of tuberculous phthisis, as originating in a morbid state of the constitution." 
It will be remembered, that when treating of this disease, as it relates to children, we attributed its origin to certain existing relations between the medulla oblongata and the cerebellum ; hence, if we are correct in this view, the disease originates in a certain organic defect, and not " a morbid state of the constitution." If we admit the disease to originate in a morbid state of the constitution, then we must admit that that state exists in direct relation to the form of disease which subsequently becomes developed, and consequently, that morbid state must be the incipient stage of the disease—the disease itself. 
It results then, that this reasoning explains nothing—it is simply equivalent to the declaration that phthisis exists. If we admit phthisis to originate in a morbid state of the system, then two other pertinent questions arise: What occasioned this state 3 and why did it not result in some other form of disease, as rheumatism or gout ? Neither of these questions admits of more than an exceedingly hypothetical answer ; but, under our view of the subject, it follows that the organic forms of the individual determine the form of the disease, under certain geographical and topographical conditions, and any cause of excitement that can produce a derangement of the secretions, which will be explained balbre we conclude, may occasion the disease, or it may even spontaneously ensue. 
Briquet, says Sweet, " states that thirty-three of his patients were of vigorous constitution, twenty-one were delicate, the remainder, one hundred and twenty-eight, possessed medium constitutions." This observation, standing unqualified or explained, would seem to stand opposed to the conclusions we arrived at upon this subject, in Book I; but let it be remembered, that an organic liability to phthisis does not necessarily imply debility, but an inequality of endowment between the medulla oblongata and the lateral 


749 
PHTHISIS—CONSUMPTION. 
portions of the cerebellum; and of this inequality there are two varieties: first, when the medulla oblongata preponderates ; and second, when the cerebellum preponderates. In the first, however stout the subject may be, the chest will exhibit, more or less, a phthisical form ; but in the second, the chest may be large and round—highly capacious, and yet the lungs will display but little expansibility, as will be indicated by the contracted character of the nares. Those of the first class will always be found to be lean, though they may be muscular; while those of the second constantly indicate a tendency to obesity. 
That phthisis may occur in vigorous constitutions we have no doubt, but according to our understanding of the word, the number, 35 in 184, is too great to consist of those who possessed no organic necessity to take on this form of disease. 
Pathologists have generally agreed upon a certain set of external signs or marks as indicating a tuberculous constitution, including that form which is known as phthisis. We confess, however, that after a patient and particular observation of more than twenty years, we have not found these signs to be of general application to the phthisical form of disease. 
"Dr. Clark (Cyc. Prac. Med.) says: " The tuberculous constitution, when of hereditary origin, is manifested by a peculiar appearance of the countenance, by the form and development of the body, by the abnormal state of various important functions, and by a peculiar disposition to certain diseased actions. The aspect of the countenance generally affords decisive indications of the presence of the affection ; in early childhood, it has a pale, pasty appearance, the cheeks are generally full, and the upper lip and alas nasi large. If the complexion be dark, the color of the skin is generally sallow ; if fair, it has an unnatural, white appearance, resembling blanched wax rather than healthy integument; and the veins are large and conspicuous. At a more advanced period of youth, the indications exhibited in the countenance are clearly marked. The 


750 
INFLAMMATORY FORMS OF DISEASE. 
eyes, particularly the pupils, are generally large, the eyelashes long, and there is usually a placid expression, often great beauty of countenance, especially in persons of a fair, florid complexion ; on the other hand, the features are less regular in those of a dark complexion, and the skin is commonly coarse and of a sallow, dingy color, although there are many exceptions to this—in the fine dark eye, regular features and delicate skin of such persons." 
We have seen all this in tuberculous constitutions, but we have seen incomparably more cases of phthisis, even in those upon whom it was entailed, without these external signs, than with them. 
The writer has discovered this peculiarity in his own mind, viz: that his capacity for detecting differences greatly exceeds his ability to discover resemblances; therefore, he is not surprised that most persons discover resemblances where he can not; nevertheless, scientific accuracy depends much more upon the former capacity. Thus it is that he has been compelled to believe that a broad distinction exists organically between those who have tabes mesenterica and phthisis, respectively. 
The description given by Dr. Clark of the tuberculous constitution applies to those who may have any form of tuberculous disease, except the pulmonary. In some instances, they may also have it, because the two organic conditions may be blended. When we speak of the scrofulous constitution, we exclude the phthisical. In the former, the organ of animal sensibility is generally well developed, while in the latter it is as generally feeble. We would suggest, for the investigation of those who have hospital advantages of observation, that scrofula depends upon a predominance of the cerebellum over the medulla oblongata, and that phthisis originates in the contrary condition ; but the former may not occasion an exemption from a modification of phthisis, such as we might denominate scrofulous phthisis. In conclusion, we would infer from the language he uses, that he entertains some doubts as to the identity of phthisis and scrofula. He says: "Phthisis does not con- 


751 
PHTHISIS-CONSUMPTION. 
sist merely in the deposition of tubercles in the lungs and its consequences. There is beside, a morbid state of the system, which precedes and attends the deposition, and upon which it probably depends. This state of system is commonly denominated the tuberculous diathesis or predisposition. It is either identical with scrofulous diathesis, or closely analogous to it." 
We regard the views contained in this extract, except the single idea for which we have made it, as a most flimsy speculation. Our statistical observations sustain the affirmative of this suggestion; but before introducing these observations, we will make a reference to Dr. Sweet. He says: 
" When you are told that constant exposure to watery vapor exerts a favorable influence (on phthisis), you may well question the fact." He now proceeds to qualify this statement, and says, " that a warm and moist atmosphere may exert a favorable influence upon the lungs, will be readily admitted." We think it very probable that no one ever contended for the contrary. He continues : "Animal and vegetable emanations are also regarded by Lombard as exerting a favorable influence upon this disease. Butchers, tanners, leather-dressers, are remarkably exempt from phthisis. But with regard to vegetable emanations, the truth of Lombard's statement may well be doubted. In certain regions, the healthful influence of vegetable emanations may be true enough ; but if the various forms of malarious disease are dependent upon this cause, then we must class these emanations among the most unfavorable influences in the production of phthisis. There is, indeed, a popular opinion in this country, that a residence in a malarious region is favorable to phthisical patients ; but this opinion is the very reverse of the truth. Malarious diseases, by impairing the general health, favor the development of phthisis, and much increase its mortality." 
Dr. Sweet, we think, has traveled considerably in advance of his well-ascertained facts. It has not been proved that the so-called malaria is a poison, or even mischievous 


752 
INFLAMMATORY FORMS OF DISEASE. 
to all constitutions. The writer has had an extensive field of observation in the south, during a period of seventeen years, and his conclusions are these: Scrofula obtains in both the white and the black inhabitants of low, humid, and marshy districts, but phthisis never ; nor do we believe it to be possible that a child of phthisical parents, in the north, or of any dry and elevated situation, and normally constituted to live to the twenty-fifth year of his age in the locality of his birth, could ever have phthisis in a southern marsh. Now, the question arises, why is not a humid atmosphere as favorable to scrofula as to phthisis % We have remarked that a high endowment of animal sensibility is associated with the organization which occasions a liability to that form of disease, and where this organ is large the skin becomes the most important of the depurating apparatuses, to which a humid atmosphere is opposed. In phthisis, this organ is small, and the kidneys constitute the most important depurators, and a humid atmosphere aids them. 
Our military surgeons, not being acquainted with the organic conditions upon which scrofula and phthisis respectively depend, have not been able to construct such statistical tables, with reference to the influence of southern latitudes upon phthisis, as could be desired, or even such as to reflect much light upon the subject. It is stated that sailors are much less liable to phthisis than soldiers, and this difference is attributed to the respective conditions of the atmosphere, that of the former being the more salubrious. We are inclined to attribute the difference to the greater development of the respiratory apparatus of the former. The statistical tables which are presented to determine the greatest sexual liability, enable us to state that, in the abstract, one sex is about as liable as the other, and that where a difference does obtain, it is altogether relative. In those countries where the women labor much in the open air, as in many parts of Germany, they are less liable than where they do not, and even less than the other sex, and we have only to examine their brawny muscles and masculine chests 


PHTHISIS—CONSUMPTION. 
753 
to be convinced that a greater development of the base of the head is the source of this exemption. 
Symptoms of Phthisis.—Although this form of disease is characterized by a certain group of symptoms, yet, in consideration of the great difference that obtains in its duration, in different individuals, much difficulty is presented to giving a lucid description of them, independently of the existence of a multitude of other circumstances, as a difference of age, of organic conditions, of previous health, and present complications. As to the length of time that tuberculous matter may be depositing before its presence in the lungs is indicated, is a question which can not be clearly answered. In some cases, in consequence of a sudden arrest of some important depuration, it may generate very rapidly, but in other instances the depuration may be deficient by a very small fraction, consequently, a long time may elapse before any apparent disturbance of the general health becomes manifest, and when it does, its progress may be so very slow as to occasion no alarm for months— possibly years. The first admonition the patient has is probably a dry, hacking cough, with some emaciation of his person and some loss of strength ; these three symptoms indicate that all is not right, but they may progress very slowly or rapidly. In the former case, though apparent, yet they are too slight to command that concern which they deserve, from the uneducated; but at length some dyspnoea, wandering pains in the chest, and hemoptysis thoroughly arouse the patient, and if a physician has not been consulted, one will now be—for these symptoms are too suspicious to be further neglected even by the ignorant. If, in addition to these symptoms, we shall find dullness under one of the clavicles by percussion, more particularly if, at the same time, there is a feeble murmur under a prolonged expiration, or if the murmur be harsh or jerking, we are scarcely permitted to doubt the existence of tubercles in the lungs. 
The cough, being the first symptom that is manifested, should claim, in a special manner, our vigilance. In the 


754 
INFLAMMATORY FORMS OF DISEASE. 
beginning of the disease, so far as we can judge, it at first appears upon getting out of bed in the morning, and then it may consist of only one, two, or three dry hacks; as the affection advances it will recur two or three times a day, particularly after exercising, and upon undressing for, or upon getting into, bed at night. After a while, expectoration from the fauces of a limpid and viscid fluid will appear in the morning cough, and at length it will attend the cough as frequently as it may recur. 
The preceding symptoms are those which are generally regarded as constituting the first stage of the malady; and morbid anatomy informs us that they have been occasioned by tuberculous matter in the lungs. 
Physical Signs.—In this stage of this form of disease much information may be derived, in some cases, by auscultation, but in many instances the contrary is the fact. In these we must be guided by the symptoms we have introduced to the best of our judgment. If the tuberculous matter be pretty generally diffused we can obtain no reliable information from auscultation; but if it be considerable in quantity, and deposited, as it most frequently is, in the superior or clavicular regions, then we may find assistance to our diagnosis. Under such circumstances the sound will be discovered to be much more clear under one clavicle than the other. "Where the duller or more obtuse sound is heard, the murmur, as heard through a stethoscope, will be less soft and free, and the resonance of the voice greater; but unless the difference between the two sides be very obvious, the information thus obtained, at this stage of the disease, will not be very reliable; on the contrary, wjhen the two sides yield very different sounds or murmurs, the information obtained by this means is the most unequivocal. It is frequently possible at this time to make profitable discoveries in the motions of the superior portions of the chest during inspiration; the tuberculous side will exhibit less expansion than the other. 
Second Stage.—The beginning of this stage is indicated by the appearance of opake and yellowish-colored 


755 
PHTHISIS-CONSUMPTION. 
particles of matter in the previously-colorless and frothy expectoration, which, as the disease advances, increase in quantity so as to form patches, that are found, when expectorated, to be floating in the limpid sputa which is sometimes streaked with blood. Pari pasu, with this change in the matter expectorated, the other symptoms progress in the strength and importance of the consequences to be inferred from them; the evening chills are more severe and uniform, and more regularly succeeded b} r febrile symptoms, as a hot skin through the night, and perspiration on the following morning; the cough also increases in frequency and in the trouble it gives the patient. Tolerably early in this stage the hectic fever becomes established—indicated by a uniformly-frequent pulse and hurried respiration. The emaciation of the patient increases in a very observable manner, and he is entirely conscious that his muscular strength and mental capacity, as regards their power of action, are daily wasting. He complains of pain of a rheumatic character in his side or about his shoulders; hemoptysis, too, is now, in many instances, of frequent occurrence, which in extent may only streak the matter expectorated, or it may consist of pure blood. Through the day the patient is usually pale, but toward evening a circumscribed blush appears upon the cheek.* 
* During this stage, a patient, under the observation of one of the authors, discharged from his lungs, during one continued effort, not less than a pint of frothy mucus; and so great was the quantity and so sudden its flow, that his life was endangered from suffocation. In the course of two weeks the patient had three of these paroxysms. Before the occurrence of these events, he was unconscious of any particular change in his pulmonary condition—they were preceded by no premonitory symptoms. The patient was an able physician, and had fought the disease in the first and second stages for fifteen years; and whatever may be the opinion of others as to the salutary influence of a southern latitude upon this form of disease, even after its commencement has been unmistakably indicated, he was thoroughly of the opinion that his removal from Massachusetts to Arkansas had secured to him not less than twelve years' of existence. He was satisfied that the disease had made considerable advancement before he left the north. Both he and the writer frequently speculated about the copiousness of the mucous discharges above described, but they could arrive at no explanation that satisfied themselves. 
48 


756 
INFLAMMATORY FORMS OF DISEASE. 
During this stage, the tuberculous matter becomes softened, and possibly diluted with morbid secretions from the substance of the organ. The certainty that this softening has taken place, is clearly to be inferred from the character of the expectoration; but during this process that portion of the pleura which covers the diseased part of the lung becomes attached to the costa through the agency of effused lymph, which finally passes into cellular tissue. The pleuritic inflammation essential to the production of this lymph is, no doubt, the cause of the pain of which the patient complains. The tuberculous softening as it progresses, which is determined by the quantity of the expectoration, forms caverns of greater or less magnitude in the superior portions of the lungs—the parts in which the disease usually begins, and from which it travels downward. 
When the malady has become thus far advanced, the sound or murmur occasioned by inspiration amounts to unequivocal evidence of the true pulmonary condition ; the sound under both clavicles, on percussion, is dull, and the ear or stethoscope discovers a cracking noise; and when coughing, there is a gurgling sound, and the voice has become more resonant, amounting frequently to bronchophony. The peculiarities above-named are more apparent usually upon one side than the other. If attention be now given to the pectoral movements, it will be clearly perceived that the superior portions of the chest are raised less freely and fully during an inspiration than when in a healthy state. 
Up to this period of the disease, tubercles may not obtain in any other part than the lungs, and yet, in its progress before the close of life, scarcely any part of the system may be clear of them. 
As to the duration of the disease, up to the close of this stage, no very definite opinion can be given. In some cases, it may progress rapidly; in others, the progress may be so far retarded, by a proper treatment, as greatly to extend the patient's existence. The disease has been know to run its course in a few weeks, and the preceding 


757 
PHTHISIS—CONSUMPTION. 
note of one of the authors shows that it has been known to continue for fifteen years. 
During this stage the purulent expectoration becomes very copious, which, with the night-sweats, rapidly exhausts the patient; and it is proper to add that these nightsweats are not necessarily dependent upon febrile paroxysms. Hemorrhage during this stage is not so frequent as during the preceding. It sometimes happens that all the above symptoms disappear, or at least to a great extent, nutrition becomes evident, and the patient flatters himself with the idea of a convalescence, when in truth, there is very probably no prospect of the kind for him—the symptoms which so much distressed him, return again, and sometimes with even more than the former violence. The delusive intermission was probably occasioned by the complete discharge of a vomica, and a fresh crop of tubercles is announced by the returning symptoms. 
Third Stage.—"This has been," says Dr. James Clark, "termed the colliquative stage, from the copious perspirations, the frequent attacks of diarrhea, and the abundant expectoration by which it is usually attended." During this stage all the symptoms seem to conspire to reduce, debilitate, and prostrate the patient. Nutrition has become greatly suspended, and the emaciation of the system the most extreme —every particle of it that can be rendered subservient to the function of respiration and the production of animal heat has been consumed. Frequent attacks of diarrhea now supervene and alternate with copious night-sweats, or occur, as they frequently do, simultaneously. The expectoration is copious and the cough is peculiarly distressing; nausea and vomiting are not unfrequently added to the other sufferings of the patient—the dyspnoea is great, and frequently attended by such extreme hoarseness as to reduce the voice to a whisper. In a large majority of instances, the fatal termination approaches very gradually, so much so that the back sloughs in consequence of the long-continued pressure of the weight of the body upon its osseous projections. Near the close of life, the 


758 
INFLAMMATORY FORMS OF DISEASE. 
tongue becomes red, loses its papillary appearance, and takes on an aphthous one; oedema seizes upon the feet and legs ; the appetite disappears; diarrhea becomes constant, and such becomes the degree of debility, that expectoration becomes impossible, the air vessels become engorged with pus, and of course death ensues, because respiration has been arrested. It must not be supposed that death always approaches thus leisurely, for life is sometimes extinguished by the supervention of pulmonary hemorrhage, the eruption of a large vomica which inundates the air-passages, or possibly by peritoneal inflammation. 
"We have now pursued this form of disease, as it usually appears, from its commencement to its termination—we have presented a general view of it; and yet, outside of this view, there are not unfrequently presented such modifications of it as may be thought to constitute varieties, and as such to claim a special consideration. 
Those forms of phthisis which writers have regarded as constituting varieties have been designated by the following names: 1st, acute phthisis ; 2d, chronic phthisis; 3d, infantile phthisis, of which we have treated; 4th, febrile phthisis ; 5th, latent phthisis. 
Yariety I. — Acute Phthisis. 
When we state that the mean duration of phthisis, as it usually appears, is about thirteen months, and that the mean duration of this variety is about two and a half months, the reader will be able to understand what is meant by acute phthisis. The brevity of existence after an attack of this form may depend upon either of two causes : first, an absolute want of viability—an exceedingly defective vital system, and hence it is a form that is usually confined to youth, and from the nature of its cause it must be regarded as necessarily fatal. Those who become the subjects of this variety constitute extreme illustrations of the third class, Book I, page 20. The second cause of this variety is said to consist in the "activity of the morbid process." If this be true, then it does not depend upon a 


759 
PHTHISIS-CONSUMPTION. 
want of vital power, but upon some unbalanced condition of it. We are therefore permitted to suggest, for the purpose of future observation, that they belong to the second class, Book I, page 20. In this, the medulla oblongata is comparatively feeble, while the lateral departments of the cerebellum are fully endowed. In these subjects tuberculous matter and adeps may both accumulate at the same time, and the former may exist for a long time before its presence becomes to be suspected—the tuberculous matter exists in a state as perfectly latent as do the adeps, and when excited into activity, no matter by what cause, the work of mischief is exceedingly active. Much has been said upon both of these sub-varieties of phthisis, but it is so foreign to our conceptions of the truth, that we must pass it over, trusting that the explanation we have given will prove, sufficient to enable the reader to connect them with the general form of phthisis. 
Variety I. — Chronic Phthisis. 
The acute form is measurably confined to young people, and the disease continues only a few weeks ; but this variety never assails the young, and when developed it may continue for several years more than the other did weeks. 
Dr. Jas. Clark supposes that in these subjects the hereditary predisposition is not strong, or if so, it has been kept in check by favorable circumstances. It is known that we deny the whole of the doctrine of hereditary predisposition—the whole doctrine, in our opinion, conveys but one idea, and that one is negative, namely, our ignorance. We contend that all forms of disease are referable to certain organic conditions and exciting causes, and they can be investigated. If we shall classify those who become the subjects of these several varieties of phthisis, we shall soon discover that the special liabilities have resulted from certain organic conditions, and that these by a timely interposition may be changed or greatly modified. 
Like the acute, this variety is divisible into two subvarieties. In the first, the medulla oblongata and the cere- 


760 
INFLAMMATORY FORMS OF DISEASE. 
bellum are both small or moderate, the cerebrum and finally the whole head is below the average size of heads— all of the animal functions are active but feeble—the mental are also peculiarly active, even to the manifestation of genius, but never powerful or forcible, and the vegetative functions are but feebly discharged. This being the normal condition of the system, we can certainly have but little difficulty in comprehending either the origin or cause of phthisis, when once developed. In this peculiarity of constitution, tubercles never commence their development until the vital forces begin to sink under the accumulation of mental toil and responsibility—the depuration is not equal to the metamorphosis, and tubercle results, but it must progress as slowly as does the declension of the vital force or the depurative processes. Persons thus constituted may have the disease and die before the meridian of life, or they may live to be threescore and ten years old. 
In the second sub-variety, we have in many respects a reversed condition of the constitution. The brain is again rather below the average size—it has measurably the athletic size and form. In the earlier part of life, the muscles are large and strong, but not active—the cerebellum and medulla oblongata are nearly balanced—the nostrils and nose are of medium size; and if he live a life of active and muscular habits, he will probably never have phthisis, but he may probably have rheumatism. If his pursuits be mental, and he be overtaken by care and responsibility, difficulty and trouble, he will probably become intemperate in the use of ardent spirits, and more or less obese, and so continue until the powers of nutrition become exhausted and then phthisis will supervene. If his life be one of ease and pleasure his cerebral forces will acquire an ascendency over the medulla oblongata, and then obesity will ensue (if he has escaped pulmonary hemorrhage), and then, any cause that can disturb the nutritive process may develop tubercle, which may derange his health for years. We have witnessed both of these forms of phthisis, and we believe that we have given an accurate description of those 


761 
PHTHISIS—CONSUMPTION. 
who are, respectively, liable to thern; hence the so-called acute and chronic varieties happen to be nothing more than such modifications as result from peculiar organic conditions. 
As we have before remarked, we have treated of infantile phthisis in Book III, and therefore we will now proceed to the consideration of the so-called, 
Variety IV. — Febrile Phthisis. 
With this modification of phthisis we have no acquaintance, and therefore will give Dr. Clark's opinion of it, and a mere suggestion of our own. He says: "It occurs suddenly and differs in its symptoms from all other forms of the disease, and also in its pathological results. It occurs in a state of apparent health, after exposure to cold, or even without any evident cause. It commences with shivering, followed by heat of skin, quick pulse, and other symptoms of fever, which often continue for several days with little or no indications of pulmonary disease. In some cases, it puts on the characters of bilious fever, and in others of catarrhal fever, for both of which it is sometimes mistaken; indeed it would have been such in a healthy constitution, but occurring in a person laboring under tuberculous cachexia, the rapid deposition of tuberculous matter in the lungs is the consequence of the disturbance created in the system by the febrile attack. Cough, however, soon appears, and the breathing is noticed to be particularly rapid, which is one of the most marked and constant symptoms of this form of phthisis. The cough, when it has once occurred, becomes speedily more frequent, and is soon accompanied with some expectoration, which is at first colorless, afterward assuming a yellowish or greenish hue, and occasionally being streaked with blood; but it rarely puts on the character of the expectoration in the advanced stages of ordinary phthisis. Pain of one or both sides frequently occurs, and occasionally diarrhea is present. The fever, in the meanwhile, continues without abatement, and is so much out of proportion to the other 


762 
INFLAMMATORY FORMS OF DISEASE. 
symptoms of pulmonary affection, that the true character of the disease is liable to be overlooked. In the course of from six or seven weeks the patient sinks." 
He has stated that this form of disease "occurs in a state of apparent health; and he repeats, "we say apparent health, because we believe that the disease never occurs in a healthy constitution." If the constitution upon which phthisis becomes ingrafted is never healthy, what is the pre-existing disease ? By the same rule of reasoning, may we not say that no constitution is healthy upon which diseased action supervenes ? Rheumatism attacks constitutions which were apparently healthy, and we now inquire, were they not as really so as can possibly happen ? There is, organically, as strongly-marked signs of this constitution as there are of the phthisical; and we are of the opinion that we have seen persons of the " tubercular diathesis," as he calls it, having as good health and being as free from disease as we have ever seen the rheumatic. He continues, " the most marked cases " of this variety of phthisis, " which we have seen, occurred in persons having a strong hereditary disposition to phthisis." The strength of all the symptoms which he has given, as being characteristic of all the symptoms of febrile phthisis, induce us to doubt the existence of a truly phthisical organization in the premises ; and to suspect that of the rheumatic, and that instead of phthisis—the disease, normally, should have been rheumatism. If it be possible for the remote and exciting causes of rheumatism, under any modifying influences, to produce phthisis, we would cite febrile phthisis as illustrations of it. 
Yariety Y. — Latent Phthisis. 
Under this head we shall again extract from Dr. Clark, who says : " The presence of tuberculous matter in the lungs gives rise, in a large proportion of cases, to those symptoms which are usually considered to indicate the commencement of phthisis ; there are, however, cases in which this accidental product may exist for a long time, 


PHTHISIS—CONSUMPTION. 
763 
and even to a considerable extent in the lungs, without giving rise to any local symptoms indicative of its presence, such as cough, expectoration, or hemoptysis, but nevertheless effecting its silent work of destruction. It is to cases of this kind that we apply the term latent.'''' 
Latent phthisis presents itself in two different forms. In one, we have constitutional symptoms, such as fever, nightsweats, emaciation, diarrhea, etc., without any local indications of the pulmonary disease; or if they be present, they are of so slight a character as to pass unnoticed. The other form of latent disease is still more important, because it is more insidious; being attended neither by constitutional nor local symptoms, until the tuberculous disease has made extensive progress. This form of latent phthisis, therefore, claims our closest attention; because, from the slowness of its course, and the more limited extent of the tuberculous disease for a long period, we may possibly be able, in many cases, to check its further progress entirely, should we detect it at an early stage." 
We shall not pursue Dr. Clark's treatise on this variety of phthisis any further, because it must already have become apparent to the reader that it is nothing more or less than a modification of the chronic form or variety. 
Inasmuch as we are required to determine the character and condition of disease by its signs and symptoms, we deem it proper to pass briefly in review a few of the latter, for the purpose of determining how far they are to be considered as indicative and diagnostic of this disease. 
Codgh and Expectoration.—These symptoms may be dependent upon several forms of disease, and although generally present in phthisis, it is not unifoimly the case except at or near the close of it. It is not the cough, in the abstract, that so much demands our attention at present, as the character or peculiarity of it. When it is laryngeal, it is known to be loud and barking; when bronchial, loud and ringing; when occasioned by pleuritis, it is feeble and suppressed; when symptomatic, as of dyspepsia, it is generally dry, and in degree, a matter of small moment. 


764 
INFLAMMATORY FORMS OF DISEASE. 
In bronchitis, it is sometimes dry and continues so for a time, but sooner or later it will be attended with expectoration, which will be thin and frothy, opake and thick, purulent or muco-purulent, streaked with blood or mixed with it. In pneumonia, the expectoration has a rusty appearance, and thus becomes diagnostic; so likewise is a grayish and fetid one of pulmonary gangrene. When the cough is occasioned by pulmonary tubercles, it is slight and hacking, but if complicated, with nervous irritation, it may occur in irregular and distressing paroxysms. In the general course of phthisis, the cough is very much as we have before described it, but toward the close of the complaint it sometimes becomes deep and hollow, which is thought to indicate a fatal termination. 
Dyspncea.—Any cause that can impair the action of the air upon the capillary circulation will produce this distressing symptom. It is very frequently produced in health by rapid exercise, which occasions a too rapid circulation of the blood through the lungs—it results also in fever from the same proximate cause. It may, furthermore, be occasioned by a retardation of the blood through the lungs, as in mitral disease of the heart. It may also result from pulmonary compression, as in pleuritic affections; hydrothorax ; destruction of the air cells, as in pneumonia; and from many other causes, beside tubercles, in which it is not so prominent a symptom, as it is in some other forms of disease. 
In many instances this disease progresses to the verge of the grave before this symptom becomes particularly or even observably troublesome. This circumstance may possibly be explained by the fact, that in this disease the emaciation and reduction of the patient maintain the circulation in harmony with the pulmonary function. 
The unpleasant and painful sensation arising from dyspnoea arises from the insufficient oxygenation of the blood; if, therefore, the lungs have sufficient capacity for this purpose, and the velocity of the blood is in harmony with this capacity, then the symptom will not obtain. When phthi- 


765 
PHTHISIS—CONSUMPTION. 
sis becomes complicated with pleuritic effusion of pneumothorax, as it frequently does toward the close of the disease, then dyspnoea becomes peculiarly distressing. 
Pain.—This is not usually a prominent symptom —fre- it is very considerable, and often it is very severe ; in a majority of cases, however, it may be said to be either pleuritic or neuralgic, fugitive and occasionally severe. 
Hemorrhage.—We can not, perhaps, state that this symptom invariably attends phthisis, but it does very generally. Sometimes it is the first observed symptom, but it more generally occurs in the course of the disease and more frequently in the second, than in the other stages. In a few instances, it is copious, but generally it is very slight. When the patient has had for sometime a cough, the occurrence of this symptom becomes more clearly diagnostic than any other. Louis, says Dr. Wood, "goes much further than this, and states that since his attention had been directed to the subject, he had seen hemoptysis in no other affection than phthisis, except in females attacked suddenly with amenorrhea, and in cases of external violence." To this statement, Dr. Wood makes objections, and we indorse them. He says that he has known many cases of pulmonary hemorrhage that were never associated with phthisis, and he concludes by stating: "I have insisted more than I otherwise should have done on this point, because I believe that the impression of the almost certainly-fatal significancy of hemorrhage from the lungs is calculated to .do much harm, by alarming patients, and discouraging their medical advisers." 
Nervous Symptoms. — Dr. Wood says, that when the liver and stomach are sound, the patient is cheerful and hopeful, and disposed to believe to the last, or at least, to so late a stage as to preclude all rational hope, and yet, he says, even intelligent physicians, who understand the value of the symptoms, are thus self-deceived. The writer had a medical friend who was throughout his sufferings a better judge of his own condition, than any of his medical friends were ; but it must be observed, that his stomach was 


766 
INFLAMMATORY FORMS OF DISEASE. 
so diseased as to occasion the greatest amount of his sufferings. 
Sexual Symptoms.—Nothing worthy of remark obtains in this relation with the male sex, but the opinion is very prevalent that with the other sex pregnancy and lactation have a decided tendency to arrest the disease. We are aware that the contrary has been maintained, or admitted no further than amounts to a mere suspension. When the constitution is organically phthisical, and the climate is favorable to the development of the disease, we have no faith in the potency of any remedy ; but when the disease exists under contrary circumstances, we as much believe it to be curable as many others ; and it is under such circumstances that we believe gestation and lactation promotive of recovery, and it is because of the extensive depuration which these processes provide; and, under contrary circumstances we would never advise their introduction. 
Nature and Causes.—Upon these subjects we have but little to add to what we introduced in Book III. To talk about a morbid state of the system — tubercular diathesis, laxity of the tissues — hereditary predisposition, etc., is equivalent, in our opinion, to an acknowledgment of our ignorance or a mere statement of the fact, that the disease occurs. We know of no organic condition that may not, under appropriate circumstances, become tuberculous, but when it is essentially liable—necessarily so very frequently in a cold climate, no hope cau or should be indulged as to recovery, and we are very sanguine in the opiuion that no such case of phthisis was ever cured. On the contrary, we are equally sanguine that many cases even spontaneously recover. Why not ? Suppose the suppression or impairment of some essential depuration should occasion it in a rheumatic constitution, why should not recovery follow the restoration of the depuration ? Post-mortem examinations of many, who had died of other forms of disease, have furnished the most unequivocal evidence that the subjects had had phthisis, and had been well and clear of it for many years. 


767 
PHTHISIS—CONSUMPTION. 
Much has been said about the predisposing and exciting causes of phthisis, and it may be applicable to those cases in which there does not obtain an organic necessity for the disease, under circumstances necessary to its development, instead of some other form of disease. In such cases, it is spontaneously developed, and as necessarily so as the beard on a man's face. Among the predisposing causes, care or mental responsibility and sedentary habits are the greatest, and among the exciting, an improper exposure to cold is of the greatest consideration. 
Diagnosis.—It is only during the first, or initial stage, that any difficulty can exist on this subject, and even in this no uncertainty need to exist, with a close observer, in a vast majority of the cases. The short, dry cough, or cough with slight expectoration, continuing as it does for weeks or months, and attended with more emaciation than can be attributed to observable causes, should awaken a very strong suspicion that phthisis is generating; but when with these symptoms we have an increased frequency of the pulse and fugitive pains between the shoulders or in the breast, all previous doubt yields to a probable certainty, and when blood appears with the expectoration, we may conclude that we have absolute certainty. But these symptoms do not appear and progress in the above order in those cases that do not depend upon an absolute organic liability as the cause. It is true, that the exceptions are not numerous, but they exist, and their manner of commencing is so Protean that no reliable diagnostic symptom can be given. In such case, we must fall back upon our general acquaintance with pathology and calculate the chances. "When the disease is occasioned by the suspension of a depuration that holds an intimate relation with the perfection of the pulmonary function, the first symptoms may be of alarming character. 
That form of disease which bears the greatest similitude to phthisis, is bronchitis, and yet the difference between them is sufficiently striking, in extreme cases, to admit of no mistake. In the latter, there is an observable agree- 


768 
INFLAMMATORY FORMS OF DISEASE. 
ment between the indications of disease and the consequences upon the system. It is usually attended with more fever, more copious expectoration, advances more rapidly, is attended with a louder cough, and lastly, the auscultatory signs of phthisis are absent. 
Prognosis.—If the patient has always had lean, small, and flaccid muscles; a flattened chest; a small neck, and more particularly if it be thin, then we may regard the case as incurable, because it depends upon an organization that can not longer exist without it, for it is now supposed to be too far advanced for a resort to any prophylactic measures. If the patient has been obese from his youth to the time of the attack—has small and contracted nares— small muscles, although the chest may be large, the case may be esteemed as hopeless, because it resulted from an organic necessity of adeps or tubercles, and it is now too late to change the action from the latter to the former. Lastly, if the nares, neck, chest, and muscles be those of a man —so well developed that circumstances could possibly have inflicted upon him rheumatism, gout, or a high stage of any form of inflammation, we may, by judicious treatment, indulge a hope of his recovery, because his disease did not result from an organic necessity, but from a tardy or interrupted action of some important depurator. 
Many writers now believe that phthisis is sometimes curable, and that it has been cured ; but none of them appear to know anything about the conditions under which the possibility exists. Dr. Wood says, that such cases " are undistinguishable from symptoms which in other cases are the forerunners of confirmed phthisis," and he might have added—of death. We admit all this, but it does not prove that there is not an organic difference of such magnitude as to account for the difference of the results. He says: " It occasionally happens that consumptive symptoms disappear entirely, even in the second stage of the disease, after the formation of a cavity. This event, it is true, is comparatively rare." We admit it, and we believe it on the grounds that very few persons have phthisis who 


769 
PHTHISIS—CONSUMPTION. 
are not organized, under some circumstances, with reference to it. The mental pursuits and sedentary habits incidental to civil society produce the organization that is favorable to it; and under such influences no organization is necessarily secure against it. 
Treatment.—In the treatment of this disease, little else can be done than to make use of means which will enrich the fibrinous portions of the blood, strengthen the nervous and muscular system of the patient, and relieve troublesome and dangerous symptoms as they may appear. 
For the accomplishment of the first indication, various agents have been recommended, none of which can be said to have proved even generally successful, at least, so far as regards a cure of the disease, yet which, at the same time, will always be proper for the practitioner to employ, with the hope that either transient or permanent benefit may follow. Among the agents recommended for this purpose, we will select those which we have employed ourselves, as well as those which, from their nature, we would suppose the best calculated to meet the indication. Iron, in various forms, is one of the articles which has a more general application than any other. The precipitated carbonate of this metal will be found well adapted to most cases. "We have derived much advantage in several instances from the Prussiate of Iron, combined with Sulphate of Quinia and Hyoscyamus. Equal parts of common salt and the precipitated Carbonate of Iron, combined together, and administered in such quantities as the stomach will bear, to the extent of two or three drachms a day, have in several instances apparently aided in effecting a permanent cure. 
In addition to these, many of the vegetable alterative tonics have seemed to produce beneficial results, as various combinations of Stillingia Sylvatica, Rumex Crispus, Inula Helenium, Solanum Dulcamara, Ptelea Trifolata, Cimicifuga Racemosa, Prunus Yirginiana, etc., and these will always prove more useful when given in the form of cordial, or in that of syrup or decoction, with some alcoholic liquid added, as good French Brandy, Jamaica Spi- 


770 
INFLAMMATORY FORMS OF DISEASE. 
nts, or Holland Gin. The next indication is to mitigate urgent symptoms, among which cough stands most prominent and distressing, though occasionally absent until in the latter stages ; and whatever remedies are used, or however beneficial they may at first appear, it must be remembered that all of them speedily lose their influence over this harrassing symptom, and consequently the practitioner must be prepared with a knowledge of several means for checking or arresting it. 
If the cough be occasioned by elongation of the palate, as we find frequently to be the case, and will not yield to the action of astringents, a sufficient portion of the uvula must be excised. If the cough still continues, or is not connected with any elongation, demulcent mucilaginous draughts may be drank, either with or without narcotics, as each particular case may require ; and it will generally be found that sooner or later this class of agents must be employed. Among these, Opium and the Salts of Morphine, in small doses, repeated as often as the urgency of the case may require, are most esteemed among practitioners ; however, there are many others which may be advantageously administered, as Hyoscyamus, Stramonium, and Conium Maculatum. We have used a syrup of Helianthus in severe cases of cough with the most marked effect. Hemoptysis is likewise a symptom generally present to a greater or less extent, requiring prompt attention. It may be treated with an infusion of Lycopus Yirginicus and Liquorice-root, or an infusion of a combination of Lycopus, Beth, and Geranium. 
In very severe cases of hemoptysis, we have found Geranin, in doses of ten grains every half hour, to exert a very beneficial influence upon the hemorrhage. If there should be pain attending this symptom, Opium or some of its preparations may be administered in small doses. Oil of Turpentine has been highly recommended by various practitioners as an excellent agent to check the above symptom. 
Diarrhea is a symptom almost always present in this 


PHTHISIS—CONSUMPTION. 
771 
disease, and more generally occurs in the latter stages ; it is often very difficult to overcome by any means that have been recommended. We have met with more advantage from the use of a powder composed of two drachms of Myricin and one of Geranin, than any other preparation we have employed. Opium, so universally recommended by authors, we have never found to exert the least influence in palliating this symptom. 
The rapid pulse so common to phthisis is seldom the result of inflammatory action, except perhaps at the commencement of the disease; but, in our estimation, it is almost invariably the result of debility, a striking example of which may be seen in the quick pulse attending the stage of prostration in typhoid fever. The result of our treatment, based upon this view, would seem to indicate its correctness. We are in the habit of administering stimulants and tonics, which are generally followed by the reduction of the pulse, and a decrease of the temperature of the surface. 
With regard to dyspnoea, and bronchial inflammation, but little can be done by the administration of internal remedies; palliation is all that can be expected, and to effect this, we have found the most advantage from inhalation of vapor of vinegar, or vinegar in which Lobelia or Stramonium has been tinctured. 
Night-sweats are nearly always attendant upon the latter stages of this disease, and notwithstanding the many articles which have been recommended for their removal, it is seldom accomplished. Elixir Vitriol seems to exert a more marked influence over them than any other means we have used. When the disease is to terminate fatally, nightsweats can not be controled, at least, for only a few nights at most; if a cure is to be the result, or a suspension of the disease, of course they will cease. 
The diet, in phthisis, must be of a stimulating, nutritious character; beef, veal, mutton, oysters, etc., may be used as freely as the stomach of the patient will permit. Pork, in any shape, is inadmissible. Wine, beer, porter, 
49 


772 
INFLAMMATORY FORMS OF DISEASE. 
ale, or even the more stimulating alcoholic liquids, may be likewise employed in moderate quantities with advantage. The patient must take gentle exercise daily, and practice long inhalation and exhalation, especially in the earlier stage. Depletive agents, as emetics, cathartics, diaphoretics, and the like, must positively be prohibited — the seeming advantage from their use is but transient, and followed by serious consequences. 
Genus V.—Parotitis— 
Cynanche Parotidcea — Mumps. 
This disease may attack adults, but it is generally confined to childhood, and it is sometimes a very simple matte —too unimportant to command medical attention ; at other times, it proves to be very troublesome, painful, and serious in its consequences ; but it is perhaps never, or at most very rarely, fatal. It consists of inflammation and tumefaction of the parotid glands, but sometimes the submaxillary and sub-lingual glands are either implicated at the outset, or in the course of the disease. Sometimes it is confined to one side ; at other times it seizes upon both sides at once —but most frequently, after seizing one side it then attacks the other. 
When all the glands above-named are involved in the inflammation, the swelling extends from the ear to the chin. Soreness at the angle of the jaw, or soreness in attempts to open the mouth, is usually the first indication of its approach. Slight fever usually attends these local symptoms. Under proper treatment, it usually terminates in resolution in a few days, having given but little trouble, further than a material interruption to the function of the lower jaw. 
Through the joint influence of atmospheric and constitutional causes, it is sometimes productive of severe suffering—the inflammation running high, and the gland becoming so enlarged as to render the opening of the mouth and deglutition particularly difficult and painful. It happens in a few instances that nausea, vomiting, fever, and delirium are all attendant upon the disease; but, however mild 


PAROTITIS —MUMPS. 
773 
the complaint may be, much care and vigilance are advisable, because of a peculiar and very remarkable metastasis to which it is obnoxious. 
We can readily understand why a translation of disease may take place from the skin to the mucous lining of the bowels —from the scalp to the cerebral meninges—from the stomach to the teeth, etc., —but why there should be a fixed tendency to a translation of disease from the parotid glands to the mamma in females, and the testes in males, which observation has proved to be the fact in this disease, is more than the present state of physiological science can explain. 
When this translation takes place in the male, the testes become sometimes enormously enlarged, producing much fever, occasionally delirium, always severe suffering, and very considerable hazard—such, indeed, as to require perseverance in the use of potent and active remedies. In the female, the mamma become inflamed and enlarged, but we have not learned that suppuration ever supervenes. Sometimes another translation is made, and the disease returns to the glands—it has been known to take place to the brain, and then death may be the result. This possibility affords another reason why care should always be rendered to this disease. 
The inflammation usually rises to its highest point in two days, continues without abatement two days more, and then declines —the whole course of the disease, ordinarily, consuming only a week. The glands very rarely suppurate. 
Causes.—Like some of the contagious diseases, it but rarely attacks the same person a second time. Drs. Watson and Wood say that it is undoubtedly contagious, and it is acknowledged by all to appear frequently as an epidemic. 
Treatment.—Usually mumps require but little treatment; a diet of toast and tea, toast-water, thin gruel, and similar articles, with an especial attention to an avoidance of cold by exposure to wet, sudden changes of temperature, or other causes of cold, will generally be found sufficient. 
Should the bowels be constipated, a Seidlitz-Powder or 


774 
INFLAMMATORY FORMS OF DISEASE. 
two may be administered. There will be no necessity for the application of any liniments or washes to the affected parts, as they may act as repellants, and probably cause a metastasis to take place; a piece of soft flannel may, however, be applied, to keep them warm and favor perspiration. 
Should much fever accompany the disease, small doses of the Compound Powder of Ipecacuanha aud Opium may be administered, together with a purgative dose or two of the Compound Powder of Jalap, to which five or ten grains of Cream of Tartar have been added. 
In cases where the inflammation becomes translated to the testicle, the patient should be confined to his bed in a horizontal position, the testes enveloped in an Elm-poultice, and supported by a suspensory bandage—the poultice must be changed two or three times a day. 
In addition to the above, efforts should be made to recall the inflammation to the parotid glands by the application of a sinapism or blister over the gland, and the Compound Powder of Ipecacuanha and Opium should be administered internally. A somewhat similar course may be pursued when the mamma become affected. 
In cases where the brain, or some other vital organ, becomes affected, blisters must be applied as in ordinary, severe inflammations of such organs. 
Should a chronic inflammation of the gland remain, which, however, will very rarely be the case by the above course, an irritating plaster applied over the tumor, and kept discharging from time to time, intermittingly with the internal use of Compound Syrup of Stillingia and Hydroidate of Potassa, will be found sufficient to remove the difficulty. 
Genus VI.—Gastritis. 
This term is commonly used to express an inflammation of all the tunics of the stomach, with the exception of its serous covering; but, as it is now generally believed that this diseased action commences in the mucous membrane and glands, the term is employed to designate an inflam- 


775 
ACUTE GASTRITIS. 
mation of the internal tunic, which may or may not affect the remaining tissues from the violence or chronicity of the disease, the habit of the patient, etc. — Cyc. Prac. Med. 
1. Acute Gastritis. 
That the mucous membrane of the stomach is liable to as many varieties of inflammation as that of the fauces or mouth, we do not entertain a doubt; but as we can not distinguish these varieties (and if we could, we do not readily perceive a therapeutic advantage in it), therefore we shall treat of gastritis as a simple inflammation—acute and chronic. 
Gastritis is a rare disease of infancy, and to find it unassociated with inflammation of a portion of the intestinal tube, is still more rare. Such are the sympathies of the stomach, that the symptoms of gastritis scarcely ever appear clear and indisputable. It requires close attention and accurate discrimination to sift the truly gastric symptoms from the adventitious ; but this difficulty can not be said to exist to much extent, except so long as it may continue in a simple erythematic form. When the inflammation shall have thoroughly invaded the mucous membrane, or inflicted upon it a well-marked lesion, nearly all doubt is dispelled as to the character of the complaint. 
When the attack is attended by vomiting, tension, and pain of the epigastrium, by cries when this organ is subjected to pressure, by alterations of the countenance, expressive of severe pain or suffering, we can scarcely doubt as to the character of the disease, in infancy. In adults, it may be known by severely-acute pain in the praecordia ; a sensation of heat in the stomach ; a pulse more or less hard, contracted, and weak ; great mental anxiety ; continually-painful vomiting; excessive thirst; watchings ; inquietude ; tossing of the body; coldness of the extremities ; exquisite pain upon belching; fainting fits or a strong disposition to syncope; an increase of pain when deglutition is attempted, or a deep inspiration. 
Gastritis is not always confined to the mucous lining of 


776 
INFLAMMATORY FORMS OF DISEASE. 
the stomach and the sub-mucous cellular tissue, but extends sometimes to the other coats, and may involve the whole organ. To the symptoms which have been detailed, we may add, that the vomitings at the onset bring up the food or chyme, and henceforward bile, or mucus, and whatever else may have been swallowed, which is tinctured sometimes with blood. The pulse is frequent, and usually small and corded, respiration short and hurried, skin hot and dry, and the urine highly colored. 
These symptoms are liable to considerable modification, depending upon the more or less violent character of the attack. If it has been produced by a corrosive poison, the disease may run its course in twenty-four hours, but when ordinarily produced, it may continue from two to four or five weeks, and then terminate fatally, or in a slow convalescence, or lastly in a chronic form. However mild the attack, it should be attended with no neglect or indifference, because it may continue in such a state for weeks, and then assume the chronic form. 
Whatever may be the variety of this disease, it is liable to run into a true disorganization of tissue, inasmuch as all its varieties are sometimes followed by ulceration or gangrene. Such consequences, however, very rarely happen in infancy, but are not unfrequent occurrences with adults. 
Causes.—Irritating food, strong acidj cold, and poisons. Pretty extensive observation has decided that the Tartrate of Antimony and Potassa is much more apt to produce gastritis in the south than the north. During the time the writer was in Arkansas, some five years, he was informed of many deaths that were occasioned by the use of this article as an emetic. Prom such fatality in the south we may well question its safety in the north—indeed, in every modification of latitude. 
Diagnosis.—It is barely possible that a young and inexperienced physician might mistake colic or flatulence of the stomach for gastritis, therefore a few diagnostic symptoms will be sufficient. In the former, the pulse con- 


ACUTE GASTRITIS. 
777 
tinues normal, or nearly so; vomiting is usually absent; the pain is intermittent, and it is relieved by pressure; the pain is heavy, aching, and twisting, and the skin is rather cool and moist — while the reverse of all this attends gastritis. 
Prognosis.—A fatal termination is indicated by a restless tossing about, a vomiting up of whatever is taken into the stomach, hiccoughs, fainting fits, an intermitting pulse, disturbed mind, and convulsive movements of the extremities. This form of disease is always dangerous, but when the pain and vomiting gradually subside, attended with a lateritious sediment in the urine, feculent discharges from the bowels, a compressible pulse, and a gentle moisture of the skin, a favorable termination may be expected. 
Treatment. —If the gastritis be the effect of poison, and the poisonous substance remains in the stomach, it will be necessary to remove it by giving a mild emetic, using at the same time, as well as subsequent to the evacuation of the stomach, the proper antidote to the poison. If the inflammation should still continue, the usual means to subdue it may be employed. 
In all cases of gastric inflammation, the treatment must be commenced by the application of fomentations over the epigastric region, as hot as the patient can bear, which should be often changed, not allowing them to become cool. The feet and legs must be frequently bathed in hot water, and sinapisms placed on the soles, and even around the ankles in severe cases. Perspiration must be induced either by the use of the spirit vapor-bath or injection of the Compound Tincture of Virginia Snakeroot, one to three drachms of which may be placed in about a half-gill of warm starchwater, and injected at one time into the rectum. Professor King is in the habit of applying sinapisms over the epigastric region, in connection with the hot fomentations, and also sinapisms the whole length of the spinal column. 
Internally but little active medication can be employed ; the best preparation with which we are acquainted, however, to overcome the tendency to vomit, by reducing the 


778 
INFLAMMATORY FORMS OF DISEASE. 
inflammation, is an infusion of peach-leaves and elm-bark, which may be given in teaspoonful doses to the patient every fifteen minutes, with one drop of the Tincture of Aconitum added to it; and as soon as the more active symptoms become lessened, the Aconitum may be omitted. 
Should the patient crave cold water, or cold lemonade, it may be given, provided it does not increase the tendency to vomit, otherwise no other drink must be given than the above infusion. 
As soon as the patient becomes able to retain anything upon the stomach, the Compound Powder of Ipecacuanha and Opium in very small doses, combined with half to a grain of Hydrastin, may be given at intervals of two or three hours, still continuing the peach-leaf infusion. Constipation must be overcome by purgative injections. 
As to diet, but little can be taken during the active stage of the inflammation; but after this has subsided, Gum- Arabic water, barley-water, rice-water, or toast-water, may be given, and when the inflammation has entirely subsided, a cautious use, at first, of chicken-broth or beef-tea, gradually accustoming the stomach to the usual food of the patient. 
2. Chronic Gastritis. 
It is not always possible to distinguish between that functional derangement of the stomach which constitutes dyspepsia and chronic gastritis, and therefore the error of confounding the two is readily fallen into. In very many instances, as is well known, dyspepsia is occasioned by a too-free use of stimulating or highly-seasoned food ; and it is also well known, that no variety of functional derangement can exist without passing ultimately into one of structure ; in cases of long-standing dyspepsia, therefore, it is much more than probable that it consists of both functional and structural derangement, and the difficulty of arriving at a diagnostic difference between the two forms of disease, and more especially when existing conjointly, has occasioned much error and disappointment in the practice for dyspepsia ; and yet, as humiliating as it really is, the pro- 


CHRONIC GASTRITIS. 
779 
fession has it not in its power to indicate a single symptom that seems to distinguish the two forms of disease from each other, until the inflammatory shall have so far advanced as to render its complaints more imperious than those which are usual to the other. 
There is probably no other form of disease that is more insidious in its assault and initiatory stage than this ; so much so is this the case, that the earliest indications of its existence are allowed to pass unobserved, and therefore we are compelled to begin the history of it with those which are sufficiently troublesome to force their observance, and of these the most frequent and appreciable are pain and vomiting—the first is the usual companion of the patient during the process of digestion, while vomiting not unfrequently supervenes to relieve him of it. 
In many cases, before any particular pain is felt, the patient feels some uneasiness in the epigastrium shortly after eating, and discovers that his appetite has become irregular and fastidious. He is also troubled more frequently than formerly with headache, feels fatigued—complains of pains and soreness in his limbs. The symptoms gradually increase in variety and severity; the epigastric uneasiness has passed into absolute pain, but it is exceedingly variable, being sometimes acute, spasmodic, slight, dull, and even lancinating. Instead of, and sometimes conjointly with, the preceding varieties of pain, there is a tormenting sensation of heat or burning which may even extend to the chesu. At other times, instead of the pain, there is a sense of fullness, weight, distention, or constriction. The pain is occasionally exceedingly severe, but subsides as the stomach becomes empty ; it may extend to the back, or appear under the margins of the ribs or sternum, but generally it is in the epigastrium or hypochondrium. Vomiting is not an unfrequent occurrence and generally occasions much relief; the injesta alone is usually rejected, and its supervention is generally proportioned to the irritating character of the food ; but sometimes the most bland ingesta will produce it; and indeed, it occurs sometimes when no 


780 
INFLAMMATORY FORMS OF DISEASK. 
food has been taken. In the matter ejected, there is sometimes much variety—at one time it may resemble the white of eggs ; at another, insipid and watery; it may also be intensely acid, dark-colored, bilious, or bloody. Hematemesis is not an uncommon attendant —indeed, it even begins the disease, in some instances ; it may result from exhalation in some cases, and in others, from the ulceration of the gastric vessels. Without the ulcerative form, it is in some cases so nearly allied with the disease under consideration, that inflammation can immediately succeed to it, and in such cases the proper remedy for the one is also the best for the other. 
It happens sometimes that the digestive process goes on very well until it reaches a certain stage, or probably arrives at a certain part of the organ, and then pain is occasioned and the food is rejected. Sometimes the presence of food gives temporary relief, by allaying a gnawing sensation in the epigastrium, which the writer knows to be peculiarly distressing. It occurs usually a little time before the regular period of taking food ; in some instances the desire for food is entirely lost, but this only occurs in the most violent cases. The tongue, in this disease, is generally an untrustworthy guide as to the condition of the stomach. The bowels, in many cases, are habitually costive, which so much increases the suffering that purgatives are greatly demanded by the sufferer —indeed, he is strongly disposed to regard this as his disease, and by its treatment renders his condition worse; he becomes usually emaciated, and the abdomen, by its accumulation of fasces and flatus, becomes distended —the shoulders more or less droop, through the extension of the abdominal muscles.* This abdominal 
* The writer was compelled, at an earlier period of his life, when afflicted with this disease, to take cathartic medicine every night to remove constipation. To avoid this necessity, he determined to try abdominal compression, and for this purpose he buckled around his waist a Russian riding belt, in the morning, after the evacuation of his bowels, and determined not to loosen it. On the next day, the compression was remarkably uncomfortable, and on the third day peristaltic action commenced ; and by the use of l he belt he avoided the further necessity of taking cathartic medicine. The 


781 
CHRONIC GASTRITIS. 
distention is not a conspicuous symptom in all cases, but it is always presented, more or less frequently, in those cases in which gas is evolved in the stomach. 
There is apt to be an aphthous exudation on the tongue, in the advanced stages of this disease, which is thought to indicate an ulcerated condition of the stomach; at all events, it is held to be an unfavorable symptom. The pulse, in general, makes but little departure from that of health—sometimes it is a little more frequent and others a little slower, and perhaps intermittent. A slight febrile paroxysm after dining is a common symptom in the confirmed condition of the disease. Some patients complain of much heat in the soles of the feet and palms of the hands, but with the most of them the extremities are cold. The secretions are generally much deranged, but nutrition is not always so defective as might be supposed. In some cases the disease continues for a long time without an apparent loss of flesh, but in others the emaciation is tolerably rapid and runs to a great extreme. 
The influence of this disease upon the nervous system, in producing nervous affections, can not be expressed by any use of language, and it is very probable that no two patients ever suffered in the same manner. From this disease the writer has suffered partial blindness, deafness, baldness, also palpitations, asthma, heartburn, headache, toothache, rheumatism, gout, bronchitis, fugitive pains, lithiasis, and mental dejection. 
Causes.—Dr. "Wood says that this disease occasionally follows the acute, but that a large majority of the cases are independent of it. The use of alcoholic liquors is said to produce it, but of this we have some doubt. "We have seen many cases of it among those who had never used such liquors, and we have observed remarkably few even among 
belt has been his remedy ever since when his bowels manifested a tendency to a habit of constipation. He has applied it with equal success in perhaps fifty other cases. He recommends it to the profession as a useful application, in all cases of habitual constipation, but particularly when it is attended by abdominal enlargement. 


782 
INFLAMMATORY FORMS OF DISEASE. 
habitual drunkards. This is not all—we have known the disease to yield to the use of them. The writer attributes his recovery to brandy and traveling. He is of opinion that the use of mustard, as a condiment, is worse than alcohol, and next to this is excessive eating. But a more fruitful cause than either, and one that we have found noticed by no writer, is excessive venery, but it acts indirectly by first producing dyspepsia. 
Diagnosis.—The maladies with which chronic gastritis may possibly be confounded, are cancer of the stomach, dyspepsia, and gastralgia, to which we refer. 
Prognosis.—This disease exists almost uniformly in a peculiar organic liability—a deficiency of the organ of alimentiveness—for the power of the stomach depends upon the endowment of this organ ; consequently, although the patient may recover, he has no security, during life, against as many returns of the disease as he shall be guilty, for indefinite periods, of violating the laws which are indispensable to his own health. When the disease becomes confirmed, no hope need to be indulged of a recovery under a year or two, and it may continue for four or five—for much depends upon the constitutional liability. It does not move steadily on to its final termination, but is attended with irregular intermissions, the patient appearing quite well even for weeks or months, and suddenly, because of some imprudence in diet, or some atmospheric change, it becomes manifested again. If it should not become complicated, it will very probably terminate favorably, for it is rarely fatal. The stomach may become ulcerated—adhesions may form, and perforations may be effected, communicating with the bowels, and still the patient may recover. 
Treatment. —In this disease, the mucous coat of the stomach only is affected, and the treatment must be directed to it, using such agents as exert a more especial influence on the mucous tissues. When the inflammation is rather active, bordering on the acute, it will be necessary to give the patient, internally, the Compound Powder of Ipecacuanha and Opium, combined with Hydrastin, together with 


783 
CHRONIC GASTRITIS. 
mild, unirritating, and mucilaginous drinks. The diet must also be especially attended to, and should consist of nutritious but easily-digested articles of food, as Gum-Arabic water, barley-water, rice-water, Sago, Tapioca, soft-boiled eggs, toast and tea, and similar preparations. 
The surface of the body should be bathed daily with a weak alkaline-solution; an irritating plaster may also, if the case proves obstinate, be applied over the region of the stomach, and continued intermittingly as the case may require, and the patient should be kept quiet, and free from any exposures. 
If, however, the inflammation be purely of a chronic character, and attended with much debility, a more nutritious diet will be required, as animal jellies, oysters, poultry, venison, tender beefsteaks, birds, or other meats easy of digestion. 
Should there be any particular craving of the patient, however much it may be in opposition to the views of the physician, it will generally be found better to grant the use of the desired food, commencing with it gradually and carefully ; many instances have occurred where this course has resulted in permanent benefit to the patient. 
The agents to be used internally must be given with a view to the promotion of absorption and stimulation of the secretions to a normal standard. We prefer, for this purpose, combinations of Hydrastin, Cornin, Supercarbonate of Soda, Myricin, Caulophyllin, and Macrotin. The combination to be employed must be adapted to the emergencies of the case, and may be composed of two or more of the above articles. The following is a favorite formula with us: 
R. Hydrastin, 
Cornin, 
Myricin, da grs. x. Mix. 
Divide this into ten powders, one of which may be given every three or four hours. 
Should constipation be present, it will most generally be found connected with acidity of the stomach, or rather, in 


784 
INFLAMMATORY FORMS OF DISEASE. 
cases of constipation, the acidity will be found present likewise, and to overcome both of which symptoms the following compound will be found fully sufficient: 
B. Pulv. Rhei, grs. xx, 
Podophyllin, grs. ij, Supercarb. Soda, grs. xx, Pulv. Carbo Ligni, grs. xx. Mix, 
Divide into ten powders, of which from one to three may be given daily, to produce not over two alvine evacuations; or, if the medicine proves very active a still smaller dose of it may be administered, sufficient to effect the desired result; if acidity of the stomach be prominent, a solution of Supercarbonate of Soda may be given in tablespoonful doses, daily—repeated every one, two, or three hours. 
Other laxative agents may be employed, as Apocynum Cannabirum, Asclepias Incarnata, Iris Yersicolor, Juglans Cinerea, etc., which may be given alone or in combination, as the practitioner may deem best. The skin must be attended to, bathing daily with cold or tepid water, as may be found more suited to the case, and using considerable friction in drying. Too much exercise of any kind must be prohibited. 
In that form of dyspepsia in which chronic inflammation of the stomach exists, with constipation, we have derived the greatest benefit from the following course of treatment: 
R. Pulv. Prinos Yerticillatus, Pulv. Hydrastis Can., aa 3ss, Myricin, 9j. Mix. 
Divide this into four powders; one of these powders is to be placed in half a pint of boiling water, infused for a few minutes, and the whole taken in the course of twentyfour hours, and thus continue daily with each powder. 
The irritating plaster must likewise be placed over the epigastric region, and a free discharge kept up during the continuance of the disease. For the constipation, injections of cold water may be used, or the above-named laxative powder. Occasionally cases will occur in which counter-irritation applied the whole length of the spinal column 


785 
DUODENITIS. 
will be of advantage. The diet should be nutritious, of easy digestion, avoiding fats, acids, and all agents which may induce flatulency or constipation. Moderate exercise in the open air, and frequent bathing with cold water should be advised. 
Genus YII. —Deodinitus— 
Inflammation of the Duodenum. 
From continuity of structure, as well as an intimate affinity in function, it is but seldom that this viscu" is inflamed or otherwise diseased without involving its neighbors. If its inflammation extenda upward, the stomach may become implicated, and gastritis, more or less evident, may be the result; if it extends downward, the jejunum may become involved, and an enteritis may thus, also, become manifest. In its various forms of disease, the liver and pancreas may become involved; hence it is, that because of its intimate functional and pathological relations, rather than through any therapeutic considerations, does it become proper or important to note its most striking pathological and diagnostic symptoms. 
The most striking circumstance in the history of duodenitis is its tendency to derange the function of the liver, and the most obvious instance of this kind is a jaundiced condition of the skin. But the pathological sympathy between the duodenum and liver is not more striking than the physiological. Chyme received into the duodenum so excites the liver that its bile is immediately discharged into the former. This intimate relation shows that a morbid condition of the duodenum cannot fail to increase, or diminish, or otherwise affect the function of the liver. If its action, through this mean, be increased, such may be the quantity of bile thrown into the bowels, that by absorption, enough may be taken up to produce jaundice ; and on the other hand, if its secretion be diminished, jaundice may result from an accumulation of bile in the blood; and, again, if the secretion be vitiated, it may produce diarrhea, for we think it very questionable whether healthy bile is ever an exciting cause to diarrhea. Some 


786 
INFLAMMATORY FORMS OF DISEASE. 
writers attribute jaundice to an obstruction of the common duct of the liver, by an inflammatory thickening of its coats, in duodenitis, or by mucus. It may possibly be sometimes effected in this way, but it is rendered certain that this is not always the case. 
Prof. Dunglison, we believe it is, teaches that mercury promotes the secretory action of the liverj by its impression upon the duodenum or the mouth of the hepatic duct. If this be true, and it strikes us as being probable, we have another source of uncertainty as to the action of this drug. The functional sympathy that exists between the liver and duodenum affords us an explanation of an important phenomenon in the digestive process. In a dyspeptic condition of the organ, the chyme, its normal stimulus, is incapable of making such an impression as would be received by it, if it was in a healthy state ; and consequently it can not communicate to the liver a normal impression—hence it is made to secrete too much or too little bile, or bile of a vitiated quality. Notwithstanding that duodenal derangements may produce others in the liver, we are not prepared to believe that they are the most fruitful source of them. 
Diagnosis.—When we have no evidence that the liver is inflamed or enlarged, and pressure produces pain immediately to the left of the right hypochondrium ; when the skin is jaundiced and the urine bilious ; when pain is felt deepseated about the pylorus, reaching below and leftwardly of the stomach — then we may suspect the existence, of duodenitis. 
Treatment. —In this form of disease, the treatment recommended under gastritis will be indicated—or if any variation is made, it may be in the administration of more active laxative measures, with an especial attention to the biliary secretions, for which Podophyllin and Leptandrin will be found of particular efficacy. 
Genus VIII. —Enteritis. 
The name enteritis is, strictly speaking, applicable to inflammation of any portion of the bowels; yet, as this 


ACUTE ENTERITIS. 
787 
affection, in the upper and lower extremities of the intestinal tube, has received the designations of duodenitis and dysentery, and as the symptoms of these two complaints are in a certain degree strikingly peculiar, it becomes convenient to give a distinct name to inflammation of the intervening portion, and enteritis may, perhaps without impropriety, receive this restricted meaning.— Wood. 
1. Acute Enteritis. 
Enteritis, as an idiopathic affection, is of rare occurrence, but as a symptomatic one, it is not unfrequent—particularly with reference to scarlatina, rubeola, and low nervous fevers ; and when it does occur, it is more generally of the sub-acute or chronic form. When it is acute, and involves the sub-mucous tissue, the mucous membrane, and t the peritoneal coat, the symptoms generally are intensely pungent, consisting of a burning pain in some particular spot, usually in the umbilical region, increased by the slightest pressure ; also a sense of tightness, heat, and abdominal distention, attended with mental anxiety, and violent thirst (which is generally aggravated by cold drinks), constipation, vomiting of slime and bile, and sometimes excrementitious matter, inflammatory fever,, flatulence, obstruction of urine, occasionally, and a small, contracted pulse. 
When the disease appears in its simple or sub-acute form, but little pain is felt, compared with what obtains when the peritoneal coat is involved ; it consists rather of a diffused soreness over the abdominal region, which may, or may not, be increased by pressure; but the symptoms are always increased by indigestible food and cold drinks. Indigestion, nausea, and vomiting are more or less present, depending upon the portion of the intestinal canal which is principally affected. If it shall so descend as to involve the colon, diarrhea, with mucacious and bloody stools, will be produced, and if the rectum be invaded by it, pure blood may be expected, with straining efforts to stool. The tongue is more or less red on its tip and margins, whatever may be the condition of its center; sometimes, however, 
50 


788 
INFLAMMATORY FORMS OF DISEASE. 
the whole of it is red and smooth. The pulse is quick, the thirst is considerable, and the languor extreme. 
Usually, when the bowels are neither diarrheal nor aperient, they will be easily moved by cathartic medicine. "When diarrhea obtains, it is not unfrequent that it becomes suspended and then re-appears. Sometimes the stools are highly serous, and mixed with fecal matter, bile, mucus, undigested food, and even blood ; and again, they are sometimes of a dark, or green, or clay-color. The evacuations usually happen immediately after griping pains, which they greatly relieve, and several of these discharges may happen in the course of the day. 
When the inflammation particularly involves the muscular and peritoneal coats, and when it has been occasioned by obstructions, the bowels will be constipated. When the inflammation is attended with intense pain and tenderness, obstinate constipation, a frequent and contracted pulse and tympanites, it may be safely concluded that the disease is complicated with peritonitis. If these severe symptoms occur suddenly in the progress of the disease, it may be safely inferred that a perforation has been effected. 
Dr. Stokes (Cyc. Prac. Med.) teaches, that the symptoms occasioned by sympathetic irritation vary with the idiosyncrasy of the patient and the violence of the disease. There may be, he says, a continued, remittent, or hectic fever, or an apyrexial state. It sometimes happens that the most prominent symptom is a violent excitement of the heart, such as characterizes pericarditis and hypertrophy of the organ. He thinks, that the excited condition of the abdominal aorta, as a symptom, has not been sufficiently attended to. This excitement, he says, is similar to that of the radial artery in cases of paronychia, and may be detected in an uncollapsed condition of the abdomen. 
Cerebral excitement is less apt to attend this disease in the adult than in the child, and is less liable to result in structural disease of the brain ; and it is not unfrequently difficult to determine whether the cerebral irritation in these cases does or not indicate inflammation of the brain. 


ACUTE ENTERITIS. 
789 
Andral cites a case in which the patient manifested much cerebral excitement —became lively and loquacious, and finally passed into furious delirium, and yet post-mortem investigation discovered no indications about the brain of pre-existing inflammation. 
The fever, in this form of disease, sometimes becomes the simple continued form, without any local symptoms, while at the same time the most serious local mischief is progressing; but this condition should be suspected if there be much thirst, tympanites, and irregularity of the bowels. 
Diagnosis.—If enteritis should be mistaken for colic, and it has been, the consequences may be fatal, because of the difference of treatment which the two forms of disease, respectively, require. In all cases where doubt may exist, it is better to treat the case as one of enteritis; for in this event no mischief is done, but the reverse would probably result very differently. The pains of colic and enteritis may be equally severe, but between them there is this difference : in those of the former there are complete intermissions, which is not the case in the latter. Again, in colic, the patient is apt to be constantly twisting, turning, and rolling his body, whereas, in enteritis and peritonitis, the body is kept still, however much the arms may be thrown about. Furthermore, colic is decidedly a spasmodic affection. Pressure affords relief in colic, but increases the pain in enteritis; and again, fever is usually absent in colic, and present in enteritis. Simple enteritis may be distinguished from peritonitis by the absence, in the former, of that intensity of pain which attends the latter. 
Causes.—This is a disease which attacks both sexes and all ages, but children are the most liable to it, because probably of the more delicate and vascular condition of the mucous membrane at this age. Like catarrhal diarrhea, it may be produced by a sudden suppression of accustomed drains upon the surface or elsewhere; like sympathetic diarrhea, it may result from a suppressed irritation in distant parts, as of gout and rheumatism; and like feculent 


790 
INFLAMMATORY FORMS OF DISEASE. 
diarrhea, by the contact of irritating substances upon the mucous membrane of the diseased part, as by drastic purges, worms, mercury, antimony, etc. 
Prognosis.—If this disease does not terminate in resolution, induration of the intestines may be the result, and thus the foundation of chronic constipation, suppuration, or gangrene may be laid. It is always to be regarded as a dangerous disease. Cold hands and feet, an extensive diffusion of pain in the abdomen, a scarcely-perceptible pulse, a tense and tumid condition of the abdomen, exceedingly tender to pressure, must be regarded as indicating great danger ; but uncertainty attends all the symptoms of this morbus as regards the final result. 
Treatment.—The treatment of this disease will be similar to that named in gastritis: fomentations and sinapisms over the abdomen, counter-irritation to the extremities, and in obstinate cases to the spinal column, alkaline-bath, in some cases the vapor-bath, and emollient and mucilaginous drinks, with Tincture of Aconite or Belladonna. 
Active catharsis must always be avoided, but where there is torpor of the liver, it may be overcome by small doses of Podophyllin, Leptandrin, and Caulophyllin, say onethird of a grain each, combined, and administered three or four times a day. 
To relieve pain, and keep up a determination to the surface, it may sometimes become necessary to administer the Compound Tincture of Virginia Snakeroot. 
When the discharges from the bowels are very copious, or of a mucous character, either with or without blood, and which generally occur after a subsidence of the more active symptoms, the employment of tonics and mild astringents will be found beneficial, as Hydrastin combined with Geranin. 
As to the treatment in other respects, and as to diet, etc., the same course must be pursued as laid down in acute gastritis. 


791 
CHRONIC ENTERITIS. 
2. Chronic Enteritis ¦ — Chronic Inflammation of the Small Intestines. 
This is one of the most troublesome, depressing, and prostrating forms of disease that afflict humanity, more particularly when it constitutes obstinate diarrhea. We are much inclined to the opinion that long-continued and obstinate diarrhea and chronic enteritis are truly one and the same form of disease, and so it will inevitably appear before we conclude. The evacuations do not materially differ from those of acute enteritis, but as to the quantity and frequency of them no rule can be determined ; in frequency they may not extend beyond two or three in twentyfour hours, and they may be two or three times as many, and the quantity is equally various. It has been sometimes observed that a false membrane is discharged, showing that plastic inflammation existed. The attending pain is perhaps never acute, rather dull and obtuse, but pressure will always detect the existence of soreness, and so will jars and jolts. If the inflammation passes into the acute state, which is occasionally the case, the pain will be quite severe, but it is relieved by the evacuations it occasions, which are sometimes so frequent as to distress the patient very much. 
It sometimes happens that no pain is felt until a definite time after eating ; in such cases we may infer that the inflammation is local, and that no suffering is produced until the ingesta reaches it. In some instances, again, the only function that appears to be disturbed is that of nutrition— the patient becomes feeble and emaciated, but scarcely complains of any local symptom. The abdomen is occasionally distended, but it is frequently flat or gaunt, the skin dry and harsh, the pulse more than normally frequent, and the tongue is somewhat furred, or it is red and dry, or it may be aphthous. 
As might be expected, the stomach sometimes becomes implicated, and to the preceding symptoms are added those of chronic gastritis. The remarks we made upon the 


792 
INFLAMMATORY FORMS OF DISEASE. 
duration and mutability of gastritis equally apply in the case before us—it may be cured in a few weeks, or it may continue for years, appearing sometimes quite well, and then re-appearing, and frequently without any obvious cause. When it is severe, has been of long standing, and of very doubtful recovery, the patient loses all hope, desponds, becomes fretful, and sometimes even insane. 
Causes.—It is said sometimes to originate in the acute form, but most generally it obtains in those of a phthisical organization who have been much exposed to fatigue in a hot sun. Yery many of those who served in Mexico died of this disease — some in Mexico, some while journeying home, and many after their arrival there. 
Treatment.—The treatment in this form of enteritis will be the same as described for chronic gastritis, with an especial attention to diet. See chronic gastritis. 
Genus IX.— Colorectitis— 
Dysentery — Bloody-Flux, or Acute Inflammation of the Large Intestines. 
" Dysentery," says Dr. Wood, u is inflammation of the mucous membrane of the colon and rectum, characterized by small mucous or bloody evacuations, griping pains in the abdomen, straining at stools, and tenesmus. Inflammation in the colon, without these phenomena, would rank under enteritis." 
This form of disease very rarely attacks children under two years of age —before this period, the liability, in this country, is to cholera infantum. Dysentery as rarely obtains under this period, as cholera infantum does after it. 
Dysentery and bloody-flux are names selected to represent an inflammation of the mucous membrane of the large intestines —the colon and rectum. When the evacuations are unattended with blood, the disease is called simple dysenter — the inflammation, if present, is but slight; but when it is dysentery proper, there is a constant urgency to evacuate the bowels, tenesmus, violent pains in the abdomen, a greater or less degree of fever, and the evacuations 


793 
COLORECTITIS—DYSEN TERY. 
consist, measurably, of mucus and blood. It sometimes appears suddenly, but it is perhaps most generally preceded, by a few days, with loss of appetite, nausea, or slight vomiting, costiveness, flatulence, chills succeeded by a hot skin, accelerated pulse, abdominal pains, tormina, and increased evacuations, containing usually some natural fasces, particularly scybala. In a short time more, the evacuations consist of mucus and blood, frequently fetid, and, if at this stage the disease is not speedily arrested, it may terminate in ulceration or gangrene. This is briefly a description of this form of disease. 
In simple dysentery, the symptoms may be so mild that the disease may run its course without exciting the particular attention of even the patient; at other times, the fever, tormina, and tenesmus, appear, as it were, simultaneously, and thus progressing for two or three days, it becomes one of the most formidable forms of disease to which humanity is liable. 
In violent cases, the whole pain consequent upon the inflammation appears to be concentrated about or in the rectum, and the feeling of tenesmus becomes the most important and distinguishing feature of the disease. The calls to stool are very urgent and frequent, from a dozen to a hundred in twenty-four hours, and the straining is so great as to produce prolapsus ani, more especially with children. The writer once witnessed, in an old negro laboring under this disease, a protrusion of the rectum to the extent of nearly three inches.* The fasces are sometimes so scalding or piercing that the patient so dreads the consequences of an evacuation as to resist, to the utmost of his power, the call to stool. 
In a very large majority of cases, under proper medication, the disease takes a favorable turn between the sixth and tenth days. In some cases, however, such is the 
* The old man, in looking as nearly as he could to the location of the protruded gut, concluded that it was a useless stranger, called for a knife to cut it off, but his wife thought it best to consult the writer about it first, and refused to obey him. 


794 
INFLAMMATORY FORMS OF DISEASE. 
violence of the assault, that the system never reacts; a ¦small, feeble, and frequent pulse, anxious and sunken features, a livid appearance about the nails, lips, and eyes, a pale, cool, and clammy skin, with an extraordinary violence of all the symptoms before named, mark the case from its commencement. Such cases continue but a few days—they are extremely rare — and this is exceedingly fortunate. 
When the disease has continued as long as ten days without a favorable change, it is very common for the above-described symptoms to become more violent, with an addition of others of a more alarming character. The abdomen becomes swollen and tender, the pulse weaker and more frequent—the tongue becomes dryish and brownish, or it becomes clean, red, and smooth, and to these are added increased restlessness and feebleness. 
Authors have treated of several varieties of dysentery, as the bilious, adynamic, intermittent, remittent, and typhous, but as they do not particularly interest us in this connection, being mere modifications, we refer our readers to other works for information concerning them. But there is a variety too remarkable in its features to be passed over without some notice. It is a variety in which calomel can exert no more influence than brick dust. It appeared as an epidemic in a few of the counties above Cincinnati, on the Ohio, in 1826, and yet it did not attack very many persons, but those it did attack were of a stout and healthy appearance, and between second dentition and middle age. It was almost certainly fatal—the writer does not remember to have heard of a single recovery, except those which happened in his own practice—and he lost his first two cases. His preceptors, Messrs. Ramsey and Pearson, had a few cases in the vicinity of Cincinnati. The writer prepared a report upon the disease and his treatment of it, and gave it to Dr. Drake, but what became of it he knows not. 
Dr. Thomas, in his Practice, describes a variety of dysentery which occurs, or had occurred, in the West-India Islands, that precisely corresponded to the one under con- 


COLORECTITIS—D Y"S ENT BR Y. 
795 
sideration. The writer does not intend, in this place-, to treat of this particular form in full, but simply to mention some of its peculiarities. 
The patients at no time, scarcely, complained t of anything but a feeling of extreme wretchedness, which was attended with great restlessness—it produced considerable tormina and tenesmus, but of these symptoms little complaint was made—the feeling first named prevailed over all others. The evacuations at first consisted of mucus and blood, but after the lapse of three or four days, they consisted of mucus and a verdigris-green matter, and the same appeared in the vomitings. To his first patient, who did not fall into his hands until the ninth day of the disease, he gave seventy-four grains of calomel, without the least observable influence. On the seventeenth day of the disease the patient died. The evacuations and the other symptoms continued, in kind, about the same to the last. 
Two clays before the death of this lady, he commenced to treat her brother, a likely and healthy youth of about sixteen years of age, who was seized with the same disease. The symptoms were the same—he died on the eighteenth day of the disease. During his illness he gave him one hundred and seventy-four grains of calomel, beside such other agents as the case seemed to indicate, and with about as much effect as might have been expected from an equal quantity of chalk. 
During the prevalence of this epidemic there was considerable difference of opinion in the profession so far as the writer had intercourse with it, as regarded the character of the green evacuations—some contending that they were acid, and others that they were bilious. To settle the question, he resorted to a large variety of chemical reagents, to all of which the matter proved insensible. To ascertain the fact, if possible, he tasted the vomitings, and the stools, and in a post-mortem examination of the second patient, he tasted the green contents of the colon—but in all his efforts he found them to be inodorous and insipid. His conclusion then was, and now is, that they consisted of 


796 
INFLAMMATORY FORMS OF DISEASE. 
blood changed by some hidden cause. This conclusion was strengthened by the fact that after the appearance of the green matter, anything like blood ceased to appear in the stools. 
Of the second patient, as already stated, he made a postmortem examination — the liver was much enlarged, very firm, and about the color of a newly-dressed cherry-tree board ; the gall-bladder contained a little black, tar-looking bile; stomach and small intestines measurably sound ; the coats of the large intestines about the fourth of an inch in thickness, the caliber reduced to the size of a half inch, and exhibiting no lesion of structure — except in the mucous membrane. 
As soon as he saw the liver, he became satisfied that he had been incorrectly taught as to the merits of calomel in congestive forms of disease — for he had been taught to make it the sheet-anchor of his hope in such cases. The reflection of a moment satisfied him as to why it should be insufficient in such cases. Calomel is an insoluble salt, and the congestion was too great to permit the stomach to provide anything that could render it a soluble one. 
Two sisters of this patient were taken with the same disease, three days before his death, and the instant he concluded his reflections about calomel, the writer changed his practice, saved them, and all the subsequent patients in this form of disease, to whom he was called. He has not relied upon calomel since in congestive forms of disease, and the physician who does will be greatly deceived in his expectations. But even in such cases, the calomel has sometimes the credit of effecting a cure, because after secretion becomes re-established it has salivated the patient. How long will it be before the profession generally will learn to do better by doing without calomel ? 
The writer did not hear of a single case of this disease that was saved by those of his professional brethren who had it to contend with, and he thinks it more than probable that they failed, as he at first did, in placing their reliance upon calomel. Furthermore, he thinks it reasonable 


797 
COLORECTITIS—DYSENTERY. 
to suppose that a misplaced confidence in calomel is the cause of a large proportion of the fatality which now attends the Old-School practice, particularly in congestive fever, dysentery, cholera, and cholera infantum. That a fatality, in these forms of disease, does attend their practice, which is unknown to any other, admits, at this time, of no debate. He has failed as they do, and therefore he can appreciate the full force of what he says. 
The rule that governed his practice was this : never to lose two patients by the same practice in the same disease, when he had a fair chance with the first. He recommends this course to all young practitioners. 
Causes.—In relation to the cause of dysentery, we have many facts which do not appear to have been properly appreciated. In the 17th century, London, in some seasons, produced a bill of dysenteric mortality of six thousand, but in the 18th century, this mortality became reduced to twenty. What an exceeding change to be effected in one century. The advancement of the arts and sciences, and their application to the advancement of society, are entitled to some of the credit for this reduction of a specific mortality, and the balance can be explained by the principles which we introduced when treating of the cause of cholera infantum. 
In the 17th century, a large portion of the area which constituted London, in the 18th, was not occupied by pavements, sewers, and dwellings, nor was the immediate vicinity as little calculated to furnish evaporation as it was in the 18th century; hence it is obvious, that as London decreased in its evaporation, so it decreased in dysentery. Prof. Watson, in his Practice, says : " In tropical climates it is observed to be more common and more severe when rains succeed to long-continued drought." Here again, we have the same principle illustrated. After a long drought of hot weather, the earth becomes greatly heated, and consequently great evaporation ensues after rain. 
It may be answered, that the mischief is referable to the sudden chilling of the atmosphere, in accordance with 


798 
INFLAMMATORY FORMS OF DISEASE. 
another remark of the professor, which is, "a high diurnal temperature of the air appears to be the predisposing, and exposure to cold the exciting cause." Now, let it be remembered here, that it is characteristic of a tropical climate to be hot through the day and cold at night, so cold that one or two blankets may be required before morning; and yet, without rain or a copious evaporation there will be no dysentery. He asks : " Wherefore is dysentery, which was so familiar to our ancestors, so happily rare among us ?" And here we desire to inquire: " Has the climate of London changed ? Are not the days as hot and the nights as cold as they were in the 17th century ? If the disease depends upon these atmospheric mutations, how does it happen that London is not afflicted now as it was then ? Does the earth, at London and in its vicinity, and we might include the whole island, absorb less water than it did then ? Does the rain that falls find its way to the great channels sooner and more directly than then ? It is impossible to answer these questions in the negative, and therefore, they have hotter summers there now, than then, and cooler nights; consequently, hot days and cool nights can not be the cause of this form of disease, for it was the plague of that time, and now it is scarcely ever seen. The difference between London, at the two above-named periods, respectively, amounts to about this: In the former, she had less heat and active electricity, and vice versa, in the latter. 
Those who lived in Ohio and Kentucky thirty-five or forty years ago, recollect, no doubt, that dysentery was more prevalent and fatal than now, particularly in the older-settled portions of them; and yet, our summers now are hotter, and our weather, upon an average, more mutable than then. If, therefore, with an increase of temperature, here and in England, there is a diminution of dysentery, how can we consistently attribute the disease to the temperature in cold climates? 
We are not going to point out the predisposing cause of dysentery, but by a philosophical examination of the facts 


COLORECTITIS—DYSENTERY. 
799 
we liave, to open that door to observation which has long been almost closed, and is almost closed yet, by that ignis fatuus, professionally called malaria . It can do no mischief, however, to state the conclusion to which we have been forced, namely, that an electric dryness of the atmosphere predisposes adults to summer and autumnal forms of disease, and that the reverse condition of it has a similar influence upon children. A rain, therefore, by changing this condition of the atmosphere, may be an exciting cause among adults; and so may all other departures from the accustomed condition of the system. We do not assert these conclusions to be facts, but simply that they are ours and the best we have. 
It is the opinion of some writers that dysentery is sometimes contagious—it may be so, but we hesitate to indorse the opinion. 
Prognosis.—When, in dysentery, the pains, by degrees, become less severe and frequent, the stools more copious and fecal, and less frequent, the tenesmus diminished, we may infer that a favorable change is being effected ; but on the contrary, should these symptoms suddenly subside, the extremities become cool, the feeling of the skin clammy, the abdomen swollen, the nails livid, and the pulse feeble and irregular, with passive stools, stupor, delirium, hiccough, and subsultus tendinum, we may safely predict a fatal termination. 
Treatment.—This is one of the forms of disease, which, from its excessive mortality in the hands of Allopathic practitioners, has rendered it an " opprobrium" to the profession ; but, as Prof. J. King remarked, in the Eclec. Med. Jour., vol. iii, p. 370: " The discovery of the active principles of many of our most valuable medicinal plants, has resulted in a new era for Eclectic practice, and numerous forms of disease, which at one time required days, or even weeks, for recovery, are now cured with unparalleled safety and rapidity; and the addition of these new agents to our Materia Medica, has given an impulse, character, and extension to Eclecticism, beyond the most sanguine hopes of 


800 
INFLAMMATORY FORMS OF DISEASE. 
its many zealous adherents. In no form of disease, perhaps, have the beneficial effects of these recent discoveries been so well marked, as in the one under consideration, and so constant have been these happy results, that in all places where Eclectic practitioners are located, we find them taking the precedence of all others." 
The treatment of Prof. J. King is so much in accordance with our own views and practice, that we can not do the subject more justice than by extracting the following: 
"Whatever may be the immediate or remote cause of dysentery, we invariably find the functions of both the liver and skin very much deranged, and the removal of which is necessarily the first indication to fulfill; consequently, when called to a patient suffering under this disease, with bloody discharges, tenesmus, etc., whether it be of one day's duration or a week's, our only prescription, thus far, has invariably been as follows: 
R. Podophyllin, grs. vi, Leptandrin, grs. iv, 
Lactin, 3ss. 
Mix, et div., in chart, No. iv. One powder to be given every three hours, until free catharsis is produced. In many cases, we prefer the common diaphoretic powders to the Lactin, and which has a tendency to correct much of the harshness of action of the medicine. 
The above combination, though at the first sight appearing heroic, will yet be found most effectual in removing the disease, often within twenty-four hours from the commencement of its use; it exerts a most powerful influence on the liver and skin, restoring their functions to a normal condition, and causing a free biliary and cutaneous discharge; and in addition to this, as both the Podophyllin and Leptandrin act with energy on mucous tissues, beside possessing an undisputed antiperiodic agency, this fourfold power naturally indicates them as the proper remedies, and the successful results following their administration conclusively demonstrate the correctness of the indication. 
It will generally be found, after the third dose, and some- 


C0L0RECTIT1S—DYSENTERY. 
801 
times not until after the fourth, that the patient will experience for a time very unpleasant and distressing symptoms, but this is not universally the case—there will be present nausea and vomiting, griping pains in the abdomen, cold sweat, coldness of extremities, great prostration, and copious discharges. These symptoms need create no alarm or uneasiness, and we usually prepare the friends of the patient by informing them of the anticipated effects, directing them, in case of much prostration, to support the patient with brandy-sling, or other grateful stimulant, until the purgative operation has ceased. It must be remembered, that it is only necessary to administer the above powders until their decided effect is produced, when they are to be laid aside. With but few exceptions, the termination of the catharsis is followed by the immediate cessation of tenesmus and the dysenteric discharges. 
The patient will now be found in a condition in which it will be necessary to maintain, for a few days, a hepatic and cutaneous influence, to restore tone to the debilitated state of the intestines, prevent further discharges, and preserve the antiperiodic disposition already established; for this purpose, we usually administer the following: 
R. Sulph. Quinia, grs. viii, Sulph. Morphine, gr. ss, Pulv. Ipecac, grs. ij. 
Mix, et div., in chart, No. viii. One powder to be administered every two or three hours, gradually lengthening the intervals between the doses, and continuing their use for two or three days. 
In by far the greater part of cases, this treatment will be found all that is necessary, as in a day or two the patient will be cured and able to attend to his business. Sometimes, however, and especially among those patients to whom we have not been called until they have suffered under the dysenteric attack for several days, there will be found, after the operation of the cathartics, light mucosanguineous discharges, with some tenesmus, for which, in connection with the above Quinine powders, it will be 


802 
INFLAMMATORY FORMS OF DISEASE. 
necessary to administer injections, composed as follows, and one of which should be administered immediately after each discharge, requesting the patient to retain it as long as possible: 
R. Infus. Hydrastis Can., (cold), 3i, Tinct. Opii, gtt. x., vel. xx. Mix. 
Large injections counteract the ends aimed at, viz.: to allay inflammation and check the discharges. 
If this does not readily remove the symptoms, and the patient's strength will admit, the cathartic must be repeated, but in smaller closes, and if it removes the pain and discharges, to be followed by the Quinine powders as before ; but if he be very weak, the administration of port wine, one or two drachms, in which is dissolved Tannin, two to four grains, and repeated every hour or two, according to the urgency of the case, with the above injection, will generally effect the cure. Sometimes we have found much advantage from the following prescription : 
R. Tinct. Catechu, 3iij, 
Tinct. Camphor, 
Tinct. Leptandrin, ad 3j, Syr. Zingiber, vel. Cinnamon, 3j. Mix. 
Dose —a teaspoonful every one, two, or three hours. 
Some practitioners continue the administration of the Podophyllin and Leptandrin, in minute doses, triturated with Lactin, and with excellent results. 
"Where the disease manifests a disposition to be obstinat —which is seldom the case where Eclectic treatment has been adopted from the first — the stools continuing bloody and becoming fetid, with or without tenesmus, inability to retain anything on the stomach, or, if retained, followed shortly after by a desire to stool, with much prostration, and indisposition to move or talk, it will be highly important, in addition to the other treatment, to frequently bathe the surface of the body and limbs with an alkaline wash, warm or cold, to suit the nature of the case and the 


COLORECTITIS-D YSENTERY. 
803 
patient's feelings, also to apply over the bowels and spine, intermittingly, mustard-poultices. The tongue must likewise be observed, if it be coated yellow, brown, or dark, acidulous draughts must be given, as they will in this instance, prove useful, but will be injurious if given when the coat is white. 
Oatmeal made into a cake with water, then baked and finally browned, similar to coffee, and made into a coffee, will be found not only nourishing, but will often check the nausea and irritability of the stomach when all other means fail. It must be given without milk or sugar, in table-spoonful doses, and repeated sufficiently often. Some practitioners speak highly of a tea of parched corn for this purpose, but I have never employed it. If demanded, acids or sedatives may be combined with it. 
During the whole course of treatment, the patient must remain as much as possible in a recumbent position—the erect posture, or much motion, seems to aggravate the disease. 
In the case of delicate females, or patients of not very strong constitution, the dose of the cathartic powders may be somewhat diminished, according to the practitioner's judgment. 
Such, in brief, is the treatment which I have pursued both in Memphis and Cincinnati, during the last two years, and thus far without the loss of a single patient; and a similar course is now, I believe, generally adopted by Eclectic physicians. 
In years past, I have met with considerable success in dysentery, by the use of the white liquid or saline physio, which has in many instances effected a recovery where dissolution seemed inevitable, but I have not used it for some three or four years, though I believe it will be found a very efficient remedy. The formula for its preparation is given in the United States Eclectic Dispensatory, page 18. 
The following will be found an useful preparation for children, suffering under dysentery: 
51 


804 
INFLAMMATORY FORMS OF DISEASE 
R. Pulv. Leptandrin. 
Pulv. Zingiber, (Jamaica) aa grs. v. Pulv. Podophyllin, gr. iss. 
Pulv. Creta, Preparat. grs. x. 
Pulv. Sacch, alb. 3i. 
Mix, triturate well together, and divide into ten powders. For a child from 1 to 3 years old, give one powder every three hours." 
In addition to the above treatment, and where the evacuations continue very copious, we have often found that the neutralizing cordial, geranine, tinct. opi camphorati, as in the following prescription, will give almost instant relief. 
R. Syr. Rhei et Potassa, 3iij. Geranine, grs. xxx. 
Tinct. Opi Camph. 3iss. Mix. 
Of this, give a table-spoonful every two hours. This combination neutralizes acidity when present, gives strength to the debilitated capillary vessels, and allays the pain. In many cases, if taken at the start, this prescription, with the external applications recommended by Prof. J. King, will be sufficient to break up the disease in from two to four days, and never allow it to progress so far as to be attended with any inconvenience to the patient. 
In cases where the disease has continued until it has assumed a typhoid character, with increased thirst, dryness and redness of the tongue, much heat of the stomach, and an apparent increased heat of the whole surface of the body, we have found, a wet sheet applied around the body, as often as it becomes warm, to have the most soothing and beneficial effect of any application which can be made; this should be continued as an auxiliary until those symptoms subside. This is a remedial agent which has not received that attention from general practitioners which it merits; in our opinion, ice or cold water can not be used too extensively, either internally or externally, in all cases of this disease, so long as there is an increased temperature and an accelerated pulse. 
Yet, we have not confidence enough in water to rely upon 


805 
ACUTE PERITONITIS.! 
it to the exclusion of the above treatment, or similar plans which may be adopted. 
Genus X. —Peritonitis. 
This is the term now universally used to express an inflammatory state of the serous membrane, which lines the interior of the abdominal cavity, and invests all the viscera contained therein. Cy. Prac. Med. 
1. Acute Peritonitis 
When treating of acute enteritis, we included the inflamed condition of the peritoneum when present, as it frequently is in that form of disease, but we propose to treat of it, independently of any implication of the intestines. The extraordinary severity that sometimes attends this inflammation, demands this special consideration, for, in the catalogue of human maladies, there is not one which is attended with more extreme pain and suffering. 
It is generally introduced by a sense of lassitude, an obtuse pain or aching in the knees and back, which is succeeded by a sensation of creeping chills and alternate flushes of heat; uneasiness in the epigastrium, and headache. Sooner or later, depending upon the power of the vital force, reaction takes place, which is attended with a pungent heat of the surface, constriction of the epigastrium, a sense of heat and pain in the abdomen, tenderness upon pressure, and a frequent, hard and concentrated pulse. When the disease becomes thoroughly developed, the pain becomes the all absorbing symptom —the patient appears scarcely conscious of any other; and here, it is proper to remark, that this pain even precedes, in a few cases, any febrile symptoms; and of all that we know of pain, as arising from inflammation, there is no other that presents so many and strong indications of reaching the highest possible severity. A patient of the writer likened it to a cutting screw twisted in a highly inflamed part. In some cases the pain presents a paroxysmal character, which may possibly result from the presence of flatus ; in other instances 


806 
INFLAMMATORY FORMS OF DISEASE. 
it is continuous and confined to a very limited extent, and then again it is migratory, and lastly, in a few instances, is diffused. The patient lies on his back, with his knees slightly elevated, and can repose in no other position. The pain is increased by any motion of the body, and particularly by an erect posture. It is worthy of remark that in some cases, no pain is complained of, unless pressure be used. As the respiratory motion of the diaphragm increases the pain, the respiratory function is mainly performed by the pectoral muscles, and hence it is hurried, short, and interrupted. 
The existence and degree of this inflammation are mainly to be known by the sensibility of the abdomen to pressure, which is sometimes so acute and delicate, that the weight of the lightest bed-clothing becomes insupportable. Tension and tumefaction of the abdomen are very nearly as characteristic of this inflammation, as the extreme sensibility to pressure. It should be remembered, however, that this tension and tumefaction are never very remarkable in those who have a lean, dense, and firm muscular system ; but with men of flabby muscles, and women after child-birth. It is not unfrequent that nausea and vomiting attend the disease, at least in some part of its cause, and the ejections consist of mucus and bile, after the usual contents of the stomach are thrown up. The urine is scanty and highcolored, a whitish fur coats the tongue, the pulse running, perhaps, as high as 130 beats per minute, and exceedingly small and contracted ; with these symptoms there is a great desire for cold drink, which, if taken, is speedily ejected. 
The course of this inflammation is one of great rapidity, and of very frequent mortality—it may conclude by resolution, by effusion, by gangrene, or by the introduction of the chronic form. It rarely continues beyond the sixth or seventh day without terminating in some way ; it frequently terminates fatally in three days, occasionally in twenty-four hours, and Andral says that it has terminated fatally in a few hours. 


807 
ACUTE PERITONITIS. 
Causes.—Acute peritonitis may result from mechanical violence,* long continued muscular exertions, perforation of the stomach and bowels by ulceration, and the passage of ingesta or feces into the abdominal cavity; extravasation of blood, urine, or bile, into the peritoneal cavity ; a sudden arrest of perspiration by the agency of cold; the drinking of cold water when in a state of perspiration, is said to produce it. We think that this statement requires much qualification. We admit the statement with those who habitually use ardent spirits, and those who have become exhausted by fatigue, but we have never known an instance of one being injured by the drinking of icedwater, who did not use ardent spirits, and who was only heated and perspiring without fatigue. We have made these remarks for the benefit of those who use ardent spirits, and those who may be greatly fatigued. Parturition is not an unfrequent cause; suppressed hemorrhoids and the menses ; metastasis of scarlatina and rheumatism. 
Diagnosis.—This subject, with the inexperienced, is frequently attended with much difficulty, but we think that the experienced can scarcely make a mistake that shall be attended with mischievous consequences. To mistake it for gastritis, enteritis, splenitis, or entero-peritonitis, could lead to no mischief. As pressure affords relief in colic, it need not to be mistaken for it, but if it should be mistaken for a paroxysm of hysteria, death might be the result. The writer when young, once mistook hysteria for peritonitis, but in such a case, but little if any mischief could probably result. Between these two forms of disease we know of no one diagnostic symptom, but when we take the signs and symptoms of either of them, we shall find them to be completely incongruous with the existence of the other. If the physi- 
*A young negro man, belonging to the writer, was kicked in the abdomen by another domestic, immediately after breakfast. He lived twenty-four hours. Post-mortem examination discovered that the coats of the ileum had been ruptured, and that some fecal matter had passed into the peritoneal cavity. The contents of the abdominal cavity were, by adhesions, united, apparently into one mass. The inflammation appeared to have been confined to the peritoneum. 


808 
INFLAMMATORY FORMS OF DISEASE. 
cian know the hysterical character of his patient, he need to comm't no error. 
Prognosis.—When we find the pain, tension, and tenderness of the abdomen to gradually decline, the pulse to become more full and less frequent, the skin to become soft and moist, the countenance more easy and relaxed, we may expect a favorable termination ; but when the pain suddenly ceases, the pulse becoming quicker and more feeble, the extremities becoming cold, the abdomen more tense, the countenance sunken, we may expect delirium, coma and death. 
Treatment. —In this disease we must, as with other inflammatory diseases, equalize the circulation, and which we accomplish by the spirit-vapor bath, provided, the strength and condition of the patient will admit; if not, it will then become necessary to apply fomentations over the abdomen, as hot as the patient can bear, and change them every five or ten minutes, and this course must be pursued until the pain has considerably subsided. The feet and lower extremities should likewise be bathed often in hot water, after which sinapisms may be applied to them ; these should also be applied along the whole length of the spinal column, for the purpose of counter-irritation and revulsion, and should be employed intermittingly. The body and limbs should be bathed several times a day with a warm, weak alkaline wash, and this should by no means be omitted. Internally, the Compound Powder of Jalap, or Podophyllin, may be given in doses sufficient to produce a mild purgative effect, for the purpose of removing any accumulations which may cause intestinal irritation ; or in case these can not be retained upon the stomach, purgative enema may be substituted. After the action of the purgative, the Compound Tincture of Yirginia Snakeroot must be given, both on account of its anodyne and diaphoretic effect. Sometimes it will be found advantageous to apply a mustardpoultice over the whole abdomen, in connection with the hot fomentations. Where much debility is present, and especially when attended with a tympanitic condition of the abdomen, the saturated tincture of Prickly Ash berries, 


CHRONIC PERITONITIS. 
809 
given internally, when the stomach will bear it, and also administered by injection will be found to have a most excellent influence as a stimulant and diaphoretic. The bowels should be kept regular, using mild laxatives for the purpose of causing one evacuation daily, as the Compound Powder of Rhubarb, or a combination of Leptandrin, Podophyllin, and Caulophyllin, in small doses. 
The patient should be kept as quiet as possible, both during the disease and convalescence, and the diet should consist merely of mucilaginous drinks, toast-water, and even ice or iced water may be allowed should the patient crave it. 
2. Chronic Peritonitis. 
If it had not been observed that the acute form of this disease passes into the chronic, it is possible that we should not, even at this day, have known that such a disease as the one under consideration, ever existed ; at all events we should have had but little information concerning it, because when it obtains independently of the acute form, its manner of invasion is so insidious and imperceptible as to escape notice, until it has wrought very serious mischief. When it has become established, more or less of uneasiness and tenderness are felt in the abdomen, and under-pressure or sudden motion of the body, as that produced by coughing, some soreness is perceived to exist about the umbilicus. 
When it is primitive, or not the offspring of the acute form, it may, in no part of its course, give rise to pain, and in many instances we can discover no indications of its existence during life, except, perhaps, in a few cases we may find the appearance of some ascites ; but as we have stated, it is generally attended with some abdominal pain, but it is dull, and deep, and very rarely permanent, but some soreness will always be detected upon pressure. Vomiting is sometimes observed, and more or less abdominal distention, and even tympanitis. In some instances indurated spots can be detected, which under pressure are found to be sore. In some cases the appetite and the digestion 


810 
INFLAMMATORY FORMS OF DISEASE. 
continue pretty good ; in such cases it is possible that the peritoneum of the stomach is not so seriously affected as other portions of it. In other cases the nutritive function is greatly impaired, and emaciation, increasing distension of the abdomen, and increasing tenderness to pressure, irregularity of the bowels—exhibiting alternate diarrhea and constipation, and various symptoms common to dyspepsia, attend the general course of the disease. 
When we view the symptoms as a whole, and the modes of their manifestation—for they do not appear to have any order—we are compelled to pronounce them singularly obscure. The pulse frequently continues unchanged, unless it be in the evening, when it becomes quick, and the skin more than normally heated, but in some instances these symptoms are measurably absent. With such symptoms as we have endeavored to portray, the malady slowly advances with intermissions that may continue for months, till it terminates fatally, in acute enteritis, or peritonitis, or from exhaustion, a result of diarrhea. Frequently before the close of life, ascites supervenes. 
Diagnosis.—No rules, of a diagnostic character, can be drawn to guide the physician with reference to this disease, because each case requires a separate study. He must, therefore, rely upon his acquaintance with pathology, and practical acquaintance with disease. 
Prognosis.—This, in the general, must be considered unfavorable—a few cases are said to have been cured. 
Treatment.—In the chronic form of peritonitis, mild cathartics should be administered every two or three days, unless there be diarrhea, in which case astringents must be given. The irritating plaster should be applied intermittingly over the abdomen, keeping up a discharge each time of application, as long as the patient can bear it. If pain be present, a combination of one part of Sulphate of Quinia and two of Compound Powder of Ipecacuanha and Opium, may be administered every three or four hours, in doses of four or five grains. If the pain be not very severe, the powders may be given only at night. The patient 


811 
ACUTE HEPATITIS. 
should be kept still, and placed upon a nutritious but easily digestible diet. And if the case be complicated with a tuberculous diathesis, some of the preparations of iron will be found advantageous. The surface of the body should in this, as well as in the acute form, be frequently bathed with an alkaline wash. 
Genus XI.—Hepatitis. 
Inflammation may affect the substance of the liver, its investing peritoneal membrane, or both, or may involve the whole organ or only a part; and in each of these cases presents certain characteristic symptoms which may lead to a more or less accurate diagnosis. Hepatitis varies also greatly in its degree of violence and rapidity, being sometimes acute, sometimes chronic, and not unfrequently of intermediate grades; so that it is not always easy to classify its diversities in these respects correctly.— Wood. 
Under the two heads of Acute and Chronic, we shall endeavor to present all that is of practical importance concerning the whole subject. 
1. Acute Hepatitis. 
The symptoms of this form of disease, as they are generally described by practical writers, have not been sufficiently qualified to save the young physician from error; because no one symptom has yet been discovered which may not be absent, and all of them, individually, may result from other causes than hepatitis. In judging, therefore, of the presence of this inflammation, we must judge of the bearing which all the symptoms, which may be present, have upon the morbus under consideration. In the commencement, the symptoms indicative of this local inflammation, may differ in no essential respect, from those which may be said to be common to an inflammation of any portion of the digestive system. In the forming stage, it is, perhaps, impossible to say whether the patient is about contracting gastric or bilious fever, or hepatic inflammation. The pulse will have less of the typhoid character 


812 
INFLAMMATORY FORMS OF DISEASE. 
than is common to gastro-enteritis, the fever may run high, the tongue may be covered with a yellowish fur, the thirst may be urgent, and there may be a frequent vomiting of bilious matter. The condition of the bowels will depend very much upon the number and extent of the existing implications—they may be irregular, but most frequently constipated; and the urine is scanty and high-colofed, as in febrile affections generally. 
The local symptoms indicative of hepatitis, which claim the greatest reliance, are pain, soreness and tumefaction, and the first is greatly influenced by the particular location of the inflammation. When fixed upon the convex surface, the pain considerably resembles that of pleurisy—it is in the right hypochondrium, often violent, sometimes appearing as stitches, at other times it is associated with a burning sensation ; in some instances it is directed toward the sternum, and at others, toward the right scapular; in a few instances the right foot is impressed with a sense of numbness, and the right arm with one of tingling; deep inspirations increase the pain, and not unfrequently the patient is harrassed by a dry, short cough. 
When the disease is located in the concave side of the organ, the biliary derangement is much greater, the pain much less—the principal complaint is a sensation of pressure or stricture, and not unfrequently attended by a jaundiced discoloration of the eyes, skin, and urine. The gastric irritability frequently occasions much distressing vomiting; the ioeces are generally hard and of a whitish or gray color. It is most common to find the pain, heat, and tumefaction, in the right hypochondrium, or about the cartilages of the lower ribs, or possibly in the lumbar region. It has been frequently stated, that pain in the right shoulder is quite pathagnomonic of hepatitis in the acute form. We hold this to be a mistake—we are of opinion that this pain is more indicative of chronic and functional affections of the organ, than in the disease before us. The next symptom, in point of importance to the pain, is the tumefaction of the organ. When the abdominal muscles are flaccid, and 


813 
ACUTE HEPATITIS. 
the intestines are empty, there is but little difficulty in detecting the hepatic enlargement. Jaundice has been named as a symptom, but its occurrence is too rare to give it importance, and then, again, facts enough have not been accumulated to enable us to determine why it should be either present or absent in any case. When the peritoneal coat is involved, the pain is sharp, and usually much more severe than when the organ alone is the seat of the disease. We may add, also, that the pain of inspiration and the difficulty of breathing, are also much greater. Inflammatory fever attends both locations of the disease. 
Those who have a gouty or rheumatic organization, are frequently troubled with neuralgic pains in the region of the liver, and care must be observed that they are not mistaken for those of inflammation—in the event of the latter the other indications of acute hepatitis will constitute a safe guide. The attendant fever, in the advanced stage, sometimes takes on a typhoid character. Hepatitis, it is said, has been known to run its whole course, and terminate in suppuration, without any attending fever. To account for such a fact, we feel ourselves entirely unable, without supposing the existence of some organic defect in the nervous system. 
Hepatitis may terminate by resolution, suppuration, or pass into the chronic form. When we find the fever, the gastric symptoms, the pain, and tumefaction, to subside gradually, we may conclude that resolution is going on. But in the event it terminates by suppuration, the tumefaction increases, and the fever passes into the hectic type. This event is further indicated by shiverings, small and rapid pulse, pale countenance, and a sour smell of the surface. When an abscess has formed, the organ will be found to have increased in size ; a distinct tumefaction may be felt below the margin of the ribs ; a bulging of the false ribs; possibly a tumor may be felt in the epigastrium ; and lastly, the intercostal spaces will be found more full than natural. By adhesions, the contents of the abscess have been known to pass through the parieties of the abdomen— 


814 
INFLAMMATORY FORMS OF DISEASE. 
through the diaphragm, and into the lungs, and finally into the stomach; and further, the same case has been known to do all three, and yet recover. 
Causes.—It is quite a current opinion that malafia in hot climates is, probably, a very frequent cause—possibly, the most frequent. We do not feel that we are hazarding much in asserting that it never does any such thing. If the inhabitants of the south will live in the shade, and thereby avoid an exhaustion of the cutaneous tissue, they will not have acute hepatitis. This view of the subject has been explained by Dr. James Johnson, but Dr. Eberle calls it a " novel and a very plausible " view of it. Besides a long continued exposure to a high temperature, as a cause of hepatitis, we may add mechanical contusions, metastasis of gout or rheumatism, atmospheric vicissitudes, with fatiguing exercise—the drinking of cold water when the body is heated and exhausted—biliary concretion in the gall ducts, etc. 
Diagnosis.—Hepatitis, most frequently, may be distin guished from pleuritis, by the greater severity of the cough, and thoracic oppression in the latter. In hepatitis, the patient can rest better on the affected side, but in pleuritis, he can not; pressure on the intercostal spaces gives but little or no pain in hepatitis, but it produces much in pleuritis ; in pnlmonitis the difficulty of breathing and the pain are aggravated by resting on the affected side. In gastritis, all ingesta is commonly ejected as soon as taken, but in hepatitis, though vomiting is present, the stomach does not so promptly reject the ingesta. In gastritis, pressure on the epigastrium increases the pain, but in hepatitis, it is required to be made on the right hypochondrium. 
Prognosis.—In general this can not be regarded as unfavorable, more especially under a judicious course of treatment ; its most frequent fatality attends those who have for a long time been habitually intemperate in the use of ardent spirits. When the treatment has been inefficient, the recovery is apt to be exceedingly troublesome and protracted. 


815 
CHRONIC HEPATITIS. 
Treatment.—In this disease, the treatment may be commenced by the use of the spirit-vapor bath, for the purpose of equalizing the circulation, and thereby lessening the inflammation ; and during the period of perspiration, a cathartic must be administered, for the purpose of unloading the congested vessels of the liver, as well as for its revulsive action, for which the Compound Powder of Jalap may be used at first, and subsequently followed by laxative doses of Podophyllin and Leptandrin, which have an especial influence upon the liver, increasing its secretions, and thereby relieving the congested condition of the portal system. After the operation of the cathartic, and in some instances, even during the period in which perspiration is going on, a large mustard-poultice should be placed over the region of the liver, to be removed only when its full rubefacient effect has been obtained, and then the parts are to be covered by fomentations of bitter herbs, as hot as can be borne, and which should be changed often ; and these should be used until the pain and inflammation have subsided. The surface should be bathed as in other inflammatory diseases. 
For the purpose of allaying pain, calming any irritation which may be present, and producing a tendency toward the surface, the Compound Powder of Ipecacuanha and Opium may be given in four or five grain doses every three or four hours ; and toward the termination of the disease, should there be any prostration of strength, or evidences of suppuration, Sulphate of Quinia should be combined with it in quantities of half a grain or one grain to each dose. In other respects, both the treatment and diet will be similar to that given for acute gastritis, except in the latter stage, when suppuration is present, in which nutritious food, as soft boiled eggs, oysters, etc., should be given, and if there be much debility, stimulants, as wine, ale, etc. 
2. Chronic Hepatitis. 
The liver is liable to many lingering modifications of disease, and it has been common to speak of them under 


816 
INFLAMMATORY FORMS OF DISEASE. 
the appellation of chronic hepatitis, and among these maybe named atrophy, hypertrophy, induration, tubercle, and schirrhus. This is certainly an error, and yet it may be deemed a fair expression of the little that we know, certainly, of the organic condition of this organ, after it has existed, for a long time, in a state of chronic irritation. We know that it may have suffered, apparently, a very important lesion of structure without a corresponding one of function, and we know that the contrary does as frequently obtain. The most that we can do, then, is to give those symptoms which have been found associated with certain functional conditions of the organ; and even in this, we may so far mistake, as to implicate, more or less, some of its neighboring viscera. However all this may be, the malady of which we shall now treat, will generally be recognized by the history which has been obtained of it. 
When the disease has existed but for a short time, we have but to see the patient, to be satisfied that the functions of digestion, nutrition, and biliary secretion, have become deranged, and upon a closer investigation of the patient's condition, we expect to find our first impression confirmed, and accordingly we learn that he is troubled with flatulent colic, gastric acidity, a sense of fullness in the epigastrium, and occasional nausea and vomiting. He has, or he has not, felt any pain in the region of the liver, except under the influence of pressure. He has a sensation of stricture, and uneasiness in the right hypochondrium, and upon a personal examination there is found more or less of tumefaction in this region. His bowels are generally costive, but sometimes this condition of them alternates with diarrhea, and the discharges are scanty, slimy, fetid, greenish, dark-colored, or watery and muddy. The tongue is most generally white, and only moderately moist; the taste is bitter or disagreeable, and the urine is highly of a bilious tinge. The countenance is sallow or jaundiced ; the shoulders are elevated ; the body is wasted; the skin is harsh, dry, and constricted, and so much so, as to render it next to impossible to produce moisture upon it. Slight febrile 


CHRONIC HEPATITIS. 
817 
exacerbations, with a burning sensation in the soles of the feet and palms, take place towards evening. It is stated that in the advanced stages of this disease, the gums have a and a very unnatural firmness. 
It is confidently said that when the convex surface of the organ is the principal seat of the disease, the pain is re. ferred to the chest, and when located in the concave, it is referred to the stomach and bowels. 
The termination of this form of hepatitis is represented as being exceeding various, and that all of the known organic lesions of the liver have been known to occur in the midst of symptoms of this disease; and various are the circumstances under which death takes place in fatal cases, but in a majority of cases, it is effected through a disease of some other organ, as that of the peritoneum, small or large intestines, the brain, the lungs, etc. 
Causes.—In the south, acute hepatitis is mostly confined to dry and heated situations ; in this respect it appears to have some affinity with the remittent forms of fever; but this form, partaking more or less of the character of intermittent fever, occurs most generally in low and humid situations. The first originates in an exhausted condition of the skin, and the latter in a constriction of it. It sometimes arises directly from intermittent fever, intemperate use of ardent spirits. The acute form is more confined to the first class of constitutions, and the chronic to the third class, or those who would, in a northern climate, most probably die of phthisis. 
There is no part of this continent, nor, perhaps, of any other, where chronic hepatitis is so prevalent as in Mexico, and the obvious cause there, is the very extensive use of animal food. The same remark applies to our Anglo- Americans, in some of the southern States—particularly those who are not natives. It is also an extensive cause of mortality in the slave population. During the winter, when animal food would be the best for them, they have an abundance of vegetables, which are generally consumed by the first of June, and then they have to live measurably on 


818 
INFLAMMATORY FORMS OF DISEASE. 
bacon and bread, till vegetables are again produced, and by that time the fat bacon has produced a pretty extensive crop of disease.* 
Diagnosis.—In this disease the diagnosis is peculiarly difficult, if not impossible, and yet we think it scarcely possible for an experienced physician to mistake its pathognomy for that of any other. Indeed, with those who possess, naturally, a capacity for seizing and judging of pathognomy, it is of more worth than namable diagnostic symptoms. It is said to be frequently confounded with gastro-enteritis and chronic pleuritis. As we shall not attempt that which is considered so nearly impossible, as to define the diagnostic symptoms between this and those above named, we shall conclude our remarks upon it, by referring the reader to a patient study of the natural history of the diseases with which it has been confounded. 
Prognosis.—The prognosis of this affection can not be considered as favorable, when we consider its influence upon the prospects of recovery, both directly and indirectly. It can not be regarded as being frequently fatal of itself, but it generally induces some other form of disease that will terminate fatally. In fact, the usual subjects of it are not so endowed with vital force, as to render existence possible for a long time, or for the term of threescore years. 
Treatment. —In the chronic form of hepatitis, our usual course is to apply intermittingly an irritating plaster over the region of the liver, and administer internally the following compound: 
R. Compound Syrup of Stillingia, 3iv. Iodide of Potassuin, 3i. Tincture of Aconite, 3ij. Mix. 
*It is a very general opinion that the southern soil can not be cultivated by white labor. The writer's acquaintance with the south induces him to entertain a very different opinion. But he admits that it could not be done without a great waste of life, so long as the present unnatural modes of feeding and drinking continue. A large portion of the southern population are of the opinion that the climate renders the use of ardent spirits indispensable ; and yet physiology declares that there would be as much good sense in keeping up a coal fire in their parlors, when the temperature is at 100 deg. Fah., as in using ardent spirits under a similar circumstance. 


819 
SPLENITIS. 
Of this, a teaspoonful may be given three times a day, in a wine-glass of water, and the use of which should be continued for some time. In addition to this, the bowels should be acted upon once or twice daily, by a mixture composed of one part of Podophyllin, and four of Leptandrin, which should be given in sufficient doses, three times a day, to cause the desired effect; this combination exerts a most favorable influence upon the liver, and is surpassed by no other medicine in the Materia Medica. Powerful cathartic action in this complaint should always be avoided, the disease requires time for its removal, and no hurried, energetic measures will be able to effect any immediate tendency toward a cure. 
The patient should exercise moderately, but not to fatigue, and the diet should be nourishing and easy of digestion, avoiding alcoholic stimulants, tea, coffee, and fats. 
Where an abscess of the liver is forming, it should be facilitated by the application of emollient poultices. 
Errata.—In the K, on page 818, 3, in place of 3, of the Iodide of Potassum and Tinct. of Aconite should be used. 
Genus XII. —Splenitis. 
Inflammation of this viscus, in the acute form, is rather a rare affection, but in the chronic it occurs frequently in the low.and marshy districts of southern latitudes. Because of the fact that its function has not been determined, its morbid states have not been so thoroughly investigated as those of other viscera ; and yet when we contemplate the extraordinary provision that has been made for its circulation, the importance of its function should have been so far inferred, as to command a full share of professional investigation. The conviction of the writer, that it holds, in a great measure, the same relation to the vegetative system of nerves, that the brain and spinal marrow do to the animal, has induced him for many years to observe closely the influence of its morbid conditions upon the functions of the other abdominal viscera, and he feels quite confident 
52 


820 
INFLAMMATORY FORMS OF DISEASE. 
that if physicians generally will pursue for a few years the same course of observation, they will soon cease to entertain any doubt as to its paramount importance. 
1. Acute Splenitis. 
Acute splenitis is introduced to the attention of the patient, very much in the manner of the phlegmasia in general—beginning with a chilly sensation, which sometimes amounts to a rigor, with a feeling of pain, weight and fullness in the left hypochondrium, frequently extending to the left shoulder, and as in hepatitis and pleuritis, the pain is increased by pressure and a deep and full inspiration. The reaction brings with it thirst, more or less nausea, cough, and the usual symptoms of fever. When the peritoneal coat of this organ is implicated, the pain is more deeply acute ; and if with inflammation of the organ there be much congestion, rendering reaction difficult, the pain under the false ribs is deep, full, and obtuse, having at the same time a sense of weight and downward dragging. The left hypochondrium becomes, usually, more or less enlarged, the skin becomes dry, with the eyes more or less jaundiced, and the urine participates in the same peculiarity. The nausea is frequently attended with vertigo, and a very oppressive and burning sensation in the stomach, particularly when the head and shoulders are elevated in the bed. Sometimes the patient complains of darting pains directed from the left hypochondrium through the bowels, and at other times through the left shoulder; but the greatest pain is experienced upon any twisting motion of the body, as in an attempt to turn over. A horizontal posture on either side is uncomfortable, but particularly on the affected one. We are informed that in some instances no pain becomes manifest except when occasioned by pressure; in such cases there is a sense of weight and fullness; and in some cases even this is wanting, and then the only indications of existing inflammation are pain upon pressure, and an enlargement of the organ. These remarks may be true, but we are much disposed to refer them to the chronic form. Those 


ACUTE SPLENITIS. 
821 
who have had the acute disease, in its usual form, will not readily believe them. 
Acute splenitis is sometimes attended with a remittent or intermittent form of fever, but this may be only a complication. Through some tissue or functional dependence, the stomach may become implicated, in which case the nausea and vomiting become so violent sometimes as to constitute a spleno-gastritis. Palpitation of the heart, cough, dyspnoea, and hiccough, are sometimes present, occasioned, as the writer believes, by a dependence of all the organs of automatic life upon the spleen for power or nervous innervation. In harmony with this view, we may remark that, however well the liver may be performing its function at the time of the splenitic invasion, it generally suspends its function upon the occurrence of this event, and that too, without yielding a single symptom of hepatic disturbance, except the jaundiced condition of the eyes, skin, and urine, and the absence of bile in the faeces. 
In splenitis there is a sui generis feeling which no one acquainted with the anatomy of the abdominal viscera could, in his own person, mistake as to its source; but the physician attending upon another person, especially if that person be very ignorant, or a child, may readily make a mistake, because of the immediate neighborhoodship of many important organs, as of the left lobe of the liver, the pleura, the colon, and the stomach, but more especially if the organ should not be in its normal position. If any of these contiguous parts should participate in the inflammation, the diagnosis will be rendered still more difficult. 
Causes. —Splenitis, in its acute form, is occasioned by the same causes that produce acute hepatitis, and it occurs in the same variety of constitution. 
Diagnosis.—When the reader shall make himself well acquainted with the symptoms of splenitis, gastritis, hepatitis, and colorectitis, he will not find much difficulty, generally, in diagnosing this disease. 
Prognosis.—Under a proper and prompt treatment, splenitis may generally be caused to terminate by resolution ; 


822 
INFLAMMATORY FORMS OF DISEASE. 
but under neglect, a contrary treatment, or a broken-down constitution, a fatal result may be expected. Under such circumstances, violent cases may terminate fatally in from five to ten days, preceded by hiccough, tympanitis, diarrhea, delirium, and collapse. Sometimes it terminates in suppuration in the course of ten days, which is indicated by a diminution of the pain, or some marked alteration of it, by rigors, relaxation of the skin, and probably night-sweats. In this event the pus may be absorbed, or it may be discharged upon the peritoneum, and be absorbed,* or produce fatal peritonitis, or death may ensue before the pus is discharged, or, through the agency of adhesions, it may pass through the abdominal parietes, or into the stomach and bowels, and even into the lungs, and thus make its exit out of the body, and thus the patient may be restored to health. 
Treatment.—Acute splenitis is to be treated in all respects the same as acute hepatitis, substituting for the local applications, the region of the spleen for that of the liver. 
2. Chronic Splenitis. 
There is no form of disease which is, perhaps, better calculated to harass and finally to destroy life, than this— phthisis pulmonalis not excepted. Judging of it, as the writer has seen it, in marshy districts in the south, he would prefer the latter; and those who had it, if they migrated from the north, did not make a profitable speculation in exchanging their prospect of phthisis for that of chronic splenitis, for they were organized to die, either of a thoracic or an abdominal disease of an anemic character. It is as incurable as phthisis, and it is so from the same organic necessity—a want of vital force to maintain an equilibrium of the functions which are essential to a normal continuance of existence. 
It is sometimes difficult to decide upon the presence of chronic splenitis, until the enlargement of the organ declares 
* Pus may be absorbed by the peritoneum. See the report of a case of strangulation and amputation of a portion of the spleen, by the writer, American Journal of the Medical Sciences, Vol. I. 


823 
CHRONIC SPLENITIS. 
the fact for itself, -but it will, sooner or later, become apparent to every observer. But previous to any observable enlargement the patient will complain of weight, tension, or some other variety of uneasiness in the left hypochondrium; he furthermore discovers that when pressure is made on the part, he has a feeling of soreness, and when he turns over, he feels a hurting in the location of the organ. "When the disease has so far progressed as to give evidence of its enlargement, the patient, upon interrogation, will say that he has a "feeling of deadness throughout the contents of his abdomen." The writer found this to be the most pathognomonic symptom in the south. But when the disease has been produced by mechanical injury, this feeling of deadness is still more strongly expressed by the patient. When the organ has become considerably enlarged, its magnitude alone becomes a source of mischief, by its pressure upon or against its neighboring viscera, and in this wise, deranges their functions, as the stomach, lungs, heart, intestines, etc. This circumstance, to some extent, accounts for the attending indigestion, cough, dyspnoea, and palpitations. But the great disturbance of the hepatic and renal functions which attends this disease, can not be thus explained to the lull extent of their existence. In some instances these organs appear to exist in a state of paralysis. The skin, if not sallow, is of a dusky greenish color—that is, it is of a light dusky yellow, with barely a greenish tinge added to it. The bowels are irregular, but most frequently the fasces are soft and of a light yellow-clay color and appearance. In some cases, indeed in all cases at sometimes, there is a febrile tendency of the system ; wandering pains are sometimes complained of in the extremities, which not unfrequently terminate in collections of pus under the integuments. In the advanced stages of the disease, the debility and emaciation become very great, the complexion darkens, and the appetite fails. Hectic, diarrhea, or vomiting will, in the course of the disease, come on with unconquerable violence, discharging blood upwardly and downwardly; at some other period, aching pains will be complained of 


824 
INFLAMMATORY FORMS OF DISEASE. 
in almost every part of the body, with anxiety, vertigo, restlessness and sleeplessness. 
The reader is not to suppose that in every case he will find all the symptoms, and all the pain and discomfort, which we have described, nor must he conclude that he will find none which we have not named, for if he do, he will be disappointed, if his practice should be in the low countries of the south. 
The disease may exist for many years, becoming troublesome as often as the patient may take cold or have the ague, otherwise he will appear to suffer but little from it, unless an indisposition to do anything but lounge about, can be regarded as suffering. Thus, in some cases, it continues almost the length of an ordinary lifetime. But in many instances, this form of splenitis induces other forms of disease, which speedily prove fatal, as hemorrhage, diarrhea, dropsy, or the supervention of acute splenitis. 
The terminations of this form of disease are numerous ; it may terminate by resolution, but this is a rare event, particularly in the south, unless the patient leave the country; it also terminates by a softening of the organ, in which case it becomes a cyst, filled with a dark-colored sanies, by induration, when its substance becomes hard and resembles liver, or it may become brown and hard with cartilaginous coats ; in this state it has been called scirrhus; by ossification, for it has been seen ossified, and in one instance had a cancellated structure surrounded by an osseous shell, (Cy. Prac. Med.) by gangrene—this can only happen in the most feeble of constitutions; and by hypertrophy, in this case the spleen may so enlarge, as to weigh twenty or thirty pounds, and with it the patient may live as many years, and then die of some "other disease.— {Cy. Prac. Med.) 
There are several minor forms of disease which may become located in the spleen during its chronic continuance, as hydatides, tubercles, melanosis, calculous deposits, rupture, atrophy, etc. 
Causes. —Chronic splenitis occasionally succeeds to the acute, but this is very rarely the case. Its most common 


825 
NEPHRITIS. 
cause is long-continued intermittent fever. In feeble constitutions—the most feeble of those who have it—it might be caused by a residence in a humid atmosphere, keeping up a constant engorgement of the portal circle. 
Treatment. —In the chronic form of splenitis, we pursue the same treatment as laid down for chronic hepatitis, merely substituting the region of the spleen for that of the liver, where local measures are applied. 
Genus XIII.—Nephritis. 
Dr. Cullen defines nephritis to be " Pyrexia, pain in the region of the kidney, after following the course of the ureter ; frequent desire to pass urine, which is either limpid and colorless, or very red ; vomiting, numbness of the leg, retraction or pain of the testicle of the same side." 
When we come to treat of the diagnosis of this disease, it will be all-important to have this definition well impressed upon the memory, because a failure in this respect might not only prove humiliating to the physician, but absolutely injurious, if not fatal to the patient. 
Nephritis may, like many of the other phlegmasia, introduce itself by chilly sensations and flashes of heat, and the pyrexia may become established before any indication is given of local disease, as when occasioned by cold, or a repulsion of cutaneous action. Or its first announcement may be severe pain in either or both lumbar regions, as when occasioned by strains, urinary calculi, contusions, metastasis of rheumatism, or any other affection, or by irritating substances acting through the circulation, as cantharides, etc. The pain is remarkable for its severity, and being deep-seated, is very little influenced by external pressure, but it is by all sudden motions of £he body. It has been asserted that this affection is not always attended with pain, but this statement is certainly contrary to the general experience of the profession. 
It is stated in the definition, that pain often follows the course of the ureters, and to this we may add, that it has a darting motion, rather than one of quiet travel; at least, 


826 
INFLAMMATORY FORMS OF DISEASE. 
it is so in many instances. It may, also, be acute, or obtuse, sharp or burning, and it not unfrequently extends to the neck of the bladder, the scrotum, and even down the inside of the thigh, and in the latter position it is attended with a feeling of numbness. 
As in most of the phlegmasia, indeed, all of them, under favorable indications, the bowels are costive, the urine is high-colored, occasionally tinged with blood, and always scanty in quantity, almost absent sometimes, more particularly when both kidneys are inflamed ; and however small the quantity, its presence creates a desire to urinate; and hence the desire is nearly all the time present —the reverse being the fact in only a very few cases. Nausea and vomiting attend upon most cases, and colic pains are present in a few. The pulse is generally hard and frequent during the first three or four days, and then it becomes increased in frequency and reduced in volume, particularly during the periods of nausea and vomiting. The skin is generally very dry, and more than normally elevated in temperature. When the patient aims to rest or to be comfortable, he inclines his body to the inflamed side, or lies on it, or else on his back. 
Causes.—These are indicated in our opening remarks. 
Diagnosis.—There is a possibility of confounding nephritis with inflammation of the psoas muscle, lumbago, nephralgia, partial peritonitis, colic, and hysteria. 
When in the psoas muscles, there is neither nausea, a retraction of the testicle, nor alteration in tiie flow or quality of the urine; in lumbago the pain is more superficial and is increased in an attempt to rise from the sitting posture ; in nephralgia there is no inflammatory fever or indications ot inflammation; in peritonitis, it is true that inflammation and vomiting are present, but the urinary symptoms and peculiar course of the pain are wanting, to create a likeness between it and nephritis; in colic the pain is paroxysmal, and located about the umbilicus, and not in the loins; to distinguish nephritis from hysteria is not so easy as from the other affections above named—in hysteria there may be 


827 
NEPHRITIS. 
a vomiting of green matter and an absence of the urinarysymptoms ; beyond these, if further evidence is wanted, the history of the case may enable the physician to decide. 
Nephritis is a rapid disease, rarely continuing longer than the seventh day, when it may terminate in resolution, suppuration, very rarely in gangrene, and occasionally in induration. When a termination in resolution is about to take place, all the symptoms become more favorable; but if in suppuration, it will be indicated by chills and shiverings, a dull throbbing pain. When the abscess opens into the pelvis of the kidneys, the pus will be discharged with the urine, and this may be continued for months, or even years, and finally terminate in hectic and death, or it may only continue for a short time, and end in health. But we must not regard the presence of pus in urine as conclusive evidence of renal abscess, because calculous irritation sometimes occasions the secretion of pus. Renal abscess sometimes points externally, and by an incision it may be thus discharged ; but it too frequently happens that a fistulous opening is formed, and hectic finally follows. 
Prognosis.—This is always doubtful, until it is known that a termination by resolution has been effected. 
Treatment.—During the whole course of the disease the surface of the body must be bathed frequently with an alkaline wash, and the Compound Tincture of Virginia Snakeroot should be given to allay pain, soothe nervous irritability, and keep up a tendency to the surface. The patient should be kept quiet, and free from mental excitement. 
In the early stage of the disease, when the inflammation runs high, but little diet should be used—cold water, or infusion of simple herbs, flaxseed tea, barley-water, Gum Arabic water, etc., will be all-sufficient. On the decline of the disease, chicken or mutton broth, beef tea, calfs-foot jelly, etc., may be safely allowed. But if it assumes a chronic form, the treatment must be somewhat modified, according to circumstances. In long-standing and obstinate cases, more active counter-irritation to the lumbar region may be required, and we have frequently obtained the most grati- 


828 
INFLAMMATORY FORMS OF DISEASE. 
fying results from the intermittent application of an irritating plaster. The diet should be similar to that recommended in the preceding chronic inflammation of different organs. 
Genus XIV. —Cystitis— 
Inflammation of the Bladder. 
Although this inflammation is divided into two forms, the acute and chronic, yet it may exist in various degrees, from that which is attended with a slight secretion of mucus from the internal membrane, to that of such intensity as to terminate in gangrene. These several degrees of violence may intermingle or pass into each other by gradual advance, which, to be understood, they must be contemplated in close connection. 
1. Acute Cystitis. 
When a burning pain is found to obtain in the region of the urinary bladder, and at the terminus of the urethra, hypogastric tenderness, urgent and frequent calls to urinate, and in the exercise of the function the urine appears iu small quantities, and attended with painful spasms, the conclusion may be quite safely drawn, acute cystitis is present. When pressure is made above the pubis, it is common for the pain to be much increased, and upon examination, soreness will be discovered to exist in the perineum. It is not uncommon for stillicidium to be a constant and a very troublesome symptom, and the urine that is discharged, is of a deep-red color, and sometimes tinged with blood. The bowels are usually, as is common to the phlegmasia, constipated, and if the inflammation shall extend to the inferior extremity of the rectum, which is frequently the case, there will be some tenesmus. It is quite common for the patient to complain of such sensations about the preecordia, as to produce an expression of anxiety in the countenance, which is but seldom unattended with nausea and vomiting. The thirst is urgent, the skin is hot and dry, the pulse is full, hard, and frequent, and the patient is anxious and restless. 


ACUTE CYSTITIS. 
829 
This inflammation is usually introduced with chilly sensations, or even some shivering, and as it advances, pains appear to dart from the bladder to the anus, the loins, down the thighs, and even to the epigastrium. Sometimes there is a complete retention of the urine, and in such cases the bladder rises like an oval tumor above the pubis; and the soreness or tenderness, instead of being confined to the hypogastriurn, becomes diffused over the abdomen. Hiccough and a vomiting of bilious matter may now be expected, and then delirium, coma, convulsions, and death. 
A total retention of the urine but rarely becomes effected except when the inflammation is more especially located about the neck of the bladder, and in such cases the pain in the perineum becomes exceedingly severe. Or in the event there is not a complete retention of the urine, a dysuria or feelings of strangury become incessant and tormenting. When, under such circumstances, it becomes indispensable to introduce the catheter, it is attended with great difficulty and extreme pain. In the course of the disease, it is common for the urine to undergo several changes: at first it is red, or greatly so, as in other inflammations—it then becomes blended with coagulable lymph or blood. If the disease has been occasioned by cantharides, then the urine is especially bloody. In a still more advanced stage of the disease the urine becomes highly putrescent and ammoniacal, and resembles, more or less, the washings of putrid flesh. 
This inflammation may extend to the muscular tunic, and thence to the peritoneal. When the disease originated in an inflammation of some neighboring organ, as the uterus, or the rectum, its course will be of a reversed order—it will begin in the peritoneal and terminate in the mucous coat. Under no circumstances is it common for either of the tunics to be wholly inflamed at one time. When it shall happen to invade the mouths of the ureters, they become distended — make pressure upon the kidneys, and death speedily follows. 
Like inflammations in general, this may terminate by 


830 
INFLAMMATORY FORMS OF DISEASE. 
resolution, suppuration, or gangrene; or it may terminate in induration and a thickened condition of the cystic coats. When it closes its career by resolution, beside a general abatement of the symptoms, it presents, or is attended with a general and copious diaphoresis, and a copious and turbid secretion of urine. A termination by suppuration is not common, but when it does happen, chills or rigors supervene upon a subsidence of pain and fever, and speedily following will be the appearance of pus in the urine. If the abscess forms between the coats of the organ, it may point inwardly and discharge its pus into the bladder, or it may point outwardly and penetrate to the interior of the uterus, rectum, or vagina, etc. It is said to terminate frequently in gangrene, and this is the case in most of those instances in which the disease terminated fatally in six or seven days. This event is announced by a sudden cessation of pain, prostration of strength, cold extremities, and a clammy perspiration, and then hiccough becomes introduced to close the scene. 
Causes. —This affection may be occasioned by a painful retention of the urine; by mechanical violence upon the hypogastric region, by acid ingesta through the stomach, as turpentine, cantharides, etc., irritating injections into the bladder, violence in the use of the catheter, a suddenly-suppressed perspiration, metastasis of gout or rheumatism, gonorrhea, etc. 
Treatment.—The treatment recommended in acute nephritis is applicable to this; the local applications, however, are to be applied over the pubes instead of the lumbar region. 
2. Chronic Cystitis. 
This affection is sometimes described under the name of cystirrhsea—it is not an unfrequent affection. This form of cystitis, in many instances, seizes upon the patient without any premonitory indications, but more frequently its onset is so remarkably gradual, that the patient has no knowledge of the precise period of invasion. When treating of the acute form, we noticed the fact that the urine was some- 


831 
CHRONIC CYSTITIS. 
times loaded with mucus, it now becomes proper to observe that such an event more generally belongs to this form, and hence, the closing stage, in many instances, of the acute, is but the introduction of the chronic. It is this circumstance, the flow of mucus from the internal membrane of the organ, that has caused this chronic form of cystitis to be called catarrh of the bladder. It generally appears sporadically, but like catarrh, and other affections of the mucous membranes, it may prevail epidemically. It is generally attended by a slight febrile state of the system, or it may exist only in a simple irritation of the mucous membrane. 
The existence of this affection becomes known by frequent calls to urinate, with pain in the region of the bladder and at the extremity of the urethra. There is generally some tension of the hypogastrium, caused most probably by distention of the bladder or cystic irritation. Even in health, it is common for a slight mucous cloud to deposit from the urine, upon cooling, but in this disease the urine bears a large quantity of mucus, which, perhaps, has never an entirely normal color. Upon the cooling of the urine, the mucus subsides into a jelly-like mass, which tenaciously adheres to the bottom of the vessel. Most generally, as we have remarked, the mucus is suspended in the urine, but occasionally it appears unassociated with the urine, and in considerable quantities, and so thick sometimes as scarcely to be voided. In the advanced stage of the disease, this mucus inclines to yellow, and it may then become greenish, or finally streaked with blood. Should the inflammation run on to the formation of abscesses, the mucus will then be found mixed with pus. The quantity of the mucus is occasionally astonishingly great, amounting to several pints per diem. The urine is frequently much changed in characte —containing large quantities of the phosphates, which, by alkaline qualities secreted by the bladder, are precipitated in crystals, particularly the phosphate of magnesia and ammonia. When ulceration has taken place, hemorrhage from the bladder is not unfrequent. 
This disease, in its progress to a violent stage, may be- 


832 
INFLAMMATORY FORMS OF DISEASE. 
come extended to the surrounding parts, and all its symptoms may become greatly aggravated ; the mucus may be replaced by pus; the dysuria may become more distressing; emaciation may rapidly ensue, and a hectic condition of the system may, and most frequently does, supervene to close the scene. 
Causes.—The most usual causes of acute cystitis, in first class constitutions, produce the chronic in the third class; but there are many causes of it in feeble constitutions, which would never produce the acute in the strong; such as venereal indulgence—a residence in damp situations—sedentary habits. There are, furthermore, some persons who appear to possess an organic liability to it under slight exciting causes. 
Prognosis.—Under proper treatment, the prognosis may be regarded as favorable, except with those who are feeble, more especially, if they are particularly liable to it. But though not fatal, it may continue even many years, alternating with better or worse conditions of it. 
Treatment. —In the chronic form of cystitis, the internal treatment may be the same as named for chronic nephritis. But in connection with this, in cases where there is a mucous discharge, or a tendency to ulceration of the bladder, we use the following injection : 
R. Hydrastis Canadensis, 3j, 
Boiling Water, octj. Mix ; 
When cool, strain, and by means of a catheter inject onethird of the infusion into the bladder, and repeat it three times a day, and continue it daily until the symptoms have subsided. It may be proper to state here, that at first, the use of this injection will increase the discharge; and should it cause too much irritability of the organ, its use must be omitted for a few days, and then recommenced, using it at first but once a day. 
Genus XY.—Hysteritis. 
The uterus, in its unimpregnated state, is liable to inflammation, and although, as might be supposed, it is attended 


833 
ACUTE HYSTERITIS. 
with less danger than when it occurs in the gravid state, or shortly after parturition, yet it is attended with much pain and considerable danger. That inflammation of the uterus which is attended with puerperal convulsions, will not be considered in this place. 
1. Acute Hysteritis. 
In this affection, the inflammation is sometimes so slight as only to increase the normal secretion of the organ, but in other instances, as in inflammation of the mucous membrane of other organs, it runs on to suppuration. As in the phlegmasia in general, it is not unfrequently introduced by rigors which are followed by fever; but it does happen that pain, in the region of the uterus, is the first announcement that is had of the disease. The pain is fixed in the pelvis, and if the organ be much congested, it will be dull, aching, and increased by pressure, and attended by a sensation of weight or pressure toward the perineum. If the inflammation be located in the posterior part of the organ, with severe pain in the region of the sacrum, there will be tenesmus in efforts to stool. The pain will be felt in the iliac regions, to the hips, and down the inferior extremities even to the feet, when the affection extends to the lateral portions of the organ. If the affection be located anteriorly, there will be severe pain and difficulty in urinating, if not a complete retention of the urine. An examination of the pubic region will generally find the uterus enlarged, firm, and painful upon pressure, but the abdomen is very rarely swollen before an advanced stage of the disease. 
With reference to the condition of the bowels, in this affection, the general law as regards inflammations is not violated —the bowels are usually inactive and the urine is small in quantity and highly colored. In some instances, too, the patient is very irritable, which is manifested by nausea and vomiting, and the head is afflicted with pain. 
This affection progresses with more than common celerity, and hence, if a termination is not had in four or five days by resolution, suppuration and possibly gangrene may be 


834 
INFLAMMATORY FORMS OF DISEASE. 
apprehended. In the event of suppuration, the case may be regarded as dangerous, more particularly if the pus shall work its way between the peritoneum and the exterior of the uterus into the cellular tissue in the inferior portion of the pelvis. If the abscess shall point to the interior of the organ, expectations of recovery may be indulged. The pus may be discharged into the rectum or the bladder, through the interposition of adhesions, and still the patient may recover. 
Treatment.—This, like the preceding forms of disease, will yield to almost a similar treatment, as the vapor-bath, warm foot-bath, and warm fomentations over the region of the womb; these means, in most cases, we have found to be of more service than tepid or cold applications, and they should be continued with the other treatment referred to as long as the inflammation lasts. 
As constipation of the bowels is a frequent attendant upon this disease, it is very important and indispensably necessary to effect its removal before much can be done, so far as the administration of internal remedies is concerned ; hence, in such cases, we use stimulating enemas, which should be continued until a laxative condition of the bowels is produced—this is more important on account of the inflammation which, in most cases, extends to the rectum and bladder, and is increased to some extent when cathartics are used before enemas—after which the bowels should be kept in a relaxed condition by the use of Compound Powder of Jalap. If there be much febrile action or nervous irritability present, the Compound Powder of Ipecacuanha, in five-grain doses, should be given, and repeated sufficiently often to allay these conditions and favor diaphoresis. The patient, under all circumstances, should be confined to her bed. 
If there be a retention, or even scanty and high-colored urine, use the decoction of Althea Officinalis and Ulmus Fulvis, of which the patient should drink freely. If there be much gastric derangement, sinipisms should be applied over the stomach. In addition to the local applications 


CHRONIC HYSTERITIS. 
835 
directed to be made, we have often found much benefit from the use of the tepid hip-bath, which should be taken twice a day; however, we meet with some cases which will not bear any of the warm applications referred to, in consequence of producing a constant seusation of syncope, with much distress or difficulty of breathing, under which circumstances we would advise a similar use of cold water — that is, towels wrung out of cold water and applied in the same way as recommended for the warm fomentations. Use the cold sitz-bath and frequent injections of cold water into the vagina. 
If ulceration should occur, the Susqui. Carb. Potassa should be used as follows: 
B. Susq. Carb. Potassa, 3ii, Aqua, 3iv. Mix. 
This should be injected or thrown upon the ulcerated surface every day, increasing or diminishing the strength of the preparation according to circumstances. It will be well to alternate this with a decoction of Hydrastis Canadensis, two drachms to half a pint of water, which we have found sufficient for the cure of ordinary ulceration of the womb. 
2. Chronic Hysteritis. 
It is conceded that this inflammation is but little understood ; and, furthermore, it is regarded as not being easily controlled —indeed, it is so very local in many instances as to produce but little constitutional disturbance—so little that it happens sometimes the patient is irrecoverably lost, through the extent of the local mischief, before the inconvenience it occasioned made it appear necessary to do anything. 
Most generally the disease is seated about the neck or mouth of the organ; but it may, and in a few instances does, invade the entire organ—hence we can understand why the fact is, that the uterine secretion continues in very many cases of a purely normal character—its quantity only is increased; but in some cases pus is produced as in simk lar inflammations of other mucous membranes. Some pa- 
53 


836 
INFLAMMATORY FORMS OF DISEASE. 
tients complain only of a sensation of heat and some soreness in the inferior portion of the pelvis ; others have dull or lancinating pains, with occasional intermissions and exacerbations, and a few complain of a sensation of weight and occasional pains in the superior part of the vagina, which are much increased during the venereal embrace. The os uteri is usually diverted from its normal position and peculiarly tender to the touch, at least some portion of it. A leucorrheal discharge is a very general attendant upon this disease, and it becomes white or purulent as frequently as the inflammation shall become aggravated. In cases of long standing there is apt to be considerable swelling of the cervix uteri. In a few instances it forms a large tumor, which is embraced by the vagina. Pain in the back and loins, and a variety of dyspeptic symptoms are common attendants upon this chronic form of inflammation. 
When a physician is called to treat leucorrhea, and the patient complains of heat, pain, or weight in the superior portion of the vagina, he would do well to suspect the existence of inflammation about the os or cervix uteri, and to institute an examination per vaginum. 
As may have been inferred from our opening remarks, this affection may continue for years to harass the patient without effecting any serious lesion of the organ ; but, on the other hand, the result of it may be scirrhous and ultimately cancerous ulceration. 
In those females who menstruate with pain, there is apt to be inflammation enough during the intervals of the monthly periods to produce a deciduous membrane, which is expelled during those periods, either as a closed sack filled with a fluid, or in the form of flakes, which have been known to be as large as the finger nail. 
During the menstrual intervals there is usually, in such cases, considerable uneasiness in the region of the uterus. Such women are said to be barren. It is supposed by some that the pain in menstruation, when severe, is occasioned by the presence of, or the obstruction which, this membrane creates. 


837 
CHRONIC HYSTER1TIS. 
For the pain attendant upon this form of the disease, Prof. Dewees recommends the following prescription: 
R. Gum Camphor, 9i, 
Spir. Vin. Rectif., q. s., Fiat Pulvis, add, 
Pulv. G. Arab., 3i, 
Sacch. Alb., q. s., 
Aqua Cinnam. Simpl., 3i. Mix. 
When the patient experiences the pain, one-half of this draught is to be administered, and unless relief should supervene in one or two hours, the other half should be given. After a trial of many agents, he found nothing to succeed so well as Camphor, but in some cases more will be required than above prescribed. 
1\ may be stated, as a general rule, that the digestive functions are deranged, the appetite is variable and uncertain, the bowels are inactive, the urine is discharged with pain, the anus is retracted, and menstruation disturbed. 
Causes.—Among the causes, difficult or instrumental labors, excessive venereal indulgence, metastasis of erysipelas, and suppressed menstruation have been cited. 
Treatment.—In the treatment of this form of disease, it is necessary to regulate the gastric derangement with the means heretofore recommended. As most cases of this disease are accompanied with, or produced by, a retention of the menstrual discharge, we advise the use of emenagogues, and perhaps the Materia Medica does not afford another agent of so great a value as Macrotin ; this should be given in doses of from three to four grains three times a day increasing or diminishing the dose so as to produce its specific constitutional effect, which consists of aching in the joints, dull, full heaviness of the head, accompanied with more or less dizziness. 
The foregoing treatment should be continued, in connection with the warm hip-bath, until the suspended function of the womb is restored. 
The patient should at all times be careful to avoid active exercise, and constantly wear a properly-adjusted abdominal supporter. 


838 
INFLAMMATORY FORMS OF DISEASE. 
Genus XYI. —Rheumatism. 
DuDglison's Dictionary defines this to be, "A kind of shifting phlegmasia, sometimes seated in the muscles, sometimes in parts surrounding the joints, and at others within them." We cannot adopt this definition—our observation has forced us to the conclusion that the obstruction is of a general character — that the matter producing the obstruction (a result of some defective or suspended depuration) has only the power to injure certain tissues, as the fibrous, and that the local invasions, which constitute the preceding definition, are mere results of the disease or constitutional disturbance. 
Upon this subject, Dr. Jas. Bird (Braithwaite's Retrospect) says: " Though rheumatism appears with all the phenomena of (the phlegmasia), its local inflammation still possesses a specific character more symptomatic than idiopathic in nature, and manifesting in progress that the symptoms proceed from a particular constitutional taint, which gives to them a character distinct from simple inflammation. He further adds : "Rheumatic inflammation, differs from simple inflammation, inasmuch as it proceeds from a specific cause and is associated with greater abnormal sensibility of the nerves." 
What proof have we that the proximate cause of all other forms of disease is not as specific as that of rheumatism ? What proof have we that the " greater sensibility of the nerves" is not referable to some constitutional peculiarity, rather than to any specifically morbid one ? In what does the " constitutional taint," in this form of disease, consist ? But, to our author again : 
" Regarding the origin of the rheumatic diathesis, rheumatism is considered as the result of that pre-existing lesion of the assimilating and excretory organs of the body, which, on the application of cold, errors of diet, intoxication, malaria, and like exciting causes, gives rise to that abnormal change of the blood which constitutes the rheumatic diathesis." 


ACUTE RHEUMATISM. 
839 
If our readers can obtain an idea from this sentence that is not applicable to every other form of disease, they will accomplish more than we can. We hold that the language here used is applicable to all forms of disease, and absolutely fails to explain anything, with reference to any one, and yet, in the abstract, it may constitute a truism. 
M. Andral, says Dr. Barlow (Oyc. Prac. Med.), maintains that the cause of rheumatism is in the blood, and that this cause consists of an excess of fibrin or sanguineous plethora. With reference to this opinion, we have to say, that if such a plethora exists, then it is really the disease, and the subsequent manifestations only indicate that the system is struggling to remove or remedy the evil. To assert that the disease has its cause in the blood, is only removing the difficulty one step further off. 
But there exists another difficulty, which the admission of this doctrine can not enable us to answer. It is this: all constitutions are liable to plethora, but all are not liable to rheumatism. This objection is answered by the introduction of a " constitutional taint" in favor of, or disposing to, rheumatism. Very good; but in what does this " taint" consist? If nothing is known to indicate its existence, then it is a mere assumption—an unmeaning abstraction. 
Having exposed how little is known about rheumatic constitutions, we proceed to the consideration of the subject, and will begin by dividing it into two entirely distinct varieties —the acute and the chronic. 
1. Acute Rheumatism. 
This form or variety of rheumatism is confined to those who possess a pretty nearly-balanced or equal development of the medulla oblongata and the lateral portions the cerebellum (the organs of muscular motion and animal sensibility), and both in a high degree—so much so as to occasion a large neck, one that is particularly full and broad posteriorly. This organization is slightly liable to obesity under favorable circumstances, but it is always stout and 


840 
INFLAMMATORY FORMS OF DISEASE. 
muscular. The subjects of gout, pericarditis, inflammatory fever, and epilepsy, in their idiopathic forms, are very much of the same organization. We do not know anything about a rheumatic diathesis —but the above is a description of a rheumatic organization. The most vigorous portion of life is the general period of liability ; and as it is inseparably associated with a vigorous muscular system, and high animal sensibility, it follows that females are but little liable to it. 
Dr. Barlow regards the description given of this form of disease, by Sydenham, to be the most accurate he has seen, and therefore he adopts it. If this be true, we can not do better than to do the same. 
" This disease happens at any time, but especially in autumn, and chiefly affects such as are in the prime of life. It is generally occasioned by exposing the body to the cold air after having heated it by violent exercise or some other way. It begins with chilliness and shivering, which are soon succeeded by heat, restlessness, and thirst, and the other concomitants of fever. In a day or two, and sometimes sooner, there arises an acute pain in some one or other of the limbs, especially in the wrists, shoulders, knees, which, shifting between whiles, affects these parts alternately, leaving a redness and swelling in the part last affected. In the beginning of the illness, the fever and the above-mentioned symptoms do sometimes come together, but the fever goes off, generally, while the pain continues, and sometimes increases." 
Professor Wood says: " Very soon after the local seizure, rigors and symptoms of commencing fever are experienced, followed by increased frequency of the pulse, heat of the skin, furred tongue, anorexia, thirst, and occasional headache." We do not esteem these remarks to be exactly accurate, for, in a majority of instances, the constitutional disturbance precedes the local determination. He regards rheumatism as a constitutional disease, and if this be the fact, then its announcement should be by constitutional symptoms, and not local ones. With reference to the 


ACUTE RHEUMATISM. 
841 
general symptoms, it should be observed, that the pulse, though never remarkable for frequency, is always full and strong ; the respiratory function, in the simple form of the disease, is never greatly disturbed ; the temperature of the skin, very rarely, perhaps never, becomes as much elevated as is common to most fevers, but it is more frequently moist, often amounting to a copious perspiration, which is attended with that sour and offensive smell that may be frequently observed in intermittent fever, but it does not reduce either the inflammation or the paini 
As is common to the phlegmasia, the bowels are constipated, and the urine i& scanty and high colored. The tongue is covered, generally, with a moist and whitish fur, but nausea and vomiting are only occasionally present. Cerebral suffering is very rarely present, but occasionally it amounts to delirium. The fever is generally of the remitting character, and most frequently runs its course without invading, in an essential manner, either of the splanchnic cavities. 
In some instances, although they are rare, the local affection precedes the constitutional, and in such cases the latter appears to be symptomatic of the former, and thus the general conclusion, as regards this form of disease, is reversed. The parts locally affected are swollen, red, and very painful—the least motion of the part produces the excruciating pain. Through the day the patient may acquire some rest, by keeping himself still, but such are the nocturnal exacerbations, that there is no rest for him—at most, but little. 
This form of fever, like all others, is liable to become complicated with other forms of disease, or to awaken a liability to some other form, as in the case of bilious rheumatism. In this case, the previously-acting causes have produced a liability to hepatic or gastric derangement, and possibly both, which, by the rheumatic invasion, is developed into action. The various important organs of the body are liable to become implicated by metastasis or extension. Endocarditis and pericarditis are, perhaps, the most frequent results which happen of this character. While treating rheu- 


842 
INFLAMMATORY FORMS OF DISEASE. 
matism, the physician should have this possible event constantly before his mind. 
The duration of this disease is very variable, but under a prompt and judicious treatment, it should not continue longer than two weeks, though it often continues for two or three months. In 6uch cases it consists of a succession of local attacks, each of which runs a similar course; consequently, during such a period, scarcely a single important articulation will escape. It invariably leaves the invaded articulations more feeble and stiff, which generally continues for a long time after the disease has been conquered. 
Causes.—The remote cause is to be sought in the organization, upon which we commented in the outset. We may here add, that in acute rheumatic subjects, there is a high endowment of the cerebello-spinal and ganglionic systems — < the dynamic and active forces both exist in high degree. Professor Wood, after speaking of cold as the most frequent exciting cause, adds: " But something more is requisite than cold. There must also be a peculiar state of the system predisposing to this form of disease. There must be a rheumatic diathesis. In what this diathesis consists, has not been discovered. There are no signs by which its existence can be detected with an approach to certainty." Whatever our readers may think of our opinions on this subject, it is certain that they can not charge us with being more ignorant than our brethren. We admit that cold is the most frequent exciting cause, and so it is of phthisis, chronic rheumatism, and of many other forms of disease, but not in similar organizations. The same exciting cause, in our opinion, may develop phthisis in one, acute rheumatism in a second, chronic rheumatism in a third, and pericarditis in a fourth ; and we are far from being sure that all of these forms of disease may not, like the presence of adeps, become spontaneously developed. Between fat, fibrin, and tubercle, there is sufficient analogy to justify the inference. 
Diagnosis.—It is next to impossible to confound acute rheumatism with any other form of disease except the gout, 


843 
ACUTE RHEUMATISM. 
and in well-marked cases there need to be no difficulty in this case; but it is true, that cases are sometimes seen in which it is very nearly impossible to diagnose them. Gout is most generally associated with digestive derangement, and confined to the small joints—in neither respect is this the case with rheumatism. Gout is furthermore, more paroxysmal, periodic, and remittent, and attended by a more severe pain, a greater redness and tumefaction of the part. 
Prognosis.—So long as rheumatism maintains its simple form, its prognosis must be regarded as favorable; but when it implicates the brain or the heart, it becomes associated with danger. It usually terminates favorably by resolution, yet in a few instances, where the constitution is more remarkable for its active than its dynamic forces, it terminates in suppuration, forming abscesses in the intermuscular tissues. 
Treatment.—Perhaps there is no disease or condition of the system which more clearly indicates the use of the spirit vapor-bath, than the one under consideration, and which should be employed on the first appearance of the disease; and here let me impress upon the mind of the practitioner the necessity for prompt action in this matter. The patient should be advised to inhale the vapor as it rises under the blanket, until free and copious perspiration is produced, and in fact, until complete relaxation of the system takes place, which will be manifested by difficulty of breathing, or a sensation of syncope. At this stage of the treatment, provided the above conditions have been produced, the covering may be removed from the head of the patient, who may be allowed to inhale the natural atmosphere. If the symptoms of relaxation should then pass off, without having to place him in a recumbent position, the vapor-bath may be continued for at least half an hour longer. The patient should be subjected to this kind of treatment twice a day so long as the disease continues; and if this is carried out according to the above directions, and the patient is made to perspire as freely as possible, by the 


844 
INFLAMMATORY FORMS OF DISEASE. 
treatment, continued until the above relaxing effects are produced, all constriction of the system is removed, and the disease is thrown off by establishing a healthy depuration. 
The above treatment will, in most cases, remove the disease in from two to five days, especially when adopted in its early stage. If there be much pain and irritability of the nervous system, it will be necessary to make use of anodynes and antiperiodics, as follows : 
R. Sulphate of Quinine, 
Com. Pow. Ipecac, and Opium, da grs. xx. Mix, and divide into five powders, one of which should be given every three, four, or five hours, increasing or diminishing the quantity or dose according to the circumstances of the case ; and, as a general thing, they should be used until the febrile symptoms are removed. 
We regard venesection or active purgation unnecessary; but, inasmuch as we frequently find more or less gastric derangement, accompanied with hepatic torpor, we would advise the use of the Podophyllin, Leptandrin, and Caulophyllin, in alterative doses, and so soon as the bowels become in a relaxed condition, their use should be discontinued. 
As regards local measures, we think all that is necessary in this disease, is to make use of flannel bandages, as well as to dress the patient with flannel, and keep him in bed. We do not believe that the various liniments and cataplasms recommended, are of much use ; but where the disease assumes rather a sub-acute form, even the hot-bath will be found very useful; yet we doubt whether its utility is so great as the vapor-bath. In this form of the disease, it may require more anodynes and diaphoretics, than in the more active form, as the Conium Maculatum, Macrotin, Aconite, Belladonna, etc. 
Upon examination, if there be found much tenderness of any part of the spinal column, it will be well to make use of active stimulating liniments ; if this be not sufficient to remove the tenderness, it may be well to produce pustulation with Croton Oil. Should there be any symptoms of a 


CHRONIC RHEUMATISM. 
845 
metastasis to the heart or lungs, active means should be used to prevent it, such as immersing the feet and hands in hot water, and vesication over the part originally affected, with Aqua Ammonia, Turpentine, or Granville's Lotion, with the free use of Quinine and diaphoretic powders. If the patient desires acid drinks, such as lemonade, etc., he should be indulged. The diet should be generous, avoiding all exercise and exposures to sudden changes of the atmosphere, until the disease is entirely removed. 
2. Chronic Rheumatism. 
The subjects of this form of rheumatism have lean and dense muscles — their necks are rather small, and posteriorly narrow or thin—muscular motion and animal sensibility being more feeble—forming, with the subject of the acute form, a bold contrast. They most frequently consist of the sanguine-bilious and the sanguine encephalo-bilious constitutions. In fine, their dynamic force is much greater than their active. According to our organic distinction between those who are liable to the two forms respectively, it would follow that neither of the organic conditions could have both forms of the disease. Upon this point we are pleased to find our opinion sustained by that of Professor Dunglison. 
He says (Cy. Prac. Med.): " The chronic form of rheumatism is often described as being frequently the sequel to the acute. This does not accord, however, with the experience of the writer. So far as his observation has gone, the subjects of acute rheumatism rarely suffer from the chronic form," (we think never, when the character is decided), " and on the other hand, persons who are constantly more or less crippled by chronic rheumatism, may pass through life without suffering from the acute." 
Dr. Barlow (same reference), treating of this disease, says that, "It is a prevailing impression that a chronic disease can not be inflammatory. How this originated, it is needless to conjecture ; but, however the misconception arose, it is a familiar truth, that the term chronic conveys 


846 
INFLAMMATORY FORMS OF DISEASE. 
to most minds, not the simple idea of duration, which alone it expresses, but something the opposite of inflammatory." We admit this to be the fact, and certainly we can not be surprised that such is the case, since no reason has been assigned why the two different forms should exist upon any other principle. What reason can Professor Dunglison, or any one else give why a patient may have the chronic form, and attended, too, with inflammation, yet never have the acute ? No pathologist can well reflect upon the organic difference that attends between the acute and the chronic forms respectively, and not perceive their rationale. In the first, the greatly-active forces will cast off or eliminate the proximate cause or obstruction ; while in the second, under a strong dynamic influence, the active forces are too feeble to effect, entirely, such an elimination. It should not be overlooked, furthermore, that as these forces are both comparatively strong or feeble, as they approach in strength or recede, so must the manifestations of the morbid actions become diversified ; consequently no description of the affection can be given that shall equally apply to all cases. To obviate this difficulty, two other forms have, by some, been added to the rheumatic catalogue, as the sub-acute and the nervous. But, holding it to be true, that the physician who clearly understands the nature of the disease in its acute and chronic forms, will be able to contend with all the intermediate and modified forms, we deem it to be unnecessary for us to attempt to treat of them. 
This form of the disease, like the preceding, is attended by more or less of fever, which gradually reduces the resisting power of the constitution, and with pain and swelling of the invaded tissues or articulations; and as the affection advances, the febrile symptoms become so far obliterated, as to appear only toward evening and during the night, and then they may simply consist of quickness, tension, and contraction of the pulse, and the affected parts may either cease to be red or swollen. During this period of establishment, the pain may be greatly migratory, invading in succession almost every muscle or articulation in the sys- 


847 
CHRONIC RHEUMATISM. 
tern; but at length it becomes seated in some particular part. 
The preceding symptoms may be repeated, in part or in whole, as frequently as the liability shall be excited into action by fresh exposure to cold, watching, fatigue, or any other cause that can derange the secretions. 
Cullen says: " The limits between the acute and chronic rheumatism are not always exactly marked." This we admit to be the fact, in all cases where the active forces are such as to admit of a low grade of the acute form, or a high one of the chronic ; and, in such cases, to mistake the one for the other, can do no mischief. He continues: " When the pains are still ready to shift their place—when they are especially severe in the night time—when, at the same time, they are attended with some degree of pyrexia, and with some swelling, and especially with some redness of the joints, the disease is to be considered as still partaking the nature of acute rheumatism. But when there is no degree of pyrexia remaining—when the pained joints are without redness, when they are cold and stiff—when they can not easily be made to sweat, or when, while a free and warm sweat is brought out on the rest of the body, it is only clammy and cold on the joints—and when, especially, the pains of these joints are increased by cold and relieved by heat applied to them, the case is to be considered as that of purely chronic rheumatism." 
The preceding extract sustains the remark of Dr. Barlow, that the opinion is prevalent, that the chronicity of a disease is incompatible with inflammation ; and the opinion betrays an utter ignorance of the constitutional diversity of power to manifest the presence of disease. That condition of the system which Cullen regards as chronic rheumatism, we regard as local disorganization—a mere sequela? of rheumatism, as opthalmia may be of small-pox. If rheumatism be a constitutional disease, it must be conceded that in the absence of every constitutional symptom, there must also be an absence of the disease. It is important to distinguish between a result of rheumatism, and rheuma- 


848 
INFLAMMATORY FORMS OF DISEASE. 
tism itself, because the former will require, perhaps, onlylocal treatment, while the latter must be combatted with that which addresses constitutional. 
"We have neither time nor space to review many of the opinions which have been advanced concerning the pathology of this disease. Those who desire further information, may consult Eberle, Wood, and particularly the Cyclopedia of Practical Medicine. To talk about predisposition, diathesis, relative plethora, etc., avails nothing, because there are no visible signs by which such conditions can be recognized ; but if it be true that pathological differences depend upon the anatomical, then something of real value is gained, because they can be so described as to be perceived, the desired desiderata become tangible and comprehensible, and this service to the profession we have endeavored to render. 
Causes.—Beside exposure to cold, or, which is worse, a cold, damp air, there are many other causes, and some of them impart a specific name to the disease, as the mercureal and syphilitic ; but no matter what may be the cause, the disease is confined to that organic condition which we have described. 
Diagnosis.—Gout is the only form of disease with which this can be confounded, and under that head the diagnosis will be treated of. 
Prognosis.—This disease, in its simple form, is, perhaps, never fatal, but it disqualifies the patient for the enjoyment of life, either by the pain it inflicts, or the crippled condition of the extremities which it produces. At the Hot Springs, of Arkansas, the writer has witnessed almost every possible variety of rheumatic decrepitude and deformity ; and while a majority of them are either benefitted or entirely cured by the vapor-bathing in these springs, there is one which we have never known to yield, and it is that which is produced by the external use of sulphur. We suppose this to partake of the nature of chronic rheumatism, because we have always observed it to be associated with the same organic conditions. 


849 
CHRONIC RHEUMATISM. 
Treatment.* —In this, like the other form of the disease, the affected parts should he bandaged with flannel. The Tincture of Aster iEstivus in doses of one-half drachm, may be given every three or four hours, and during the absence of constitutional symptoms, the part affected may be frequently bathed with the same tincture. We would also recommend the following as an alterative and stimulant: 
K. Compound Syrup Stillingia, 3ii, 
Syrup Ginger, 3iiij, 
Iodide Potassa, 3ii. Mix. 
Of this, give a tablespoonful from every three to five hours, unless it should produce nausea or severe pain in the head,' when the quantity should be lessened or proportioned to suit the circumstances of the case. We have found, in this disease, that the Iodide of Potassium, either alone, or in the above combination, will produce a powerful effect, and in many cases arrest it at once. It may also be used in the same way in the acute stages. 
The frequent use of the vapor-bath and alkaline wash, should not be neglected, but should be used daily throughout the disease. The diet should be generous, and the bowels kept in a relaxed condition. If the disease should become located, and produce much enlargement of the joints, it may be necessary to use the warm fomentations and irritating plaster. 
* The advantage of the Hot Springs, of Arkansas, in the treatment of chronic rheumatism, depends upon their convenience, the patient's hope or expectation of being cured by them, the influence upon him of society, and that of traveling to get to them, rather than upon any intrinsic quality of the water, which contains rather more than a large quantity of the bicarbonate of lime. While bathing in the vapor, the hot water is drank, and consequently this bicarbonate of lime may exert some medicinal effect. Certain it is, very many are permanently relieved by them—even those who had been compelled to use crutches, in walking, for many years. 
The observation and experience of the writer have induced him to believe that, with the use of proper relaxents, vapor-bathing is the best possible remedy in both forms of the disease. As remedial agents, he has no confidence in local applications during the presence of constitutional symptoms. 


850 
INFLAMMATORY FORMS OF DISEASE. 
Genus XVII.—Arthritis— 
Gout. 
u Gout," says Dunglison's Dictionary, " is an inflammation of the fibrous and ligamentous parts of the joints;" and Dr. Eberle says, that it is a " constitutional affection, depending upon a peculiar diathesis, and manifesting itself in its regular form by external local inflammation of the fibrous structures, and fever of the synochal grade." The first of these definitions is well calculated to mislead the student, by causing him to regard the affection as a local one; and the second is exceedingly faulty, and yet perhaps it is as good as can be at present framed. 
Dr. Barlow regards a plethoric condition of the blood— that is, blood which contains, either absolutely or relatively, too much fibrin, as in the case of rheumatism, to be the cause. If such a state of the blood absolutely exists, then this condition of it is the disease, which was remotely caused by the arthritic " diathesis," and the exciting was that which impaired some important depuration. The fever indicates that the system is making an effort to eliminate the obstruction, and the local affection, instead of being the disease, is merely its crisis ; and, as such, no local remedy should be used to either mitigate or abridge its violence. The physician who visits this form of disease, with these views thoroughly impressed upon his mind, will not make a blunder in its treatment. 
Between the organic conditions which are essential to the existence of rheumatism, and those which are in like manner related to the gout, there is but a shade of difference. Having seen but little of gout, and having been compelled to rely much upon the history and description of this form of disease which others have given, we can not be so confident of the accuracy of the opinions we shall express concerning it. But with even these limited means of acquiring knowledge of the subject, we do not expect to betray more ignorance of its true nature than our predecessors have done. 


ARTHRITIS. 
851 
The distinction we are disposed to draw between the rheumatic and the arthritic organizations, with reference to their acute forms, is this: in the latter the active forces much more considerably preponderate over the dynamic, and this may have been occasioned by a greater indulgence in idleness and luxury. In the chronic forms of these affections, the active forces in that of gout descend much below the dynamic, and it is feeble when compared with the chronic condition of the rheumatic. 
By way of objection, we may be told, that many persons have gout who are industrious in their habits and temperate in their modes of living. "We cheerfully grant all this. We are again told, by every writer, that gout is hereditary. To this doctrine, it is known, that we object, and in lieu of it contend for the entailment of organic conditions, with which are associated organic liabilities to certain forms of morbid action under certain circumstances. Now, let it be remembered, while treating of arthritis, and indeed of all other forms of disease, that organic form and magnitude are not alone transmitted, but also organic modes of action. 
For the purpose of securing a full comprehension of this principle, it may be well for us to present a few illustrations. Those who know anything of Bembrant Peal's family, must know that every one of his descendants have an inclination and a talent for painting. It is also well known among the growers of horses, that the colts of pacing horses, if they resemble in anywise their sires, are more disposed to pace than to trot. Finally, it is well known to hunters of the bear, that the pups of an old bear dog trail the bear spontaneously, and yet can scarcely be taught to trail any other animal. It can not be objected that this law applies only to mental or muscular action, because the facts in cases of phthisis, and other forms of disease which are said to be hereditary, prove the contrary. 
The preceding facts and reasoning must render it obvious, that a man may be seized with gout, because of a transmitted or entailed mode of action of his system under such exciting causes as would produce, under other cir- 
54 


852 
INFLAMMATORY FORMS OF DISEASE. 
cumstances, some other form belonging to the same family of disease; and we are disposed to regard phrenitis, pulmonitis, pleuritil, pericarditis, rheumatism, gout, and cancer as belonging to the same organic family—and yet we consider them to be distinct forms, because of distinct modifications of the dynamic and active forces. 
We shall treat of arthritis, as we have of rheumatism, under two forms, the acute and chronic, although nosologists have divided it into many more varieties—as regular and irregular, tonic and atonic, misplaced and retrocedent. Much has been written upon this subject — theory after theory, to an incalculable number, has been announced and denounced, and, therefore, in the little we have said about it, we entertain no fear of a worse reception than has been awarded to our predecessors. 
1. Acute Arthritis. 
This is a paroxysmal form of disease, which, like fever and ague, allows the patient to feel comparatively well during the paroxysmal intervals. We stated that the affection of the joints, though defined to be the joints, is nothing less nor more than the crisis, yet this crisis is an immense evil to old age, when the strength is so wasted and the limbs so weakened that locomotion is nearly lost; it is also a heavy tax to pay for sensual indulgence, more especially when it is imposed upon us as an inheritance. 
A paroxysm of the gout is generally preceded by indigestion, drowsiness, wind, a slight headache, sickness, and sometimes vomiting. The patient complains of weariness and dejection of spirits, and has often a pain in the limbs, with a sensation as if wind or cold water was passing down the thigh. The appetite is remarkably keen a day or two before the fit, and there is a slight pain in passing urine, and sometimes an involuntary shedding of tears. It frequently happens, that as the paroxysm approaches these symptoms become more violent. 
When the attack is of the regular character, it is most apt to appear in the spring or beginning of winter, and at 


ACUTE ARTHRITIS. 
853 
some two or three o'clock in the morning. It begins by the location of a severe pain in the great toe, the heel, the ankle, or calf of the leg, but the first position is generally the one selected. This pain is associated with a sensation as if cold water was poured upon the part, which is succeeded by shivering, with some degree of fever. The pain then increases, and fixing itself among the small bones of the foot, the patient feels all the different kinds of torture, as if the parts were stretched, burnt, squeezed, gnawed, twisted, or torn in pieces. 
The severity of the pain causes the patient to be exceedingly restless, the pulse becomes full, hard, and frequent, and the skin dry and hot. These symptoms may continue with unabated violence twenty-one or two hours, when they will begin to decline, and finally terminate in a profuse perspiration ; but it is more common for the symptoms to abate and a perspiration to supervene in three or four hours after the seizure. In the most violent cases, it but rarely happens that there is any abatement in the symptoms before the third or fourth morning—and, as a common circumstance in disease, the patient suffers more through the night than through the day. 
This affection appears to have a strong partiality for the metatarsal joint of the big toe. Dr. Scudmore, says Dr. "Wood, found that of 193 cases, 130 began in the big toe, but it may attack any of the small joints of the hand or foot —it may do even more than this after it shall have frequently recurred, for then it may invade any joint in the body, or any organ in the large cavities. 
It is common for an exacerbation of the fever and inflammation to occur toward evening, daily, and to continue measurably through the night and abate in or toward the morning; and thus it may continue for a longer or shorter period, rarely longer than twenty days, and frequently less than a week. Upon the declination of the pain and fever, the perspiration or the urine may become copious, or the bowels may become laxative; but the tumefaction, which is edematous, continues until the disappearance of the pre- 


854 
INFLAMMATORY FORMS OF DISEASE. 
ceding symptoms, when it also begins to subside, and passes off with a desquamation of the cuticle. During the inflammation, the tenderness of the affected joint is so great that the weight of the bed-clothes can not be borne upon it, the digestive functions are invariably deranged, and, during the paroxysm, the patient is irritable and fretful. 
Dr. Wood says, that sometimes before the beginning of the regular paroxysm, there may be, at distant intervals, slight attacks of pain and soreness in some part of the foot or hand, which, not being violent, the patient is disposed to attribute to a sprain or to some other accident. Among the premonitory symptoms, Dr. Cullen enumerates the following: "The ceasing of a sweating which the feet had been commonly affected with before; an unusual coldness of the feet and legs; a frequent numbness, alternating with a sense of prickling along the whole of the lower extremities 5 frequent cramps of the muscles of the legs, and an unusual turgescence of the veins." 
Two or more assaults of the gout depend much upon the habits of the patient—very few escape with one—and the intervals may be comparatively short or extended to two or three years, but most frequently they recur annually; yet, as the disease advances, the paroxysms become lengthened in duration, and may re-appear twice or four times a year, and each invasion may last so long as to allow the patient but a short exemption, which usually happens in the middle of the summer. This extension of the disease is, in a very great degree, compensated by the greatly reduced severity of all the symptoms ; but this mitigation of the symptoms, however, proves an increase of the danger, because it has resulted from a corresponding reduction of the active forces—the centrifugal action—consequently, the internal viscera has become liable to invasion. This is sometimes denominated misplaced gout. Under the weakened condition of the active forces, a retrocession of the disease may be effected by even an inconsiderable cause acting upon the exterior surface, or even a part of it. In 


ACUTE ARTHRITIS. 
855 
this wise gout has frequently proved fatal. It may assail the stomach in the form of acute gastritis—when it invades the brain, apoplexy or palsy may result—but the stomach and kidneys are the most frequent subjects of arthritic metastasis. 
As in the case of rheumatism, women are much less liable to gout than men. Dr. Gregory states, that in England the proportion is as 1 to 50, and in Scotland it is as 1 to 100; and he thinks they are indebted for this relative immunity to their greater temperance. This, no doubt, should be included in the estimate, but a greater cause of their exemption, in our opinion, is to be sought in the relative development of their vital or active forces. They are, as a very general fact, less developed in them than in men, and from what we have seen and learned, we infer that the English women have them larger than the Scotch—that they are more gross—that they exercise more in the laborious pursuits of life—that is, nationally, and thus, these forces have become more developed. 
Causes. —Dr. Wood says: " The most frequent cause of gout is inheritance. This not only gives a predisposition, but is sufficient of itself, wholly without aid from other causes, and even in opposition to whatever influences can be brought against it, to give rise to the disease." If gout do, so necessarily, succeed to the inheritance, what useful purpose did he, or could he, suppose to result from his admonition to those who have descended from gouty parents— they should " use every possible preventive measure 2" How can we prevent the consequences of an inheritance 2 We have used words long enough to conceal our want of ideas —it is time that we had done with the practice of it. 
We admit that a child may inherit a capacity for music— but no one ever inherited music, and this capacity has its organic sign—it exists in organization. No predisposition to make music inheres in the organization, but a predisposition may arise, though not in those who have no capacity, and when produced, it may readily be excited into action, and music is the result. Application:—No one ever inner- 


856 
INFLAMMATORY FORMS OF DISEASE. 
ited gout, nor a predisposition to it—but an organization having the power, under circumstances, to produce it. Under this organization a predisposition may be developed, which may be sanguineous plethora, and then it becomes absolutely the disease, but in a comparatively latent state. Furthermore, we believe that an active development of gout may be prevented in those who are organized with a capacity for it, by a change of climate and special modes of life We may be mistaken, but if the kidneys are as much involved in the production of this disease, as we think they are, it could not be produced from any strength of gouty organization, in the city of New Orleans, or its vicinity. 
As to other causes of gout, dwelt upon by writers in general, we have not much to say ; we may remark, however, that gout never obtains outside of an adequate organization. We have no doubt that idleness and luxury, in some atmospheric conditions, may convert a rheumatic or a cancerous organization into an arthritic one. All causes calculated to develop active forces, favor the production of an arthritic or rheumatic organization, but to elevate a dynamic into an active constitution, is not the work of one lifetime. 
Treatment. —During a paroxysm of gout, the sufferer may receive some relief by placing the foot in an alkaline bath, as hot as can be borne, and retaining it there for some ten or fifteen minutes, after which a fomentation of Stramonium leaves should be applied around the foot and painful joint; at the same time, powders of Sulphate of Quinine and Sulphate of Morphine may be given every half hour or hour, in doses of about half a grain or a grain of the former, and from one-eighth to half a grain of the latter, according to circumstances. The same course may be pursued when the disease attacks any other part where local applications can be made. 
As to subsequent treatment, but little can be done toward a cure, as the disease is owing to defective organization ; yet it may be suspended, or its attacks entirely prevented, by avoiding the exciting causes. Thus, moderate exercise, a 


857 
CHRONIC ARTHRITIS. 
healthy, nutritious, easily-digestible diet, regular hours, and an avoidance of acids, wines, liquors, stimulating condiments, and what is known as high-living. Yet, as the disease is usually prized by those laboring under it, as an aristocratic one, such a course is rarely adopted, notwithstanding the severe penalty resulting from its omission. 
As to internal measures, the greatest benefit is afforded by a preparation composed of equal parts of the saturated tinctures of Macrotys root and Oolchicum seed, which may be taken in half-drachm or drachm doses, three or four times a day, and continued for some time. The bowels should be kept regular, and the surface of the body should be frequently bathed with an alkaline solution, using considerable friction in drying. 
Diuretics and alkalies will also be found a very efficient part of the treatment, and should be frequently administered, especially when acidity of stomach or flying pains are present, as well as when the urine is scanty or contains an undue amount of uric acid. If torpidity of the liver is present, Podophyllin and Leptandrin may be used in small doses with advantage. 
When the gout attacks internal organs, the Compound Tincture of Yirginia Snakeroot must be given in halfounce or ounce doses, or sufficient to produce a powerful and immediate determination to the surface, as manifested by profuse perspiration ; and at the same time, sinapisms must be applied to the foot and leg originally attacked, at least as high up as to the knees—after which an active cathartic injection should be administered. When the patient has recovered, Quinia and Morphine, with solutions of Bicarbonate of Potassa or Soda, may be given to prevent a return of the attack. 
2. Chronic Arthritis, 
Dr. Wood says: " Chronic gout is generally the result of a long continuance of the acute, though sometimes the disease is of the chronic grade from its commencement." We do not doubt that a comparatively dynamic form of the 


858 
INFLAMMATORY FORMS OF DISEASE. 
acute variety may sometimes be met with ; and on the other hand, there may occur a pretty active form of the dynamic or chronic variety, but that the active or acute ever did pass into the dynamic or chronic, we are not prepared to admit. The fact, that the active forces, in the acute form, do, in obstinate cases, become so exhausted as to be incapable of maintaining a successful centrifugal action, is not enough to constitute it chronic. Even in this exhausted stage of the acute form, acute pain and suffering will still recur, although they may be of short duration. The purely chronic form is so from the beginning, and it is so because the active forces are not adequate to the expulsion of the obstruction or disease. 
Those who are inherently or organically liable to acute arthritis possess very active forces, and less of the dynamic than those who are subject to chronic rheumatism. They have a strong resemblance to those who are liable to tubercular phthisis, with this difference —the former possess a more efficient pulmonary system. 
" In this condition of gout," says Dr. Wood, u the paroxysms are more frequent than in the acute, but much less severe. There is often little pain, unless upon motion of the joint. There is also little increase of heat, and the redness is either entirely absent or of a purplish hue. When there is swelling, it is usually edematous. Not unfrequently, the synovial liquid of the joints, and the fluid of the neighboring bursa? are so much increased as to produce a considerable appearance of tumefaction, and to fluctuate obviously under pressure. This is particularly the case in the knee and the elbow." 
This inflammation may fix itself upon certain joints, or it may travel from joint to joint, like migratory rheumatism, and it may also leave the joints entirely, and fix itself upon some one of the internal organs. When it shall assume a more established character, the joints may become so greatly altered, as to be measurably useless, in consequence of their inflexibility, which is occasioned by a thickened and rigid condition of the capsules and ligaments, and the deposition 


CHRONIC ARTHRITIS. 
859 
of chalky matter into the synovial cavity, or in its adjacent cellular tissue. This chalky substance frequently accumulates in large quantities in the joints of the fingers. In old subjects they are frequently so well formed and near the surface, that the knuckle can be used like a piece of chalk, to write upon a wall. When they become thus developed, they are called chalk stones. In some instances they occasion considerable swelling, that consists of a serous fluid, and which, finally, may pass into suppurating ulcers. The chalky matter appears to be contained in the areola tissue, and is removed with difficulty, but finally it is disposed of, and the part recovers. This chalky substance has been discovered to consist of the urate and the phosphate of soda and lime ; and this fact is rendered still more interesting, by the discovery that there is, under the circumstances, a deficiency of uric acid in the urine, and too much of it in the blood. We are much more disposed to attribute the proximate cause of gout to defective renal depuration, than to the presence of too much fibrin in the blood, and the chemical facts above stated would seem to sustain the opinion ; but it is possible that both conditions may obtain. 
In this form of disease, the paroxysms are less painful and less regular in their occurrence than in the acute— the intervals, in some instances, amount to two or three months, but they continue much longer. Sometimes the paroxysms so run into each other, that a fresh attack supervenes upon the closing portion of the preceding, and the patient has but little respite from pain and suffering. 
Against the doctrine that regards an excess of fibrin in the blood—a state of plethora of the system—as being the proximate cause, we can not conclude this subject without admonishing our readers to be on their guard. Dr. Barlow teaches, that in " weakly habits, and where the constitution has been suffered to struggle long under unrelieved plethora, these derangements (extraneous symptoms, etc.) are numerous and proteiform, harassing the patient, and confounding the physician." 
We have seen cases of chronic gout where there was no 


860 
INFLAMMATORY FORMS OF DISEASE. 
plethora, and any treatment that might have been founded upon such an hypothesis, would have proved mischievous. We do not assert that plethora is not the proximate cause, but simply that we are inclined to refer the disease to imperfect renal depuration, and think it therefore more safe to excite secretion than to reduce plethora. 
As regards the cause of gout, if we admit any form of disease to be hereditary, we can not admit this to be more so than phthisis, and a very large proportion of phthisical cases are not of this character; but, as we have before shown, we regard the doctrine to be erroneous in principle and mischievous in practice. 
Diagnosis.—To distinguish between chronic rheumatism and chronic gout, is admitted to be exceedingly difficult — we must be governed, measurably, by the history of the case, as no certain diagnostic can be had in the introductory stage. 
Treatment.—In this variety of gout, the same means are recommended as in the acute form. Notwithstanding volumes have been written upon this disease, yet, save a change of habits, no cure has ever been effected, which is owing to the defective organization heretofore named, a fact not mentioned by any other writer, as far as we are aware. 
Genus XYIII.—Pericarditis— 
Inflammation of the Pericardium. 
As the symptoms and diagnosis of pericarditis, endocarditis, and carditis are particularly obscure—so much so as to render it exceedingly uncertain whether disease really exists, in either of the organs, although highly inflamed, and as our treatment must necessarily be the same in all three, we shall only treat of pericarditis. 
" Lamnec states, (Cy. Prac. Med.), that he has often, on dissection, discovered the disease, in a severe form, when nothing had afforded a suspicion of its existence; and on the other hand, that he had frequently witnessed all its signs without finding a vestige of the malady." 
The symptoms of endocarditis " are very nearly the same 


ACUTE PERICARDITIS. 
861 
as those enumerated under pericarditis, and, as in this affection they are insufficient for the positive diagnosis of the disease, though they may lead to the suspicion of its existence, and thus induce an examination by the stethoscope. 
" Whenever inflammation of the substance of the heart has been observed, it has, thus far, been almost always associated with some morbid condition either of the investing or the lining membrane, or both together. Such an affection as independent carditis, of any considerable extent, has not yet been proved to exist. The symptoms of carditis are, therefore, necessarily intermingled with those of pericarditis and endocarditis. Nor can they be discriminated."— Wood. 
The preceding extracts render it clear that nothing can be gained in a practical point of view, by the separate consideration of inflammation of the three structures above named. 
1. Acute Pericarditis. 
The symptoms of acute pericarditis consist of acute inflammatory fever, a pungent, burning, lancinating pain in the region of the heart, shooting to the left scapula, shoulder, and upper-arm, but rarely descending below the elbow, or even quite to it. The pain is increased by full inspiration, by stretching the left side, and especially by pressure between the precordial ribs, and by forcing the epigastrium upward underneath the left hypochondrium. Palpitation of the heart and oppressive dyspnoea are sometimes present. In those cases in which the symptoms are direct, it most frequently happens that the patient can not lie down, more especially on the left side. He is constrained, by the severity of the pain that motion occasions, to maintain a static and quiet position, and that is generally required to be in a sitting, posture. 
The pulse, whether feeble or strong, for it is sometimes the one and sometimes the other, is very irregular and intermitting. In the course of the disease, it is not uncommon for the eyes, temples, and extremities to become more or less edematous ; though it is common for the face to be 


862 
INFLAMMATORY FORMS OF DISEASE. 
pale, yet a flush upon one cheek is not uncommon. The epigastrium is generally tender, and the soreness is usually attended with some headache and tenderness, or even positive pain in the stomach. 
In our prefatory remarks we treated of the exceeding uncertainty of the symptoms of this affection ; the student, therefore, must not expect to find, in all cases, the symptoms we have given, or, if they, or many of them, shall be present, they may be so complicated with pleuritis, pneumonitis, carditis, or even gastritis, as to be too complex for any one to arrive at a clear discrimination—and if he could, but little perhaps would be gained by it, as the general treatment would be much the same. 
Diagnosis.—M. Louis is of the opinion, that in those cases which are independent of complications, the diagnosis is not so difficult as has generally been supposed. He says, that when in the region of the heart, there is lancinating pains, which, at intervals, extend to the back and epigastrium, with unusual smallness and irregularity of the pulse and palpitation of the heart, an inability to rest in a recumbent posture, occasional faintness, and possibly syncope, and oedema of the extremities, we may pretty safely conclude that pericarditis is present. These remarks or diagnosis may be very true, in many cases, yet it must be confessed that fatal cases occur without exhibiting a single indicative symptom ; and in other cases, again, all the usual symptoms exist in the absence of the disease. 
Causes.—In this respect there is nothing singular, except, like acute rheumatism, the disease is confined, perhaps entirely, to what we have denominated the first class of constitutions—those which are distinguished by the most active vital forces. Those exciting causes that produce visceral inflammation, in general, produce pericarditis. 
Prognosis.—Though not necessarily fatal, pericarditis is justly classed with the most dangerous forms of disease, and the danger is increased by its liability to become complicated with pleuritis and pneumonia. 
Treatment. —Undoubtedly, the most important indica- 


ACUTE PERICARDITIS. 
863 
tion in acute pericarditis is to produce a powerful determination to the surface, by means of the spirit vapor-bath, or by the use of the Compound Tincture of Virginia Snakeroot, either of which must be used sufficiently to cause profuse perspiration, and which should be maintained for several hours; after which the Compound Powder of Ipecac, and Opium may be given, in doses of four or five grains every two or three hours, for the purpose of keeping up considerable moisture upon the skin, and to allay pain and nervous irritability. At an early period the bowels should be thoroughly evacuated by some active cathartic, as the Compound Powder of Jalap, to which ten or twelve grains of Bitartrate of Potassa may be added, or one or two grains of Podophyllin, with the same quantity of the bitartrate, may be administered. Afterward, it will be necessary to obtain one or two evacuations daily, by mild laxative doses. The patient should drink freely of diuretic infusions ; one composed of equal parts of Asclepias Tuberosa and Althaea Officinalis will be found very beneficial, with which, especially in cases of rheumatic origin, when the more severe inflammatory symptoms have subsided, ten or twenty drops of Tincture of Colchicum seed may be taken, and repeated every four or five hours. 
Should the pain be very severe, sinapisms may be applied over the affected part, and afterward hot emollient poultices; sinapisms may also be placed along the upper part of the vertebral column, and in rheumatic cases over the original points of the rheumatic attack. The surface should be bathed once or twice daily, with a warm alkaline solution. 
The diet of the patient should consist of farinaceous or mucilaginous liquids ; the mind should be kept quiet, as well as the body, and all causes of excitement should be avoided, and the presence of unnecessary persons should be positively prohibited from the sick room. Animal food should not be allowed until perfect convalescence has taken place. 


864 
INFLAMMATORY FORMS OF DISEASE. 
2. Chronic Pericarditis. 
This form of the disease is thought to be more common than the preceding, and of less doubtful diagnosis. It is mostly, if not entirely, confined to those whose vital forces are of rather a low grade, but as the condition of these is of every grade between their extremes, it must sometimes happen that the fever, in this form, may run so high, as to present a low grade of the preceding variety—but most generally the fever is of the hectic character, and attended by occasional exacerbations. In most cases there is a fixed pain in the cardiac region, and the patient most frequently complains of a sensation of lullness and weight in the same region, with some degree of pectoral oppression and dyspnoea ; he is less constrained in his motions than in the acute, but usually prefers a sitting posture, with the body inclined forward. Violent palpitations of the heart are apt to succeed either mental or muscular action, when of more than ordinary strength. As in the acute, the pulse is small, intermittent, and irregular. There is no marked difference between the symptoms of the acute and chronic forms, except in the degree of their violence, which is to be attributed entirely to a physiological difference of constitution—¦ for when the normal physiological forces are of a low grade, we can not expect high inflammatory action. 
Causes.—Mechanical violence upon the chest is thought to be the most frequent cause of this form of the disease, but like chronic rheumatism, it may occur without any very obvious cause. It may also originate in, or be complicated with, pleurisy or pneumonia. 
Diagnosis.—When occasioned by violent blows or pressure upon the prascordial region, the history of the case will furnish the most reliable diagnosis, as when the patient, previously exempt from disease, suddenly complains of its symptoms, we can scarcely have a doubt as to the cause ; so likewise, when it supervenes an attack of rheumatism. But in many instances no reliable diagnosis can be had. 


CATARRHAL OPTHALMIA 
865 
Prognosis.—This form of disease has been thought to be necessarily fatal, but it is now known to have been cured ; nevertheless, it is to be regarded as one of the most formidable and dangerous. 
Treatment. —In the chronic form of pericarditis, the bowels should be kept open by laxative doses of Podophyllin and Leptandrin ; the surface should be bathed frequently, and the Compound Syrup of Stillingia with Iodide of Potassium must be given to promote absorption. If the pain be severe, or if the patient be wakeful, the Compound Powder of Ipecac, and Opium may be given to overcome these conditions. In some instances, counter-irritation over the chest and the upper part of the spinal column, will be found beneficial. The diet should be nourishing but easy of digestion, and, in patients much debilitated, wine or ale may be allowed. 
Genus XIX.—Opthalmia — 
Inflammation of the Conjunctiva. 
In conformity with the strict meaning of the above name, we should confine our treatise of the organ so far only as concerns vision, and yet it is more frequently employed to express inflammation of the conjunctiva. It has been, furthermore, divided into many varieties under names which are so arbitrary as to be, in many instances, more expressive of different stages and constitutional modifications of the same form, than of distinct varieties. But as it is probable that a more scientific arrangement would scarcely compensate for a departure from the one usually adopted, and with which the profession is generally acquainted, we shall pursue it. 
1. Mild or Catarrhal Opthalmia. 
The conjunctiva, the membrane in which this disease is located, should not, perhaps, be regarded as being purely mucous, but as partaking of the nature of the cutis, and also of a mucous structure, and therefore subject to those changes which inflammation is known to produce in both of them; such as increased vascularity, swelling, and al- 


866 
INFLAMMATORY FORMS OF DISEASE. 
tered sacretion. In mild cases, these changes are not very remarkable —the conjunctiva merely becoming red and more or less tumefied, and terminating by resolution. But in other instances, as in purulent opthalmia, it runs into a most destructive process. 
Catarrhal opthalmia is the mildest form of the disease and of much more frequent occurrence than any other. It becomes introduced to the notice of the patient by pain, intolerance of light, and a sensation that can not be compared with anything else than the presence of sand, or an inverted eyelash between the palpebrae and the globe of the eye. But it should be remembered that this sensation is common to all the varieties of conjunctivitis, and is considered by some to be diagnostic of it; and as it is occasioned by the turgescence of the vessels of the conjunctiva, the opinion is doubtless correct. The patient has no other idea than that sand or some other foreign matter is causing the irritation for which he rubs his eyes, and thereby aggravates the disease. Succeeding to this sensation is one of heat, as though the part had been scalded. 
The inflammation, in this variety, usually terminates by resolution, but sometimes a purulent discharge is observed, which is by no means copious—never so violent as to occasion chemosis or sloughing of the cornea. 
Causes. —In adults, it is most frequently produced by cold and damp air; but it is sometimes occasioned by an intemperate exposure of the eyes to a strong light, longwaking by candle-light, intemperance in the use of ardent spirits, and occasionally by gastric and intestinal irritation. Finally, the liability of this membrane to inflammation is that which is common to other mucous surfaces, and from similar causes. 
It is endemic, and appears sometimes to be epidemic but it is not known to be contagious—and yet it frequently runs through a family, and not unfrequently so invades a school, that but few of the pupils escape it. It may be remarked, in conclusion, that young subjects are more liable to it than adults. 


867 
CATARRHAL OPTHALMIA. 
Diagnosis.—As it is possible for the inexperienced to confound catarrhal opthalmia with the rheumatic or sclerotitis, it becomes proper to indicate the difference. In conjunctivitis, the vessels are tortuous, and the color a scarletred ; in sclerotitis, the vessels are fine or hair like, straight, and radiated, and the color, which is seen through the conjunctiva, is of a pink, or possibly of a violet hue. The pain of catarrhal opthalmia is slight, and the intolerance of light is but little, while in the rheumatic the pain is severe, dull, and aching, throbbing, and felt with as much severity, if not with more, in the surrounding parts than in the eye—there is, furthermore, great intolerance of light. Frequently through the day the pain is not much, but as night approaches it increases and continues to do so until after midnight. When attention is given to these diagnostic differences, a mistake can not be made. 
Prognosis.—Unless the constitution be depraved, there is no serious danger to be apprehended from catarrhal opthalmia. 
Treatment.—In catarrhal opthalmia, the feet should be bathed in hot water for some fifteen or twenty minutes ; after which sinapisms should be applied to them, and if the inflammation be severe, likewise to the back of the neck. The bowels should be purged, and the patient placed upon a light diet. 
Local applications should also be made over the eyes, as warm fomentations of Elm and Hops, or other narcotic herbs, and the eyes should be frequently bathed with an infusion of Hydrastis, or the following preparation : 
H. Tincture of Aconite, 3j, 
Hydrastin, grs .xx, Aqua, f3ij. Mix. 
In some severe instances, Professor King has derived almost immediate benefit by the application of cold water over the eye, on cloths, which must be changed every tew minutes. If much pain, watchfulness, or nervous irritability , % be present, the Compound Powder of Ipecac, and Opium may be given, or Tincture of Aconite. 
55 


868 
INFLAMMATORY FORMS OF DISEASE. 
"When the more active symptoms have subsided, stimulating applications will usually be found necessary, for the purpose of increasing the activity of the absorbent vessels, for which we prefer the above combination, with the addition of half a drachm of Capsicum. In some cases the Compound Collyrium of Golden Seal, the Compound Myrrh Collyrium, or the Compound Soda Collyrium, may be used with advantage. 
The patient, both during the disease, and for some time after convalescence, should avoid exposures, as well as excesses in eating, drinking, exercise, etc. 
2. Severe or Purulent Opthalmia — Severe Inflammation of the Conjunctiva. 
This variety of opthalmia is sometimes called Egyptian, and sometimes contagious opthalmia; it differs from the preceding, mainly, in being more severe, and in being occasioned by different causes. Gonorrheal opthalmia, and the purulent opthalmia of infants, of which we treated in Book III, are regarded as varieties of it. The only notable difference, of consequence, between purulent and gonorrheal opthalmia, consists in the difference between their respective causes. It is stated, however, that the gonorrheal frequently attacks but one eye, while the purulent most generally invades both. 
As Dr. Yitch has had more favorable opportunities for obtaining an accurate acquaintance with this form of opthalmia, we can not do better than to give his description of it. He says: 
" The first appearance of inflammation, after the application of the virus, is observed in the lining of the lower eyelid. It assumes first a mottled appearance, and then a fleshy redness. A little mucus is generally present at the doubling of the conjunctiva at its lower part. The disease, I know from observation, may remain in this state for twelve hours before it invades the conjunctiva covering the eye; sometimes it may be longer, and in some cases, Vhere the contact of the virus has been slight, or removed by im- 


869 
PURULENT OPTHALMIA. 
mediate washing, the disease never went farther than producing the redness of the lining of the palpebra. In sclerotic inflammation, the lining of the eyelids preserves, in some degree, its natural whiteness, especially just under the tarsi, for days and weeks. The progress of the inflammation, when it extends from the conjunctiva of the eyelids to that covering the globe of the eye, is often so rapid as to elude any distinct observation; but frequently it advances more gradually, preserving a defined line, until it extends over the whole membrane as far as the cornea. No part can be said to be more vascular than another, as the whole seems equally injected, and no space unoccupied. The disease is often thus far advanced before the attention of the patient is so much excited as to make him complain, a certain degree of stiffness being sometimes the only sensation which accompanies it. 
" The first and chief uneasiness, in this stage of the disease, is described as arising from the feeling of sand or dirt rolling in the eye. This sensation is not constant, as it comes on suddenly, and as suddenly departs, confirming to the patient the idea of something extraneous being lodged in the eye. I have always observed that its attacks are in the evening, about the time of going to bed, or very early in the morning. Their duration varies; sometimes an attack abates in an hour, and sometimes continues during the whole night—those coming on in the evening being always the most severe. This symptom requires particular attention, as its accession is a certain index of the disease being on the increase." 
So violent is this disease, that a yellow, thick pus is soon made to issue from between the greatly tumefied lids, and it is frequently so acrid that it excoriates the cheeks as it flows over them. It is common, too, for the matter to become effused between the conjunctiva and the sclerotica, causing the former to become elevated around the cornea, giving the idea of a ring—the cornea thus appears at the bottom of a pit, and so deeply is it invested, in this wise, in some instances, as scarcely to be seen. For the clear 


870 
INFLAMMATORY FORMS OF DISEASE- 
understanding of this phenomenon, it is proper to remark, that the union between the conjunctiva and the cornea is too close and intimate to admit an effusion of pus between them, which is not the case between the former and the sclerotica. 
Effusion of matter, also, in many instances, is effected in the sub-conjunctival tissue, producing tumefaction of a fleshy-red color, which is frequently attended with patches of extravasated blood. It is also worthy of remark, that this matter not unfrequently becomes effused into the cellular tissue which unites the conjunctiva to the palpebra, thereby causmg such extensive swelling as to conceal entirely from our view the globe of the eye. But, it is proper to add, that so long as the disease is confined to the conjunctival lining of the eyelids, no very serious consequences need to be apprehended, yet it has a tendency to extend itself to the cornea and occasion in it ulceration and sloughing—a rupture of the cornea, an escape of the aqueous humor, a protrusion of the iris, and finally a total loss of vision. 
As an illustration of its mischievous character, we may cite a statement made by Dr. "Watson, viz: in the "military hospitals, at Chelsea and Kilmainham, there were, on the 1st of December, 1810, no fewer than 2317 soldiers a burden upon the public from blindness in consequence of (purulent or Egyptian) opthalmia." 
The question is still debated as to whether it is or not contagious; from an investigation of the argument, we have concluded that the affirmative is the more ably maintained ; at all events, when we have it to contend with, prudence would dictate that we should act as though the affirmative was established. 
Causes.—That purulent opthalmia, under some peculiarities of constitution, may be produced by the same causes that produce the catarrhal, or by such as produce violent inflammation of other mucous membranes, may, we think, be admitted —namely, currents of cold air, the introduction of acrid, or indeed, of almost any foreign matter, sudden 


871 
PURULENT OPTHALMIA. 
transitions of heat and cold, and finally, those atmospheric conditions which produce other forms of inflammatory disease. From this last cause, we may even suppose the disease to become epidemic. 
"We are not yet able to determine why it is that one season produces dysentery and another continued fever, nor can we be sure that some modification of such an atmosphere might not produce purulent opthalmia. Those who deny its contagious nature, contend that it is an atmospheric disease. Assalina says (Watson's Practice): "The atmospheric conditions which are known to occasion catarrhal affections, are very frequent and powerful in Egypt: the days are very hot, the nights chilly and attended with heavy dews ; and men's eyes are perpetually exposed in the day time to a dazzling glare of light from the white and arid surface, while the air is full of floating particles of hot sand which are raised from the ground by the slightest breeze." 
We may admit all this, and still contend for the contagious nature of the disease. Whatever the abstract fact may be, it is now well known that the matter of purulent opthalmia will produce the same disease when introduced into the eye of a well person, and that when the disease invades a ship, a school, or an army, a large proportion of the individuals composing the crowd, respectively, will have the disease. 
After a few remarks upon the subject of gonorrheal opthalmia, we close what we have to say about purulent opthalmia. As its nature imports, this modification of opthalmia results from gonorrhea, most frequently, if not always, by direct inoculation or introduction of gonorrheal matter from the urethra. It has been contended that it may result from a metastasis of the urethral inflammation to the eye—it is also supposed that purulent opthalmia may result from gonorrhea, just as sore-throat may result from syphilis. While we admit the two latter, as causes of purulent opthalmia, as being perhaps possible, we confess that we have very little faith in the probability. 


872 
INFLAMMATORY FORMS OF DISEASE. 
In all casual or isolated cases of purulent opthalmia, we 
should endeavor to ascertain whether it be not of gonorrheal origin. This information may not avail us anything, in 
the treatment, but, beside affording some satisfaction, it might induce us, under some circumstances, to establish prudential measures with reference to those who may be associated with the patient. 
If the disease be confined to one eye, we may, in the proportion of one to a hundred or so, suspect it to be gonorrheal. Contagious opthalmia, according to Dr. Vitch, will occur in one eye one time in a thousand cases, and, according to Mr. Lawrence, gonorrheal opthalmia will invade both eyes once in every seven cases and a fraction. 
As there is no other disease with which purulent opthalmia can be confounded, and as the prognosis can be inferred from what we have said, we pass to the, 
Treatment.—In newly-born infants, this disease will generally yield to local infusions of Hydrastis, or Hydrastis and "Witch-Hazle leaves, or the Tincture of Myrrh, which should be applied several times a day. 
In the early stage of purulent opthalmia, should inflammatory symptoms be present, they must be treated in the same manner as named for the early stage of the catarrhal form. After which the treatment must consist of constitutional as well as local remedies. The local remedies may be the same as referred to in the latter stages of catarrhal opthalmia ; or the eyes may be frequently bathed with infusions of Hydrastis and Geranium, or Hydrastis and Statice Limonium. The Compound Syrup of Stillingia with the Iodide of Potassium, is undoubtedly the best constitutional remedy that can be given; and if the disease proves very obstinate, an irritating plaster may be applied to the nape of the neck, extending round and up behind the ears. It must be borne in mind, that if these stimulating applications irritate the eyes, rendering them worse, they must be omitted for a time, and more soothing measures employed. 
The treatment of gonorrheal opthalmia more properly 


873 
RHEUMATIC OPTHALMIA. 
belongs to the department of surgery—we will merely suggest that we employ the above constitutional treatment, with local applications to the eye of Nitrate of Silver, or a solution of the Sesquicarbonate of Potassa. For more detailed treatment, see Eclectic Surgery, pages 254 to 256. 
Genus XX. —Iritis — Rheumatic Opthalmia— 
Inflammation of the Iris. 
This portion of the eye is frequently the subject of inflammation, independently of any other structure; but the choroid, retina, and sclerotica are frequently involved with it. The iris is stretched across the anterior chamber of the eye, which is lined by a closed sack, having all the peculiarities of a serous membrane, in both health and disease, and under the influence of inflammation, it is liable to form adhesions which may change the size and shape of the pupil, and the movements of the iris; it is also liable to throw out coagulable lymph, which may entirely close the pupil. 
The presence of this disease is announced to the patient by some intolerance of light, impairment of vision, and circum-orbital pain ; and, to the physician, by a vascular redness around the cornea, in the sclerotica, which consists of fine, straight lines that converge toward, and stop abruptly at, or nearly at, the cornea, and appear to penetrate and pass through the sclerotica, to obtain the iris. In severe cases, the conjunctiva ma3 r be more or less involved, and when it is, then its red and vascular peculiarities are blended with those of iritis. The color of the iris will depend, in a great measure, upon the color it had in health. Blue or gray eyes become yellowish or greenish, and dark-colored eyes are changed into a tinge of red. This change is effected by an admixture of lymph with the original color of the iris. 
During the existence of this inflammation, there is not only cireum-orbital pain, but pain in the globe of the eye, and also in the temple, and it is generally more severe at alight. This pain and the attendant fever are quite variable, and in many instances not proportioned to the mischief 


874 
INFLAMMATORY FORMS OF DISEASE. 
that is going on. In some cases the pain is severe and unceasing ; while in others, but little is complained of. These remarks are true of the attending fever. When the disease is acute, it is common for the febrile manifestations to be very considerable—such as white tongue, full and hard pulse, pain in the head, and broken rest. 
The effusion of lymph very frequently becomes visible upon the surface of the iris, but its character varies much in different cases. In some cases, it appears in little spots or specks of a rusty color; in others, in a thin sheet or layer of the same color, and in others, in the form of tubercles some of which may be as large as a squirrel shot. In severe or neglected cases, suppuration takes place, the pus is discharged into the anterior chamber, and in sinking to the bottom of it, presents that appearance which has been called hypopyon. 
Whatever may be the grade of the inflammation, vision is always impaired by it, in consequence of the injury inflicted upon the iris, the tunics posterior to the eye, and most obviously to the cornea, which is rendered more or less opake. 
Causes.—In arthritic and rheumatic constitutions or organizations, this disease may occur from causes similar to those which produce gout and rheumatism, respectively. Those causes which produce opthalmia in general, are said to produce iritis ; but we are disposed to believe that they will do so only in the constitutions above named. It is said to occur in secondary syphilis, and is then called syphilitic opthalmia, or iritis ; it is also maintained by some to result from the use of mercury —which we regard as probable— but in both instances, we are disposed to confine it to the organizations before named. It is also said to originate in a scrofulous constitution ; and hence authors treat of strumous opthalmia, meaning iritis. About this we are sceptical—there is too much difference between the rheumatic and the strumous organizations for both to be liable to the same forms of disease. 
That form of disease known as the strumous opthalmia 


RHEUMATIC OPTHALMIA 
875 
of children, is treated of as being confined to strumous constitutions, but this the writer knows to be an error. He has seen one well-marked case in a boy, in whose family nothing of a scrofulous tendency was ever known—and now, as a man, he is very muscular and of a decidedly rheumatic organization. He admits that the so-called strumous opthalmia is associated with some depravity of the constitution, but it does not follow that it must be a strumous one.* 
Treatment.—In the treatment of iritis, the bowels must be actively purged, the purge being followed by a spirit vapor-bath; the perspiration must be kept up for several hours by nauseants and diaphoretics; sinapisms must be applied to the feet and nape of the neck. Cold water may be kept applied constantly to the eyes, on cloths, which should be changed every few minutes. Sometimes cold applications increase the pain ; under such circumstances, warm water may be substituted, or fomentations of Hops, or Stramonium leaves. This treatment should be energetically pursued and persevered in. The bowels should be kept regular during the treatment. 
If the disease should run into the chronic form, stimulating applications must be made to the eye, the same as mentioned in the previous opthalmic affections, and the above treatment continued. In debilitated patients, tonics must be administered, as Iron, Hydrastin, Cornin, Compound Wine of Comfrey, etc., and in very obstinate cases an irritating plaster may be applied, as in the previous forms, with advantage. 
In the active form the diet should be light—in the chronic, nutritious, digestible, avoiding fats, acids, and the use of alcoholic liquors. 
?Inflammation of the other structures of the eye do not often occur independently of conjunctivitis and iritis, and as the treatment of these two forms will necessarily embrace the others, a special description becomes useless, more especially, as much yet remains to be learned about them, as independent forms of inflammation. 


876 
INFLAMMATORY FORMS OF DISEASE. 
Genus XXI. —Eczema* — 
Hu mid Tetter or So all. 
This is considered, by some to be a non-contagious form of eruptive disease; but others think it to be contagious under very favorable circumstances. It is usually treated of under three divisions or varieties, as eczema simplex, rubrum, aud impetiginodes'; but as all three may exist at one and the same time, it appears more consistent to regard them as so many well defined stages or degrees of violence of the same form of disease. 
It consists of a great number of very small vesicles, disposed of, sometimes confidently, upon an irregularly'formed surface of considerable extent. When it is regarded as eczema simplex, the vesicles are exceedingly numerous, confluent, and disposed of in clusters, and attended with so little increase of color or inflammation and fever, as scarcely to be noticed. The contained serum is at first limpid, but it gradually changes to a turbid, and then to a milky color. By degrees this fluid is absorbed, the epidermis dessicates into a thin pellicle, and is then removed by desquamation. 
It is generally confined to some particular portion of the cutaneous surface, and hence the many local names which it has received, as eczema capitis, eczema faciei, etc. Nev ertheless, it is sometimes distributed generally over the body, but its most usual locations are the arms, forearms, hands, and between the fingers. 
In consequence of its tendency to produce a succession of eruptions, the disease is frequently continued for several weeks, but as it is, in a great measure, without danger and without constitutional symptoms, and leaves omthe skin no evidence that it ever existed, the only annoyance it is to the patient, arises from the itching it occasions, which is considerable. To this simple form of the disease, a slight 
*In Book III, we treated of so many forms of cutaneous disease, that but two remain which we deem it essential to consider, and they are vesicular, namely, Eczema and Miliaria. 


877 
HUMID TETTER. 
itching is the only premonitory symptom, and during its course it never, spontaneously, produces inflamed surfaces. It is said to be sometimes associated with itch, and to be occasionally produced by some of the remedies which are used in the treatment of it. 
When the disease is of such violence as to be entitled to the appellation of eczema rubrum, the surface becomes much inflamed, and of a vividly-red color, and covered with small pointed pimples of a white, shining luster. After some days, small vesicles appear on the inflamed surface, which are bounded by a well-defined red areola. When the affection is of moderate or usual violence, the vesicular fluid, in the course of a week, is absorbed, and the vesicles disappear by absorption, leaving the surface of a pale-red color, having scattered over it many small, round papula?, based in a whitish disc. 
But should the inflammation fail to terminate thus favorably, and continue to increase, and the vesicles should so increase in number as to become confluent, then it is that their contents, at first limpid and transparent, become turbid and milky, and then burst, leaving inflamed and excoriated surfaces which furnish a large quantity of matter that is so irritating, as to increase the magnitude of the excoriations. The exposed derma is highly inflamed—of a crimson color, having patches of a whitish, membraneous film ; and the secretion from it forms scabs of varying extent and thickness. When the disease is of this severe character, it is apt to continue two or three weeks, and by neglect, or the continued presence of causes calculated to irritate, it may become chronic. A tingling sensation in the skin, with some heat and stiffness, are the only symptoms that precede the eruption. 
Eczema impetiginodes is another variety or form of the disease, which is as much more violent than the preceding, as it was more so than the one that preceded it. It is characterized by violent inflammation, more or less of swelling, vesicles, which are greatly crowded or confluent, and filled with a sero-purulent matter, which, upon a rupture of the 


878 
INFLAMMATORY FORMS OF DISEASE. 
vesicles, a circumstance that soon follows their formation, forms, upou dessication, extensive scabs or crusts, exposing, when detached, red surfaces that secrete an abundance of ichorous fluid of a reddish tinge, which hardens, by exposure, into a thin, dark-colored scab, that continues until the part is healed. By successive crops of the eruption, the disease may be continued for several weeks. When it is local, as it most generally is, the constitutional symptoms are very light, or else entirely absent; but when it is general, all the symptoms that usually attend inflammation are present. The' local symptoms always indicate the violence of the disease, by the burning, smarting, and throbbing pain it occasions, which is so much increased by the warmth of a bed as to prevent sleep. 
Like other acute forms of disease, eczema sometimes appears in the chronic form, more particularly when it has been severe, protracted, and aggravated. It is marked by extensive excoriations and fissures in the derma, more especially in the flectures of the joints and axillae. They exude a serous fluid, which, upon dessication, causes an adhesion of the dressings or clothing to them. Sometimes when the disease appears nearly well, it will, without any known cause, re-appear with still greater violence ; and thus, by a repetition of the same course, it may continue for years. The cracked and fissured derma sometimes continues dry with a firm adhesion of the crusts, and when they finally become detached the surface appears of a slightly reel color ; but in some cases it is very red and so continues for a long time. The itching in this affection i3 frequently distressing, no matter on what part of the surface it be located ; but when it is the pubes, the arm-pits, scrotum, groin, and pudendum, the annoyance is not less than the distress, and both are very great. Eczema is said to occur more frequently in women-than men, and in summer rather than winter. . ' 
Causes.—Upon this subject but little is certainly known. It is thought that irritating applications to the skin, as blisters, sinapisms, irritating ointments, dry frictions, ex- 


HUMID TETTER. 
879 
posure to the sun, lime, sugar, and the use of mercury, will produce it. We think it possible that these causes may be sufficient to produce the disease in constitutions that are organically liable to it. 
Diagnosis.—Eczema has been mistaken for the itch, and sometimes it resembles it; but in the former the vesicles are flat and crowded together, while in the latter they are pointed and separated. Eczema impetiginode has been confounded with impetigo ; but the former is vesicular, and the latter is pustular; furthermore, the former occupies large spaces, and the latter small ones. Chronic eczema has been confounded with lichen, particularly with lichen agrius, which it most resembles ; in this, the scabs are thick, small, and yellow, and when they drop off, the surface they left is papular; but in that, the scabs consist of thin lamina and their detachment leaves the surface red, smooth, and shining, and probably some little excoriated. 
Treatment.—In the inflammatory condition of this disease, the Compound Powder of Ipecac, and Opium may be given, to allay pain and inflammation, as well as to keep up a moisture of the surface. The bowels should be kept regular by laxative doses of the Compound Power of Rhei and Potassa, and the surface should be frequently bathed with a warm alkaline solution. The diet should be light, but as nutritious as the condition of the patient will allow. Mucilaginous diureties will also be found beneficial. 
When the more active inflammatory symptoms have subsided, as well as in the chronic form of the disease, chalybeate tonics must be given, for the purpose of improving the vigor of the constitution, and especially the capillary system, which is nearly always debilitated or torpid. Equal parts of Sulphate of Quinia and Prussiate of Iron may be given, in does suitable to the age of the patient, and repeated three or four times a day, in connection with a nourishing but digestible diet, avoiding fats and acids, or articles disposed to produce acidity of stomach. 
The bowels must be kept regular, and the surface of the body attended to; and if the eruption be very painful, or 


880 
INFLAMMATORY FORMS OF DISEASE. 
cause much itching, soothing applications must he applied, as Tallow or Sweet Oil, to either of which a small proportion of Glycerin may be added ; sometimes powdered Stramonium or Belladonna leaves may be added to the local remedy, with advantage, as far as mere palliation of disagreeable symptoms is concerned. This is the only treatment we have found available in these affections. 
Genus XXII.—Miliaria— 
Sudamina. — Miliary Vesicles. — Miliary Eruption. 
Miliaria is characterized by prominent vesicles, of a rounded form and of about the size of millet-seeds. When they first appear they have a reddish hue, and are then denominated miliaria rubra ; but, in the course of twentyfour hours, they become milky or opake, and are then known as miliaria alba. They are very generally, if not always, discreet, though frequently very numerous. They may appear on any part of the body, but most frequently they select the trunk of the body. It is common for them to give no premonition of their appearance, or if any, it consists of a little irritation and redness of the skin. 
It was named miliaria from the resemblance of its vesicles to millet-seed, and it was called sudamina, because it is always, or very generally, attended with a high cutaneous temperature and a copious perspiration. It occurs more frequently in summer than during the other months, and more commonly attacks those who possess a thin and delicate skin. Miliaria is sometimes met with during the course of the eruptive fevers ; and it also occurs occasionally as an attendant upon typhoid and some other fevers, as the remittent, and many of those forms of inflammation which are attended by copious perspiration. 
Causes.—Upon this subject there has been much contrariety of opinion, and some still exists. Before the time of Sydenham, when a highly-heating and perspiring state of the skin was aimed at, in the treatment of fevers, it was regarded as a dangerous form of disease—one of a specific character and of frequent occurrence. This frequency, as 


881 
PHLEBITIS. 
well as the attendant danger, is now thought to have resulted from the practice in the treatment of febrile forms of disease which then prevailed. Considerable probability is due to this opinion, inasmuch as it is now a rare disease— and has been since that mode of practice was abandoned. 
It is thought to be, by some, uniformly symptomatic, more particularly of those forms of disease which we have before named ; nevertheless, it is contended, by others, to be occasionally idiopathic. Yiolent exercise, in the heat of summer, it is said, by those who maintain that it may obtain idiopathically, will produce it. It is thought that it may be occasioned by a heating practice in almost any form of febrile disease, and occasionally when the best treatment has been adopted. From the discussion which has been had about this form of disease, we are disposed to believe that it would never appear in any form of febrile disease, if the best treatment should be adopted. 
Treatment. —No attention is required by this exantheme when it is symptomatic; upon the cure of the disease to which it is an attendant, it will disappear; and when it is idiopathic, it is usually so mild as to require but little or no treatment. An infusion of Elder flowers, Maidenhair, and Asclepias Tuberosa, will be found generally sufficient to meet all cases, the bowels being kept regular. Unfavorable symptoms usually attend its recession—such as demand nauseants, diaphoretics, and in some instances counter-irritation. 
Genus XXIII. —Phlebitis— 
Infl animation of the Ve i n s 
This is an inflammation of the lining membrane of the veins. It sometimes attends common venesection, also the ligature or excision of varices, amputation, gun-shot wounds, the ligature of the umbilical cord, etc. When it is consequent upon a local injury, the first symptom is inflammation of the injured part, and then a tense, knotty, and painful cord may be traced along the direction of the inflamed vessel, which is attended with febrile symptoms, 


882 
INFLAMMATORY FORMS OF DISEASK. 
proportioned to the extent and violence of the inflammation. It has been known to terminate by resolution, suppuration, ulceration, and gangrene. 
Pathologically considered, the first effect of inflammation of the lining membrane of a vein is the effusion and adhesion of the coagulum upon the interior of the inflamed surface, which may be to such an extent as to dam up the venous channel, or it may only exist to such an extent as to fur it over. The danger of this form of inflammation does not depend upon its abstract severity, but upon the magnitude of the invaded vein—as it must be obvious that the destruction of a small vein could be attended with no very serious consequences, but the severest suffering, and even death, may readily be supposed to follow the obstruction or obliteration of one of the large venous trunks—and yet the absolute intensity of the local inflammation may be as great in the one case as in the other. 
Most generally, phlebitis does not run beyond the adhesive stage, and the mischief, therefore, that may ensue must be regarded as resulting from the mechanical obstruction of a portion of the venous circulation — but such an arrest in the cerebral sinuses would necessarily prove fatal. If the organ in which such an obstruction takes place be not highly essential to life, the patient may recover through the establishment of a collateral circulation. Recovery is sometimes effected by a softening of the coagula to such an extent that the blood forces a channel through it. 
Even in the suppurative stage, the disease may be confine —continued as a local one, by the adhesive process bounding the accumulated pus, and thus establishing a local abscess; but the greater probability is that the pus, or some of it, will enter the circulation, and become the agent to establish or cause abscesses in distant and indispensably-important organs, more particularly the liver and lungs, inasmuch as part of the blood must pass through the former and all of it through the latter; because the capillary vessels of these viscera will arrest whatever foreign matter the blood may contain, or should any escape, it may 


883 
PHLEBITIS. 
produce mischief in some other part of the system, after being transmitted to the left side of the heart. It is now, pretty generally we believe, thought that particles of pus become thus transmitted to distant parts, and excite inflammation and suppuration. The experiments that have been made with mercury would seem to render this hypothesis much more than probable. 
Upon this principle, suppurative phlebitis may be occasioned by very trifling injuries, as well as those of the gravest character. It may also arise without a mechanical lesion of any part; that is, it may produce other inflammatory affections. It is not contended that the pus which produces dangerous, and very often fatal, abscesses, in distant parts of the system, found its way into the circulation by absorption, but mechanically, as pus, unchanged or modified by absorption. Its entrance into the blood may sometimes happen thus mechanically—therefore, it is probable that in a majority of instances the pus is formed in suppurative phlebitis. 
Phlebitis is sometimes quite prevalent, so much so as to bear the character of an epidemic. It appears, therefore, that some peculiar condition of the atmosphere prevails at the time, which so modifies the susceptibilities of the system as to increase its liability to this form of disease. 
When the joints or parts near them are selected as the seats of suppuration, much pain and soreness are complained of and for a time they may be supposed to be rheumatic ; and when it takes place in the serous cavities the pain is even more severe than when located about the joints. 
Chills or shiverings, profuse sweats, usually attend this form of phlebitis, and sometimes the bowels are greatly deranged—producing copious and very abnormal discharges. To be more particular in presenting the phenomena of this dangerous malady, we can not do better than to give from the Medical Cyclopedia, Mr. Arnott's account of it: 
' "In from two to ten days after the receipt of the injury, the secondary or constitutional symptoms of phlebitis mani- 
56 


884 
INFLAMMATORY FORMS OF DISEASE. 
fest themselves, and they may be thus briefly characterized: Great restlessness and anxiety, prostration of strength and depression of spirits, sense of weight at the prsecordia, frequent sighing or rather moaning, with paroxysms of oppressed and hurried breathing, the patient at the same time being unable to refer his sufferings to any specific source. The common symptoms of fever are present; the pulse is rapid, reaching to 130 or 140 in a minute, but is, in other respects, extremely variable. There is often sickness and violent vomiting, especially of bilious matter. Frequent and severe rigors almost invariably occur, sometimes to the number of three or four in the course of a few hours. The general irritability and deep anxiety of countenance increase ; the manner is quick, and the look occasionally wild and distracted. When left to himself, the patient is apt to mutter incoherently, but on being directly addressed, is found clear and collected. The features are pinched, and the skin of the whole body becomes of a sallow or even yellow color. 
" Under symptoms of increasing debility, and at a time when the local affection may appear to be in a great degree subsiding, secondary inflammations of violent character, and quickly terminating in effusions of pus or lymph, very frequently take place in situations remote from the original injury; the cellular substance, the joints, and the eye have been affected ; but it is more particularly under a rapidly-developed attack of inflammation of the viscera of the chest, that the fatal issue usually occurs. Whether this is observed or not, death is always preceded by symptoms of extreme exhaustion, such as those of a rapid, feeble pulse, dry, brown, or black tongue, teeth and lips covered with sordes, haggard countenance, low delirium." 
Phlegmasia dolens or crural phlebitis is a modification or a variety of this disease, which requires from us a special notice. For a long time the true pathology of this malady was entirely unknown, as may be inferred without further evidence, from the names by which it was designated. It was, furthermore, supposed to be confined to puer- 


885 
PHLEBITIS. 
peral or lying-in women, as may also be inferred from the same evidence, viz: oedema, lactium, metastasis lactis, hysteralgia lactea, phlegmasia lactea, phlegmasia dolens, etc. But now, that its pathology is better understood, and observation is more extended, it is known as not being confined to puerperal women, but may occur in those who have never been pregnant, and also to the other sex; it does, however, occur much more frequently to the first class of persons. It is now, furthermore, pretty well ascertained that it does not consist in a metastasis of the lacteous secretion, nor to an obstruction of the lymphatic vessels, nor to lymphatic inflammation, commencing in the glands or elsewhere, nor is it an inflammation of all the tissues of the limb, as maintained by Professor Hossack; and yet there are a number of circumstances of a prima facie character, which militate against the idea that it is a pure phlebitis, as the white and edematous appearance of the limb, the hectic character of the fever, and its more uniform and less fatal termination than usually characterizes phlebitis. Nevertheless, if we are to be guided by legitimate inferences from the apparent results and the facts disclosed by postmortem investigations, we must conclude that phlegmasia dolens is phlebitis, modified, possibly, by some prevailing condition of the system. 
When this is a puerperal affection it appears, according to some observers, between the fifth and the ninth day after parturition; others state that it most generally appears about the twelfth, but it may supervene at a period as late as six weeks. It may occur in the superior extremities, but it very generally selects the inferior extremities, and one rather than both. 
For the purpose of doing the greater justice to our readers, we will extract from the Cyclopedia of Practical Medicine, a description of two cases, furnished by Dr. Lee, and for another reason, namely, the one which the author himself gives, which is, that " they afford good examples of this affection in its most mild and most severe forms, and illustrate, better than any general description could do, the 


886 
INFLAMMATORY FORMS OF DISEASE. 
phenomena of the disease, and the alterations of structure produced by inflammation in the hypogastric and crural veins." 
" A patient of the British Lying-in Hospital, who had been suffering for some weeks before delivery (May 8, 1829), from the usual symptoms of tubercular phthisis, experienced, on the 4th June, a sense of soreness in the left groin, which gradually extended along the inner surface of the thigh to the ham, and from thence along the posterior surface of the leg to the foot. She stated that for two days before the occurrence of pain in the groin, she had felt great uneasiness in the region of the uterus, that this suddenly quitted the hypogastrium, and passed into the groin, and that from thence it extended downward along the inner surface of the thigh to the leg. The limb became swollen twenty-four hours after the invasion of the disease. 
"The whole left inferior extremity is now affected with a hot, painful, colorless swelling, no where pitting on pressure, except over the foot. The thigh is fully double the size of the other, and any attempt to move the limb produces excruciating pain along the inner surface of the thigh; and the pain excited by pressure along the tract of the femoral vein is so acute, that the condition of the vessel can not be ascertained. Several branches of the saphena major, above the knee, are distended and hard ; pulse 120; respiration quick and laborious ; tongue peculiarly red and glossy; diarrhea continues. 10th. Pulmonary affection aggravated. The limb continues extremely painful, and is still more swollen. The groin is so tender that she can not bear the slightest pressure over it. The same is the case with the inner surface of the thigh. The branches of the saphena are still hard and painful. 11th. The femoral vein under Poupart's ligament can now be felt indurated and enlarged, and it is exquisitely painful when pressed, as is the inner surface of the thigh, the ham, and the calf of the leg. There is comparatively little tenderness along the outer surface of the limb. 17th. Diarrhea, emaciation, colliquative sweats, and difficulty of respiration increasing. 


887 
PHLEBITIS. 
The left inferior extremity is still much swollen ; but there is less pain in the groin and in the course of the femoral vessels. Died on the 2±th." 
" Dissection. — Thorax. —Adhesions between the pleura on both sides. Scarcely a portion of lung could be observed which did not contain tubercles in various stages of their growth. The right and left superior lobes contained several large tuberculous excavations. The vena cava and right common and external iliac veins were in a sound state. The left common external and internal iliac veins were all impervious, and had undergone various alterations of structure. The common iliac, at its termination, was reduced to a slender tube, about a line in diameter, which was lined with a blueish, slate-colored, adventitious membrane. The remainder of the common and the external iliac veins were coated also with a dark-colored membrane, and their center filled with a brownish, ochery-colored, tenacious substance, rather more consistent than the crassamcntum of the blood. 
u The left hypogastric or internal iliac vein was in the same condition, but in some places reduced to a cord-like substance, and its cavity throughout completely obliterated. The branches of this vein, taking their origin in the uterus, and usually termed the uterine plexus, were found completely plugged up with firm, red coagula. From the commencement of the branches of this plexus of the hypogastric vein, to the termination -of this vein in the iliac, the whole had become thickened, contracted, and plugged up with coagula and adventitious membrane of a dark-blue color. 
" The same changes had taken place in the uterine plexus, and trunk of the right hypogastric vein, from the uterus to its unusual termination in the left common iliac vein. The coats of the left femoral vein were thickened, and closely adherent to the artery and surrounding cellular substance, its whole interior lined with adventitious membrane, and distended with a reddish-colored coagulum. The same morbid changes presented themselves in the 


888 
INFLAMMATORY FORMS OF DISEASE. 
deep and superficial branches, as far as they were examined down the thigh. 
" A woman, aged 40, who had been delivered of twins a month before, and had nearly perished from flooding, and subsequently from an attack of uterine inflammation, was seized on the 27th August, 1829, with a violent fit of cold shivering, followed by pyrexia and pain in the right iliac region and groin. In the course of the two following days, the pain increased in severity, and extended down in the inner surface of the thigh toward the ham, and the whole leg and thigh became much swollen. The whole right inferior extremity affected with a general intumescence, and completely deprived of all power of motion. The temperature of the limb, particularly along the inner surface, much higher than that of the other ; but the integuments retain their natural color, and do not pit on pressure. The femoral vein for several inches under Poupart's ligament, is very distinctly felt enlarged, and is very painful when pressed. Out of the course of the crural vessels, little uneasiness is produced by pressure. In the right side of the hypogastrium there is also great tenderness; pulse 120 ; tongue furred. She appears pale and depressed, and complains of deep-seated, acute pain in the lower part of the back when she attempts to move. From this period until the 22d September, when she died, she suffered from repeated fits of shivering, which occasionally assumed a regular intermittent form ; there was diarrhea, with brown tongue ; the glands in the right groin became much enlarged, and the left inferior extremity became affected in a manner similar to the right. 
" Dissection. —The veins presented nearly similar appearances to those observed in the preceding case. The divisions of the vena cava were, in this instance, both affected. On the left side, the cavities of the iliac and femoral veins were filled with a dark-purple coagulum, their coats being not much thicker than natural; while on the right side, the coats of these veins were dense and ligamentous, and the cavities blocked up by adventitious mem- 


PHLEBITIS. 
889 
branes, or lymph, of a dull-yellow color. The lower part of the vena cava, for the space of two inches, as well as the right common iliac, was obstructed by a tough membrane of lymph surrounding a soft, semi-fluid, yellowish matter. The right common, external, and internal iliac veins were imbedded in a mass of suppurating glands, the purulent fluid of which had escaped into the adjacent cellular membrane, and forced its way downward in the course of the psoas muscle as low as Poupart's ligament. The right hypogastric vein was reduced to a small impervious cord, and its branches were distended with coagula of lymph of a bright-red color. The right femoral vein and its branches were in like manner impervious, their coats being greatly thickened, and their interior occupied by coagula. The cavities of the left common external iliac and hypogastric veins contained soft coagula, disposed in layers which adhered to the inner tunic of the vessel. 
" The trunk of the left hypogastric vein was contracted, its coats somewhat thickened, and its branches filled with worm-like coagula. The spermatic veins were healthy. The cellular membrane of both lower extremities was infiltrated with serum." 
The facts detailed in these two cases should scarcely leave a doubt upon the mind of any one as to the true pathology of this disease, however difficult it may be to arrive at a satisfactory conclusion as to its etiology. 
The description given of this disease by Dr. Hull (Cy. Prac. Med.), is so interesting, that we can not refrain from placing it before our readers, although it will render our article longer than we had intended. He says : 
" It has in many instances attacked women who were recovering from puerperal fever, and in some cases has supervened or succeeded to thoracic inflammation. It not uncommonly begins with coldness and rigors. These are succeeded by heat, thirst, and other symptoms of pyrexia; and then pain and stiffness, and other symptoms of topical inflammation supervene. Sometimes the local affection is from the first accompanied with, but is not preceded by, 


890 
INFLAMMATORY FORMS OF DISEASE. 
febrile symptoms. Upon other occasions, the topical affection is neither preceded by puerperal fever, nor rigors, etc., but soon after it has taken place, the pulse becomes more frequent, the heat of the body is increased, and the patient is affected with thirst, headache, etc. The pyrexia is very various in degree in different patients, and sometimes assumes an irregular remittent or intermittent type. 
" The complaint generally takes place on one side only at first, and the part where it commences is various ; but it most commonly begins in the lumbar, hypogastric, or inguinal region, on one side, or in the hip or top of the thigh, and corresponding labium pudendi. In this case, the patient first perceives a sense of pain, weight, and stiffness in some of the above-mentioned parts, which are increased by every attempt to move the pelvis or lower limb. If the part be carefully examined, it generally is found rather fuller or hotter than natural, and tender to the touch, but not discolored. The pain increases, always becomes very severe, and in some cases is of the most excruciating kind. It extends along the thigh, and when it has subsisted for some time, longer or shorter in different patients, the top of the thigh and the labium pudendi become greatly swollen, and the pain is then sometimes alleviated and accompanied with a greater sense of distention. The pain next extends down to the knee, and is generally the most severe on the inside and back of the thigh, in the direction of the internal cutaneous and crural nerves; when it has continued for some time, the whole of the thigh becomes swollen, and the pain is somewhat relieved ; the pain then extends down the leg to the foot, and is commonly most severe in the direction of the posterior tibial nerve; after some time the parts last attacked begin to swell, and the pain abates in violence, but is still very considerable, especially on any attempt to move the limb. The extremity being now swollen throughout its whole extent, appears perfectly or nearly uniform, and it is not perceptibly lessened by a horizontal position, like an edematous limb. It is of the natural color, or even whiter; is hotter than natural; excessively tense,, 


891 
PHLEBITIS. 
and exquisitely tender when touched; when pressed by the finger in different parts, it is found to be elastic, little if any impression remaining, and that only for a very short time." 
He further remarks, that it sometimes happens, when the disease has abated in one limb, the other is attacked in a similar way ; and that instead of terminating by resolution, it sometimes terminates by suppuration in one or both legs, and occasions ulcers which are difficult to cure. In a few instances, he says, gangrene has supervened, and in others, the patient is destroyed by the violence of the disease before the supervention of either suppuration or gangrene. 
Causes.—In the course of our remarks upon simple and undisputed phlebitis, we indicated its usual causes ; and as to the cause of crural phlebitis, or phlegmasia dolens, we had as well, perhaps, have nothing to say, because we really know nothing, further than the attending phenomena. Dr. Lee says: "In uterine phlebitis the inflammation can not, it is true, be traced in all cases to the semi-lunar shaped orifices in the lining membrane of the uterus which communicates with the sinuses where the placenta had adhered; yet it scarcely admits of a doubt that the frequent occurrence of the disease arises from the orifices of these v.eins, in the lining membrane of the uterus, being left open after the separation of the placenta, by which a direct communication is established between the cavities of these veins and the atmospheric air, in a manner somewhat analogous to what takes place in amputation and extensive wounds." 
This, at best, is mere speculation, but it is as good as can be offered, and therefore it is useless for us to pursue this branch of the subject further. 
When this form of disease takes place in women who have not been recently delivered, it is under the circumstances of suppressed menstruation, malignant ulceration of the os and cervix uteri, and other organic diseases of the uterine organs—so says Dr. Lee. When the disease happens to men, it may have originated in " hemorrhoidal, 


892 
INFLAMMATORY FORMS OF DISEASE. 
vesical, or in some of the other branches of the internal iliac veins, in consequence of inflammation or organic changes of structure in one or more of the pelvic viscera. Crural phlebitis in men, arises much more frequently, however, from inflammation being excited in the superficial veins of the leg, extending upward, and involving the great venous trunks of the thigh and pelvis."— Cy. Prac. Med. 
Treatment.—In the early stages of phlebitis, mild cathartics may be given, after which the bowels should be kept regular daily. The affected limb should be exposed to a vapor-bath until perspiration has been induced, after which an anodyne poultice must be applied, and the whole limb enveloped in it—we prefer a poultice of bran and hops. This should be continued, alternating the use of the vapor-bath and poultices, until the inflammation has subsided. 
Internally, the Compound Tincture of Virginia Snakeroot, or Compound Powder of Ipecac, and Opium, should be given in sufficient doses to keep up moisture of the skin, as well as to relieve the pain which is present. In very obstinate cases the addition of nauseants and relaxants will be found advantageous. 
The patient should be kept in a recumbent position, and allowed a light diet; and after the inflammation has been reduced, if any edema remains, the limb should be bandaged, but not too tightly, and cooling diuretics given. 
In cases of debility or prostration, arising from whatever cause, stimulants and tonics must be given to sustain the strength, of the patient, such as wine-whey-wine, Quinia, Cornine, Hydrastin, preparations of Iron, etc.; and in chronic cases, to favor absorption, the Compound Syrup of Stillingia with Iodide of.Potassium should be given. 


CLASS II. 
NON-FEBRILE FORMS OF DISEASE. 
In this class of morbid actions, neither fever or inflammation is ever to be regarded as an essential element of the disease, and yet, it is not to be taken for granted that neither of them will ever be present; but when it occurs, it may be pretty safely affirmed that the type or character of the disease has changed—lias become to belong more or less to the first class. 
This class is clearly divisible into two orders. The morbid actions comprised by the first, proximately at least, appear to inhere in the vascular system —these are hemorrhages. Those of the second appear as clearly to inhere in the nervous system, and are usually denominated nervous or chronic diseases. Their pathology, as yet, is but imperfectly understood, aud their treatment is tedious, uncertain, and too generally unsuccessful; and both for the reason that cerebral organization has not been sufficiently investigated in relation to its functions. Hitherto, so far as the writer has learned, no one has thought of referring phthisis, asthma, apoplexy, epilepsy, catalepsy, etc., to defective or peculiar cerebral organization. 
This order is obviously divisible into three genera ; the first consists of the morbid actions of the organs of internal relation — those which affect directly, the existence and well-being of the individual. 
The second embraces the morbid or deranged actions of the organs of external relation—those which adapt us to the surrounding world ; and, 
The third consists of morbid actions of those organs which have for their fnnctions, the perpetuity of the species. Their relations are of a mixed character. 
893 


894 
NON-FEBRILE FORMS OF DISEASE. 
ORDER I. 
MOEBID ACTIONS FKOM VASCULAR IRRITATION. 
Hemorrhages have been divided into traumatic and spontaneous, and the latter into idiopathic and symptomatic. The idiopathic alone will now engage our attention. We propose to group together into one order, the usual forms of hemorrhage, not through any conviction of propriety, but through obedience to fashion or custom, and under this custom for the sake of convenience. We can not conceive of an idiopathic hemorrhage, nor of a hemorrhagic form of disease; but custom has decreed that certain hemorrhages shall be treated of as so many forms of idiopathic disease, and we obey. In this place it is proper to say so much of hemorrhage as is common to all of the socalled idiopathic forms of it. 
At one time, and naturally enough, it was supposed that all hemorrhages depended upon a rupture of blood-vessels, and this opinion is not, even now, without its advocates ; but since the investigations and expositions of Bichat, they have continued to become reduced in number, so that, at this time, they are indeed few. 
That hemorrhages do occasionally result from lesions of the vessels, will probably be denied by no one, but such instances must be so few in number, comparatively, as barely to constitute an exception to what may be safely regarded as a general fact, that they result from a transudation, or exhalation ; for Bichat maintained that it was effected through the exhalants. But it may pass the vascular extremities, either through a local absence of normal resistance, or an increased propelling force. 
Hemorrhages have been again divided into active and passive; the former is said to obtain when there is in the system an increased vascular excitement, and consequently a preternatural flow of blood to the part. The general cir- 


MORBID ACTIONS. 
895 
dilation does not, however, always manifest an increased momentum in active hemorrhages; on the contrary, the activity of the heart and arteries is sometimes depressed, but in such cases there is a strong hemorrhagic excitement in the organ itself. Thus, we sometimes have active pulmonary and uterine hemorrhages in persons who are feeble, and whose pulse is small, weak, and frequent. Nevertheless, active hemorrhages usually occur in the young and plethoric—in those who have an excess of stimulus—those in whom the vital forces are largely developed, and whose temperament possesses a high admixture of the sanguine. This species of hemorrhage is sometimes preceded by a full and rebounding pulse, redness, and fullness of the skin, alternating flushes of heat and chills, with a sense of weight and pressure in the part; but frequently it is attended by no premonitory symptoms —suddenly breaking forth in a full stream. 
In the passive variety of hemorrhage there is decreased vascular activity in both the general circulation and in that organ or part in which the hemorrhage occurs. The fact that this hemorrhage is passive, is strongly to be inferred from the circumstance that stimulants are the most effective remedies. It is thought to depend upon mere relaxation or inactivity of the vessels, and not upon any morbid quality of the blood. It generally results from the exhaustion that is effected by chronic forms of disease, particularly scurvy and the typhous forms of fever. It is contended by some that all hemorrhages are active. This is true, if we contemplate the phenomena merely in its mechanical relations, but when we regard it as a vital one, it does not appear difficult to conceive of such a deficiency of vital tonicity in the small vessels as to render them incapable of resisting a hemorrhagic flow of blood. This very fact is sometimes witnessed after death, when there is no other propelling force than that of gravitation. A state of debility very nearly approaching death often happens in cases of extreme debility from disease. In many cases of such debility there seems to bo a pretty general tendency to hemorrhage, 


896 
NON-FEBRILE FORMS OF DISEASE. 
more especially in those parts which offer the least resistance. 
Microscopists, however, deny that any pores exist in the capillaries large enough to admit the egress of blood corpuscles, but we can more easily believe that they have not discovered all of the minutiae of the human system, than to conclude that so many ruptures have taken place, in close contiguity, as will account for many of the hemorrhages which have been and are frequently witnessed, more especially as the ruptures, as well as the supposed existence of pores, have not been discovered. We might speculate upon supposable changes in the blood or in the tonicity of the capillary vessels, through the agency of supposable causes, and thus entertain the reader without instructing him. We prefer to be useful, and not being able to perceive the advantage to the practitioner of knowing how hemorrhages take place, we shall enter into no particular investigation of it. 
The consequences produced upon the system by an extensive loss of blood, are too well known to require that much should be said about them; we may remark, however, that the sensible phenomena produced by it, are paleness of the face, coldness of the extremities, feebleness of the pulse, nausea, vertigo, convulsions, syncope, and death. But such fearful results as convulsions, etc., do not frequently occur, because, when it has been so copious as to produce an obvious depression of the circulation, it spontaneously stops. The apprehensions of the patient greatly aid in bringing about this result. So long as the cause of the hemorrhage continues to exist, there will be much liability of its return. Sometimes it is of a periodic character, and when it returns annually, it is most generally in the spring, and the subjects are those who have a thin and delicate skin, and large organs of animal sensibility and muscular motion. It frequently recurs monthly with those females who have suppressed menstruation. 
Professor Wood treats of " constitutional hemorrhage!" Could we not with the same propriety speak of constitu- 


897 
MORBID ACTIONS. 
tional intermittent fever or catarrh? He says: "In some persons, a strong constitutional tendency to hemorrhage exists, so much so, that the slightest causes will often bring on an attack, and, when the blood begins to flow, it is exceedingly difficult to arrest it. A slight wound, even the scratch of a pin, will sometimes occasion a serious and even alarming hemorrhage." Is not the same true of many persons with reference to intermittent fever and catarrh ? This hemorrhagic " tendency," amounts at last to nothing more than a liability which is stronger in some persons than in others—merely an organic peculiarity. 
" The constitutional predisposition" (?) he says, " is sometimes a family peculiarity." He further adds, that it is " not unfrequently hereditary ," and then cites some interesting examples of it, and notes a remarkable peculiarity in connection with it, viz: that this family predisposition was almost entirely confined to the males; and lastly, he says : " Nothing has been noticed in the habits or previous health of the individuals affected, sufficient to account for the peculiarity." 
The writer has witnessed some phenomena in human society as strange and unaccountable as the preceding. He once saw a family of seven children, consisting of four sons and three daughters, all of whom, like the father, had red heads ; but between the sons and daughters there was this peculiar difference: the boys, as they reached puberty, commenced having a beard ; there was, furthermore, certain sexual differences. Nothing had been noticed in the habits or previous health of the individuals sufficient to account for their peculiarities ! 
To be serious, is there anything in either of these cases more strange than the fact that apple-trees bear apples, and not peaches or plums ? "Would it be proper to call the organic constitution of the apple-tree, to bear apples, a "predisposition V But the females did not have the hemorrha- 
' gic liability to the same extent that males had, and for the reason that females, as a class, have not the high stimulus (according to Hall), or the vital forces so largely developed 


898 
NON-FEBRILE FORMS OF DISEASE. 
as the males. Professor "Wood, in the same connection, states that this hemorrhagic "predisposition " was, in mature age, replaced by rheumatism. Have we not shown, under the head of rheumatism, and under some other heads, incidentally, that acute rheumatism is always associated with a high endowment of the vital forces ? In the cases cited by Professor Wood, not a single fact is given to show that the smallest degree of predisposition existed in either case ; there was merely a greater liability to hemorrhage under the usual causes of it, than is common to the race, just as some persons are, under temptation, more liable to steal than others. 
Professor Wood, however, is not the only one who has manifested surprise at the peculiarities above referred to; Eberle and others speak of the same as being unaccountably singular, and yet there is nothing about the subject that can be regarded as strange, for we witness a manifestation of the cause in a hundred other forms every day, and there is nothing in them that is mysterious, except the integrity of the laws of procreation, that secures to progeny, as a part of their inheritance, ancestral peculiarities of organization, whether favorable or unfavorable. 
With these remarks upon hemorrhage in general, we proceed to notice some of its special forms. 
Genus I.—Epistaxis— 
Hemorrhage from the Nostrils. 
Of all the special hemorrhages, this is, perhaps, of the most frequent occurrence; and it may be either active or passive—so the writer supposes, for he never witnessed a nasal hemorrhage of the passive variety, nor has he ever witnessed one of the active, when spontaneous, except in young persons who possessed a high endowment of the vital forces, such as would occasion a strong liability to rheumatism at a more advanced age. But, according to authority, it may occur even to those who are advanced in years. 
The approach of epistaxis is sometimes indicated by a sense of fullness, heat, and itching in the nares, or by a 


EPISTAXIS. 
899 
feeling of fullness, and a dull pain in the forehead, or by giddiness, or by dizziness, or deranged vision, or coldness of the extremities; but the most uniform sign of its approach is redness of the eyes and flushing of the face. Though it is common for it to be preceded by some of the above symptoms, as premonitory, yet it frequently occurs without any observable or conscious introduction. 
It may appear in drops, or it may flow in an unbroken stream, and the quantity may consist of only a few drops, or it may continue to flow until enough is not left to sustain existence. The color of the blood is florid, and its character coagulable. 
This hemorrhage is irregular—that is, it is very rarely strictly periodic in its recurrence ; and it is equally irregular in its course and duration. When it occurs in the plethoric, and in those who are so organized as to be liable to active congestion of the brain, it is, when not excessive, highly useful; it is frequently useful, also, when it occurs vicariously. It is not generally to be considered as of much moment; still it is sometimes very alarming, and possibly in a very few instances fatal; the writer is of the opinion that he has twice prevented a fatal termination. 
The passive variety is said to be the most dangerous, but this, perhaps, never happens, except with those who have become so prostrated by previous disease, that the hemorrhage appeared only as a preferable mode of death. 
Causes.—Professor Wood says : " Where no predisposition to epistaxis exists, it is seldom produced except by direct violence ; but, with such a predisposition, very slight causes are sufficient to induce an attack." How can we know those who are predisposed ? This is a very important point to the physician. Professor Eberle says: "Whatever has a tendency to produce a preternatural determination of blood to the head, may give rise to this variety of hemorrhage, such as insolation, stimulating ingesta, protracted study, the warm-bath, sneezing, coughing, playing on wind instruments, violent parturient efforts, straining in evacuating the bowels, a depending position of the head 57 


900 
NON-FEBRILE FORMS OF DISEASE. 
violent affections of the mind, strong Hushing, intestinal irritation, heavy lifting," etc. Now, it has so happened that the writer has been subjected to all of these producing causes, except the parturient efforts, and has never had epistaxis but once, and then it was occasioned by a severe blow on the nose, and he is fully satisfied that more than a half of the community, in this respect, are constituted like himself—absolutely not liable to this hemorrhage from the causes above assigned. It appears, then, that the teachings of the professor will not apply to at least one-half of the community, consequently, it i3 evident that some further information is requisite to render them available. The flow of blood to the head, under the circumstances named, is not preternatural, but entirely natural—and not to happen would be preternatural—and y et epistaxis will not result from it, except in a very few. If the professor had said, insolation, stimulating ingesta, etc., are calculated to produce epistaxis in those who possess highly-endowed vital systems, those who possess so much stimulus that any increase proves mischievous, he would have been instructive. 
Professor Eberle adds, as causes of this hemorrhage • " Chronic visceral disorders, particularly indurations of the spleen and liver ;" also, " suppression of the menstrual and hemorrhoidal evacuations," and concludes by stating that it " is of no uncommon occurrence in dropsical patients, and in the latter stage of cachectic diseases, particularly scurvv." 
Diagnosis.—In some cases of epistaxis the blood flows posteriorly, and in such instances it is sometimes swallowed and occasions nausea and vomiting, and sometimes a little of it enters the glottis and produces coughing, and hence fears sometime arise that the patient has hematemesis or hemoptysis. This is more especially the case when the hemorrhage occurs during sleep. But all doubts may be solved by causing the patient to blow his nose and clean the posterior nares, for by so doing some remains of epistaxis will be brought to view. 
Treatment.—In those cases of epistaxis where no con- 


EPISTAXIS 
901 
stitutional symptoms are present, and no plethora or fullness abcut the head, if it does not soon cease spontaneously, means may be used to check it; ordinarily, bathing the nostril in cold water will suffice, but where this does not answer, various other means may be used. The patient should be placed in a sitting posture, with the neck free from compression by cravats or otherwise, and cold water, snow, etc., may be applied to the nostril and to the back of the neck ; but the best means are astringent applications ; thus a mixture of equal parts of Alum, Gum Arabic, and Geranin, may be passed into the nostril upon a piece of moistened lint or cotton, and retained there for some time; or other astringents may be applied, either in solution or by snuffing up the dried powder, as of Kino, Catechu, Galls, Extract of Rhatania, Matico, etc. Dried beef, grated fine, and the nostril filled with it, has proved very serviceable; also pressure on the outside of the nose over the artery. 
If the extremities become cold, hot pediluvia with sinapisms to the feet may be employed ; and where the pulse is full, strong, and excited, with symptoms of determination to the head, a brisk cathartic will be found very beneficial. If both arms are raised suddenly and perpendicularly while the patient is standing, and retained in this position for some time, it is very apt to give permanent relief. Various other means have been advised, but we have always succeeded with the above. 
Where there is a tendency to a return of the hemorrhage, with an irritable state of the nasal membrane, it may be removed by applying an infusion of Hydrastis, with Sesquicarbonate of Potassa dissolved in it, on a piece of lint or by means of a camel's hair pencil, to the affected membrane ; from eight to twenty grains, or more, of the salt may be added to an ounce of the infusion. 
Should the epistaxis be owing to some constitutional difficulties, or be vicarious, the proper means must be used in connection with the above, to remove the difficulties, before much relief can be expected to follow. The nostril may be plugged with sponge, with Beloc's nasal instrument. 


902 
NON-FEBRILE FORMS OF DISEASE. 
This, perhaps, will not be as effectual as the following treatment by Professor Powell, who says: 
In the treatment of epistaxis, the writer is of the opinion that he has a certain, a never-failing remedy, which is not in the possession of the profession, and although the duty of adding the treatment does not devolve upon him, yet he feels it to be his duty to lay it before the public, more especially as he feels sure that Professor Newton will have no objection. 
Upon being called to a case of expistaxis, in which every means known to the profession have been tried without apparent advantage, and the dissolution of the patient is strongly threatened, for he has never had an opportunity of trying the remedy under any other circumstances, he immediately orders the procurement of a portion of the small intestine of a pig (in the country a pig can always be had, and in the city every physician should be provided with some of it,) and orders it to be cleaned and scraped as though it was intended for sausage meat. He ligatures one end, and with a curved wire or probe introduces it into the posterior nares ; another ligature is placed around it immediately in front of the anterior nares and placed under the care of an assistant who is instructed to draw it as soon as he finds that the operator has that portion which is in the nose completely inflated, which he does by blowing into it through a goose's quill. This intestinal membrane being very thin, insinuates itself into every little inequality, coagula form upon it, and hemorrhage is instantly arrested. When arrested in one nostril, it will frequently commence in the other, and when it does, apply to it the same remedy. After a proper time has elapsed, cut the anterior ligature and cause the patient to blow through his nose, and the membrane will be dislodged. The writer does not believe that this application will ever fail, and he believes that he has saved several patients by its use. 


903 
HEMATEMESIS. 
Genus II.—Hematemesis — 
Hemorrhage from the Stomach. 
This affection may be active or passive, acute or chronic* It consists generally of a sanguineous exhalation from the mucous lining of the stomach. The hemorrhagic matter is generally thrown up by vomiting, but occasionally it finds egress by stool, and has very generally a grumous aspect, of a very dark color, and sometimes in coagulated clots. In the active variety, it is sometimes florid and liquid. Sometimes it is black and tar-like, but in such cases the true seat of the affection is thought to be in the liver. When hematemesis is symptomatic its character of course will be modified by the reigning disease ; but with its symptomatic peculiarities we have nothing to do in this place. 
The premonitory symptoms of hematemesis consist of a feeling of weight and pressure in the epigastrium ; foul breath ; loss of appetite, or else it is voracious ; tenderness in the hypochondria, possibly pain ; acid eructations ; alternating flushes of heat and cold; a tendency to syncope ; cold extremities ; a shriveled countenance ; a contracted and irritated pulse ; great anxiety ; a feeling of constriction about the breast; extreme sickness at the stomach ; a confusion of the senses, and lastly, ejections of blood, by vomiting, make their appearance. 
Causes. —The most frequent of these are said to be indurations of the liver and spleen. It is sometimes occasioned by a suppression of hemorrhoids; menstrual irregularities in young females, frequently produce it; and it is sometimes occasioned by the final cessation of the menses ; it appears sometimes to be occasioned by pregnancy. To these and similar causes may be added such as are chemical, as acrid substances, and such as are mechanical, as blows on the epigastrium. 
Prognosis.—The danger of hematemesis does not depend upon the quantity of the hemorrhage, but upon the functional derangement it may occasion to the stomach, which may eventually end in dropsy, hysteria, dyspepsia, great 


904 
NON-FEBRILE FORMS OF DISEASE. 
relaxation, debility, and death. "When occasioned by visceral obstructions, and more especially with the intemperate, the most danger is to be apprehended. When it supervenes suppressed hemorrhoids, or the menses, the danger is not considerable; indeed, it has been known to occur monthly instead of the menses without any mischievous results. 
Treatment.—It is only in the uncomplicated condition of this species of hemorrhage that we can expect to accomplish much permanent benefit; if it be dependent upon softening of the liver or of the stomach, cancer of the stomach, or other organic affections, but little can be done. In the treatment of it, we pursue a similar course to that named for hemoptysis, with the exception of the addition of of Geranium Maculatum, or Geranin, to the astringents administered. Geranium, added to the Compound Powder of Ipecac, and Opium, may be given with advantage, and sinapisms over the epigastric region will often afford rapid relief. In cases attended with constipation, or where catharsis is indicated, stimulating purgative enema should be used in preference to the administration of this class of agents by mouth. 
When complicated with other organic diseases, these must be treated, as recommended under their respective heads. 
Genus III.—Hematuria — 
Hemorrhage from the Urinary Organs. 
This hemorrhage may be from the kidneys, the ureters, the bladder, or urethra, and like other hemorrhages it may be active or passive, and like hemorrhage in other mucous membranes it must take place by exhalation, for in these membranes ruptures are exceedingly uncommon. This variety of hemorrhage sometimes occurs periodically, more especially when its source is the neck of the bladder and is associated with a hemorrhoidal condition of the system. 
The aged are more liable to this form of disease than the young, more especially when of a rheumatic organization, and those of this class are still the most liable to it who 


905 
HEMATURIA. 
have been troubled with hemorrhois. It is said to occur frequently with young children during the process of dentition. 
The essential symptom is the evacuation of blood by the urethra, preceded by pain in the region of the bladder, or kidneys, and attended by a feeling of faintness. 
Diagnosis.—There are but a few instances in which a correct diagnosis is more essential to the practitioner than in this ; not in the way of distinguishing this hemorrhage from others, but in the discovery of its particular seat; because it can not be a matter of indifference whether it proceeds from the bladder, ureters, kidneys, or urethra. If, therefore, the blood be unmixed with urine, and evacuated without an effort, the very probable inference must be that it proceeds from some portion of the urethra. If the hemorrhage be from the bladder, it will be attended with a dull or stinging pain about the neck of the bladder, with much uneasiness, and probably a feeling of pressure or fullness in the perineum, painful erections of the penis, and sensation of burning in the glans penis and about the anus. The blood will appear with small flocculi and coagula suspended in it. The coaguli, sometimes, is too large to pass the neck of the bladder, and consequently produces a suppression of the urine and a demand for the catheter. 
When the hemorrhage is from the kidneys or ureter it is without flocculi or coagula, but so intimately blended with the urine as to give it a bloody appearance, but upon standing sometime the blood settles to the bottom of the vessel, leaving the urine clear. 
Causes.—These are numerous, particularly with those who possess a strong hemorrhagic liability ; but, as we remarked in treating of hemoptysis, those who possess a lean and dense fibrous system are scarcely vulnerable to it under any circumstances, except from calculous concretions and gonorrhea. With its proper subjects it may be occasioned by acrid diuretics ; scirrhus ; ulcerations ; tumors in the ureter, kidneys, or bladder ; mechanical agitation of the body, as rough carriage riding, by any cause, indeed, 


906 
NON-FEBRILE FORMS OF DISEASE. 
that increases the momentum of the arterial circulation, or very greatly relaxes the capillary. With the aged, a suppression of hemorrhois is not an unfrequent cause. It is sometimes occasioned by a suppression of the menses ; in such instances it may be considered vicarious. 
Prognosis.—Hematuria is never attended with danger from the loss of blood ; but when it is of frequent recurrence and copious, as it sometimes is with the aged, it results in dropsical effusions. Its vicarious appearance is never attended with danger. The passive variety of it in the last stage of a severe form portends the utmost danger- 
Treatment.—When uncomplicated, hematuria is to be treated similar to the other hemorrhages, by astringents, rest, abstinence, and cooling mucilaginous drinks, with other auxiliary means, as indicated by the symptoms. When it is of a passive character, the Oil of Turpentine may be used with benefit, and which agent will be found of much service in all passive hemorrhages not connected with conditions which would contra-indicate its use. Intrusions of Lycopus Virginicus, Geranium Maculatum, Althea Officinalis, or Uva Ursi, may be used alternately, in obstinate cases. 
Genus IY.—Hemoptysis — 
Hemorrhage from the Lungs. 
Professor Eberle says: " This term is applied to hemorrhages from the respiratory passages, whether they proceed from the larynx, the trachea, or the bronchia." Why not add the nostrils ?—they too, are respiratory passages. Dr. Robert Law says, that if this term was taken in the full latitude of its etymology it would include " every discharge of blood from the mouth, but use," he says, " has annexed to the term a more limited signification, restricting it to expectoration of blood, or that which originally issues from the respiratory organs." The first part of this clause is a correct definition, but the second part is erroneous, because, as in that of Professor Eberle, it embraces the nares, and at best, the definition is far from being definite—nevertheless, it is generally understood. 


907 
HEMOPTYSIS. 
There is no period of life that is entirely exempt from this hemorrhage, although its most frequent appearance is between the ages of fifteen and thirty-five years —the period in which the organization is most actively merging toward an equilibrium ; and there is no other hemorrhage that excites in the mind of the patient so much alarm, and for the reason, no doubt, that it is a frequent indication of a very incurable malady, phthisis pulmonalis. 
The quantity of blood discharged by this hemorrhage varies, very greatly, in different cases; sometimes it amounts to a mere tinge of a single sputum, while in other cases, and possibly in the same at other times, the quantity is truly alarming and equally surprising that so much can be expended without an extinction of life ; yet the waste of this large quantity is frequently repeated at comparatively short intervals for months and even years, and still leaves in the organization a possibility of its return to good health. 
When we contemplate the similarity that exists between the effects of both fear and hemorrhage, it will sometimes be difficult to determine how much of the constitutional symptoms, in any given case, is to be attributed to the latter. In a person of firmness and fortitude, the symptoms measurably may indicate the disease ; but in the nervous, timid, and fearful, the greater number may have been occasioned by the fright which the hemorrhage produced. 
This morbid action, like that of epistaxis, is sometimes introduced without any premonitory symptom, but most generally it is preceded by some of the following symptoms, viz : a feeling of lassitude in the extremities, particularly in the inferior ones ; a short or hacking cough ; palpitation of the heart; a stricture across the breast; anxiety and frequent sighing ; a chilly sensation which may amount to a moderate chill; a deep-seated and burning pain under the sternum, much like that which sometimes precedes an attack of intermittent fever ; irritability of disposition ; a quick, frequent, and small pulse, and flushings of the face. 
After the continuance of these symptoms, or many of them, for some time, there occurs some evidence of, appa- 


908 
NON-FEBRILE FORMS OF DISEASE. 
rent, reaction in the system, such as a sensation of warmth in the chest, which is felt to rise toward the larynx, and appears to provoke some hawking, or possibly coughing, which is followed by the hemorrhage. "When premonitory symptoms are absent, the hemorrhage is apt to be slight; but whatever may be its character in this respect, when this hemorrhage has appeared, it is apt to recur frequently for sometime afterward. 
When this hemorrhage is of that kind which we propose to consider—the idiopathic—the blood is florid and frothy ; but when symptomatic, or a mere attendant upon some other form of disease, as scurvy, fevers, etc., the blood is dark, and even very dark. In determining the precise locality of the hemorrhage, considerable difficulty is sometimes experienced. When the blood runs passively out of the mouth, or is spit out, without coughing or hawking, we may rest assured that its source is not below the fauces; but it does not certainly follow that when it is coughed up, its source is below the fauces, because more or less of it may reach the glottis, and occasion such irritation as to produce coughing and even vomiting. 
When hemoptysis has once occurred, a strong probability exists that it will, at irregular periods, recur again. It has been known to recur periodically, as at a particular hour every day or every other day, and continue for months. It has also been known to occur every month instead of the catamenia. The writer once had a case of this kind which had been treated as a case of undisguised hemoptysis. 
It is said that some persons are predisposed to this hemorrhage. This position we deny ; but we admit that some persons are, normally, much more liable to it than others. A predisposition to it, however, does sometimes exist, but it is an attendant upon some other form of disease. To idiopathic hemoptysis, or any other hemorrhage, a predisposition can not exist. In such cases the fault is organic and not pathologic. 
Causes. — With some constitutions, as the lean and fibrous, scarcely any cause, except mechanical violence, can 


HEMOPTYSIS. 
909 
produce it, and hence those in whom it occurs from other causes, may be regarded as being organically liable to it. With such it may be caused by violent muscular exertions ; atmospheric changes; the sudden suppression of ulcers ; the repulsion of cutaneous eruptions ; a sudden reduction of atmospheric pressure ; costiveness ; mental excitement, ; loud speaking; the inhalation of acrid matter; organic disease of the heart; functional derangement of the liver; interruptions to the circulation of the blood; and in muscular men, the abandonment of accustomed muscular labor, proves a more frequent cause than has hitherto been imagined. 
Prognosis.—This affection is, in all cases, calculated to excite fearful apprehensions, and yet it is never fatal through a loss of blood, nor particularly dangerous except to those who have a phthisical organization. Most generally, the danger is but moderate when the hemorrhage is copious, as this usually happens to those of a rheumatic organization; and yet, it is with them sometimes fatal. When the hemorrhage is so slight as merely to stain or streak the matter expectorated, much danger should be apprehended, because such cases are generally confined to a phthisical organization. But, whatever may be the character of the hemorrhage, if it be associated with a phthisical organization, danger should be apprehended. If it has occurred in a contrary organization, and from such causes as are calculated to produce pulmonic congestion, as great muscular exertion, particularly in a stooping posture, no very serious consequences need to be expected. 
Treatment.—In the treatment of hemoptysis, we place our principal reliance, as far as medicinal means are concerned, upon astringents, tonics, and sedatives, and have found the greatest benefit to accrue from the following preparation : 
H. Lycopus Virginicus, 3ss, Boiling Water, O. ss. Mix, 
Infuse for fifteen or twenty minutes, and when cold, about two fluid ounces may be given two or three times a day ; 


910 
NON-FEBRILE FORMS OF DISEASE. 
and if the hemorrhage be very copious, it should be given every fifteen or twenty minutes, and continued until it is checked. This agent exerts both a powerfully sedative and astringent influence. 
After the hemorrhage is arrested, to prevent a return of the attack, as well as to impart tone to the general system, the following tonic compound will prove beneficial: 
R. Pulv. Hydrastis Canadensis, Pulv. Prinos Verticellatus, da 3j. Mix. 
One-fourth of this is to be added to one pint of boiling water, and when cold, the infusion is to be taken in the course of the twenty-four hours, and thus repeated daily. Or the following may be substituted: 
H. Sulphate of Quinine, Hydrastin, da grs. xx. Mix, 
Divide into ten powders, and administer three powders a day. 
In connection with this treatment, the patient must be kept still, lying in bed, on his back, the body being comfortably warm, and the room properly ventilated. He should be enjoined to keep as still as possible, and any mental excitement must be avoided. 
In cases attended with febrile or inflammatory symptoms, the feet may be bathed in warm water and sinapisms applied to them; and diaphoresis should be produced either by the spirit vapor-bath, or by the agents usually given internally for that purpose. In very severe cases, ligatures may be applied to the limbs. If cough be present and proves very troublesome, it must be allayed by expectorants, for so long as this exists the hemorrhage will continue. 
To convey an idea of our treatment in hemoptysis, we select the following case from our clinical reports for March 29, 1853: 
" Case ix.—H. R., aet. 20, Hemoptysis.—The hemorrhage from the lungs has been very bad. He was first attacked about two weeks since, and theri he bled nearly a pint. 


911 
MENORRHAGIA. 
He had suffered severely from pain and soreness of the chest for four weeks previous to the attack. He is a printer, and thinks much of the difficulty was produced by working too hard at the press. He has a very flat chest; can discover no organic derangement of the lungs. Two of his sisters have died of consumption. There appears to be much debility of the respiratory action ; has frequent paroxysms of coughing, but unattended with much expectoration. This hemorrhage may have been produced by a debilitated condition of the lungs, and not the result of any acute or inflammatory condition of the lungs. He has bled several times from one to three ounces. 
H. Lycopus Virginicus, 3ss., Aqua, O. ss. 
Make a decoction. Take from two to four ounces at a time, and repeat four or five times a day ; and at the same time give the following expectorant: 
R. Syr. Squills, 3ij, 
Syr. Ipecac, 3i, 
Syr. Senega, 3i, 
Tr. Sanguinaria, 3ij, 
Simple Syrup, 3ss, 
Tr. Opi. Camphor, 3ss. 
Mix, and give one drachm every hour. For a tonic give 
R. Pulv. Hydrastis, 
Pulv. Prinos Yerticellatus, da 3i, 
One-fourth of which is to be added to one pint of boiling water, and this quantity to be used daily." 
This course was continued for about two weeks, and the young man was discharged cured, and has had no return of the hemorrhage since, though still pursuing his occupation as a printer. 
Genus Y. —Menorrhagia — 
Hemorrhage from the Uterus. 
This hemorrhage, like the preceding, is from a mucous surface, and like them results from exhalation, much more probably than by a rupture of small vessels. Of menor- 


912 
NON-FEBRILE FORMS OF DISEASE. 
rhagia there are many modifications, but for the present, our remarks will be confined to those which claim an idiopathic character. Like those hemorrhages which we have considered, it may be either active or passive. This distinction, to some, is exceptionable. Broussais maintained that all hemorrhages are active, and we admit that such is mechanically the tact; but the idea we intend to convey by the two terms, respectively, is this: the former is attended by a high endowment of vital force, and the second by a great diminution of it—depends upon a state of great debility or prostration. 
There is more liability to a great waste of blood from this hemorrhage than is common to any other, and its occurrence is, perhaps, more frequent. Sometimes it occurs so suddenly, that the patient has no warning of its approach, but more generally it is produced by a sense of weight and fullness in the uterus, and a frequent desire to urinate. If it be of the active character, the pulse will be full and rebounding, but if of the passive, then it will be small, frequent, and contracted. In females of a full habit, it may be very copious, but of short continuance —only a few hours ; but according to its general character it continues from several days to as many weeks. It occasions, sometimes, in delicate and prostrated women, amaurosis, and probably a pain in the head over one of the orbits, such as is commonly produced by gastric derangement. There is no form of hemorrhage so destructive to health as this ; those who are afflicted with a frequent recurrence of it, become dyspeptic, feeble, and anasarcous. The most prostrating attendant upon this hemorrhage is leuchorrea, which fills up the hemorrhagic intervals. 
Diagnosis.—Menorrhagia has been confounded with copious menstruation—the former is ' strictly a hemorrhage, while the latter is as certainly a secretion, and as such, it may be very copious, and yet compatible with good health. It is true, that copious menstruation is sometimes very prostrating, but in such cases it is not normal, and yet it does not become a hemorrhage. A proper attention to the 


913 
MENORRHAGIA 
evacuation will always furnish the means of diagnosis ; in hemorrhage the blood either coagulates or betrays such a tendency, but the menstrual evacuation continues fluid and exhibits no tendency to coagulation. 
Causes.—With those who possess a hemorrhagic organization, the active form of this affection may be produced by any cause that would produce epistaxis or hemoptysis with the same class of persons of the other sex, as wines, cordials, high-seasoned food, an intemperate use of the warmbath, and also of sexual indulgence ; with these may be named a tardy or costive condition of the large intestines. Passive menorrhagia may be produced by all the causes which are calculated to produce general debility ; as deficient nourishment, defective ventilation, a residence in a humid atmosphere, etc. But it should be remembered that these causes will never produce it in those who have a hemorrhagic constitution, until the general stamina of the constitution is destroyed. Those who are especially liable to this variety, are the organically feeble. 
Treatment. —In the treatment of this form of hemorrhage, the patient should be kept in a recumbent position, and everything calculated to induce a determination of blood to the pelvic region, must be avoided ; if constipation exists, it must be obviated by laxative enema, and if there be congestion of the portal circle, owing to hepatic torpor, Leptandrin, or some other agent which exerts an influence on the liver, without causing active catharsis, may be given. 
Applications of cold water or vinegar should be made over the abdomen and genital organs in connection with warm or cold astringent vaginal injections, as appear to be most suitable to the case, together with astringents administered internally. Should much nervous irritability be present, the Compound Powder of Ipecac, and Opium will be found serviceable, and in some cases Camphor, Valerian, Assafetida, or other antispasmodics. The following extract from Ashwell on Females, is in accordance with our views, and we give it in addition to the above : 
" Sexual intercourse stimulants, mental excitement, 


914 
NON-FEBRILE FORMS OF DISEASE. 
and physical effort, must be avoided for ten or twelve days before the periodic returns. When there is increasing pallor, edema, threatened dropsies, softening of the cervix, and aggravated debility—sea air, a mild but nutritious diet, consisting of animal food and milk, or malt liquor, must be enjoined. Where there is universal coldness of surface, especially of the extremities, frictions, by stimulating embrocations, the flesh-brush, and horse-hair gloves, the wearing of flannel, and worsted stockings, are indicated. The salt hip-bath, the local salt shower-bath, applied night and morning, by a common garden watering-pot, over the hypogastric and lumbar regions, are often advantageous. Nor is the injection of cold water, once or twice a day, into the rectum, to be forgotten. Astringent vaginal injections are deservedly relied on, especially if carefully administered during the intervals. Still there are cases, and occasionally I meet with a good many, where cold injections can not be borne. Local fullness, excitement, and pain, follow their use, and sometimes I have attributed to their employment an earlier and larger return of the hemorrhage. They are most beneficial where there is copious leuchorrhea, and from the cure of this morbid secretion, good may be invariably anticipated. It is to be remembered that the unmarried are liable to congestive menorrhagia, and I have often thought that their cure was more difficult aud protracted, and their hemorrhages larger, than where many children had been borne ; but I am not prepared to give a positive opinion. During an attack, the patient should lie on a hard mattress, be kept perfectly quiet, covered lightly with bed-clothes, and have warmth applied to the feet and legs ; hot bottles or mustard-poultices, may be used for this purpose. Her drink must be unstimulating and cold, except where there is syncope, and then wine in small quantities may be given." 


NERVOUS FORMS OF DISEASE. 
915 
ORDER II. 
NERVOUS OR FUNCTIONAL FORMS OF DISEASE. 
Introductory Remarks. — The forms of disease embraced by this order are very numerous, and are distinguished by the circumstance that they are measurably confined to those who possess an imperfect organization—some portion of the encephalon is in excess or deficient. This principle may be illustrated by a reference to apoplexy—in the active form the cerebellum is in excess, and in the passive it is not only small, but the cerebrum is decidedly large. 
The'difficulty of treating this order of morbid actions, is universally admitted, but so far as we have learned, it has never been attributed, directly and necessarily, to imperfect organization. That we are correct in this declaration, every physician may satisfy himself in a few years, by well-directed observation. There is no fact more certain than that some persons can not have acute rheumatism —that some can not have apoplexy, either active or passive. 
Finally, we do not hesitate to affirm that all forms of disease have their primary source—an organic liability, in the imperfections of the cerebral organization, and the time will come when the form and the size of the brain will as certainly reveal the morbid liability, as it now does the mental and physical character. 
Genus I.—Morbid Actions in the Organs of Internal Relation. 
As the functions of the organs of internal relation have for their object the well-being and perpetuity of the individual, their disease constitutes an assault upon life ; and but for the connection that exists between the ganglionic system or that of vegetative life, and the cerebel! > spinal 
58 


916 
NERVOUS FORMS OF DISEASE. 
system, no animal function would necessarily be involved. The ganglionic system, then, primarily and in reality, constitutes the organs of internal relation—their functions becoming manifest only through their instruments, the various viscera and tissues of the body. This system may be deranged or diseased to any extent compatible with life, without a necessary invasion of the mental and sexual functions. Hence the cerebral hemispheres, the posterior and anterior lobes, and a large portion of the cerebellum, if not the whole, have no necessary participation in this genus of morbid actions; the medulla oblongata or the mesocephale constitutes the only portion of the encephalon that is connected with the ganglionic system, and this for the purpose only of producing or securing an animal or mental consciousness of the condition of the vegetative system. 
Species I.— Asthma. 
This form of disease is characterized by great difficulty of breathing, usually occurring in paroxysms ; it is seldom attended with fever or organic derangement of the heart or lungs, but is evidently a nervous disease, and is entitled to the same classification as angina pectoris. Upon this point, we copy the following extracts by Dr. Kneeland, from the "American Journal of Medical Science." He says: 
" Both come on by sudden paroxysms, at irregular intervals. In both there is a sense of painful constriction and suffocation, of epigastric tension, with eructations, yawnings, coldness and paleness of the face, the pulse comparatively unaffected, difficulty of speaking, the health good in the intervals, until the arrival of secondary causes of dyspnoea (usually emphysema, or other symptomatic asthma). Both are alike brought on and influenced by atmospheric changes ; by the action of a cold, dry wind ; by mental emotions —perhaps also by hereditary predisposition. Both have been ascribed to the same lesions of the respiratory and circulating systems, even to ossification of the costal cartilages, coronary arteries, and cardiac valves ; both are 


ASTHMA. 
917 
relieved by the same treatment—narcotics, antispasmodics, and revulsives. 
Many cases of angina are recorded in which symptoms of asthma first appeared and disappeared in the course of the disease, viz: fits of nightly suffocation, after the first sleep, which compelled the patient to fly to an open window for relief. 
" The difference between angina and asthma may be explained by the different functions of the filaments of sensation and motion in the par vagum. In asthma, the dyspnoea is more characteristic than pain ; every muscular power is brought into action to introduce air into the lungs ; the diaphragm and pectorals contract convulsively; the desire for air is extreme, and the patient seems continually on the point of suffocation. During the paroxysm there is more or less absence of the respiratory sounds, from the difficulty the air finds in entering the pulmonary vessels; hence the violent and noisy laryngeal respirations. When the fit ceases there is copious expectoration, with mucous rales and cough. The muscular fibers of the bronchi and their ramifications are animated by the spinal accessory nerve ; the dyspnoea of asthma depends on the spasmodic contraction of these fibers, the partial obliteration of the air-passages requiring violent respiratory efforts to secure the necessary introduction of air ; in this constriction the larynx is involved, as evinced by the whistling of the inspirations—the non-introduction of air into the pulmonary vesicles accounts also for the diminution or even absence of the respiratory murmur." 
Prognosis.—When this disease is uncomplicated, it may be considered curable, notwithstanding the paroxysms are very alarming ; but when there is complication, with organic derangement of the heart or lungs, it should be considered as a fatal disease, and the treatment under such circumstances can be only palliative. 
Treatment.—During the paroxysm of asthma, relaxants and antispasmodics are to be used, in connection with the following liniment, which appears to exert almost a specific 


918 
NERVOUS FORMS OF DISEASE. 
influence over the spasm, as well as to assist in preventing a subsequent attack: 
R. Oil of Stillingia, 3j, 
Oil of Lobelia, 3ij, 
Alcohol, f3iij. Mix. 
The throat, neck, chest, and vertebral column, as far down as the fifth or sixth dorsal, must be bathed with this three or four times a day. With this, the following may be used internally: 
R. Syrup of Ipecac, 
Syrup of Senega, 
Syrup of Squills, da 3j, Tinct. Lobelia, 3ss. Mix. 
Of this, give about a fluid drachm every fifteen minutes, until nausea is produced. This course has always, in our practice, promptly removed the paroxysm, and if pursued for some time, giving the last preparation in nauseating doses three or four times a day, will effect a permanent cure. 
When asthma is complicated with gastric, hepatic, or other derangements, in addition to the above treatment, measures should also be directed toward the removal of the complication by the means recommended under their respective heads. 
Species II.— Asphyxia. 
By this term is understood an interruption of the respiratory functions, and consequently of the vitalizing effects of the air on the blood. Death soon follows the interruption of respiration, in man and the warm-blooded animals, resulting from asphyxia. Recovery is possible only after a short continuance in the asphyxiated state. In syncope there is a suspension of respiration, and also of the pulse, as in asphyxia, but we would not say of a female who had 


ASPHYXIA. 
919 
fainted that she was in a state of asphyxia. The sudden interruption to breathing that would be occasioned by a plaster being stuck over the mouth and nose would produce asphyxia. This was the mode employed by the notorious murderer, Burke, of Edinburgh, for providing the schools with anatomical subjects some years ago, and which received the appellation of Burking. This summary mode of preventing the ingress of air into the lungs by closure of the air-passages, and thus producing death by asphyxia, is termed suffocation. Foreign bodies lodged in the trachea, croup, etc., produce death in this way.' Death produced by compression of the larynx from without, as by hanging, is called strangulation. Another cause often producing asphyxia is submersion or drowning, the organization of the lungs of animals breathing atmospheric air not being adapted to appropriate the oxygen in water to the renovation of the blood. Another set of causes is the respiration of the gases, as hydrogen, carbonic, etc. The strong gases, as chlorine, etc., produce spasmodic closure of the glottis. Chloroform proves fatal now and then. External compression of the thorax and abdomen, from violence, or internal distention by air or water, as in pneumothorax and dropsy, may produce death by asphyxia. Spasmodic closure of the glottis and tonic contraction of the diaphragm and other muscles concerned in respiration, as in tetanus, may cause death by asphyxia. Division of the eighth pair or pneumogastric nerves, or other cause paralyzing the muscles of respiration, will cause death by asphyxia. Opium seems to produce death in this way —hence the indication of keeping up artificial respiration under poisoning by this drug. The phenomena and appearances vary more or less under the various causes by which asphyxia is produced, and the indications in the treatment will vary accordingly. 
Phenomena.—The distress which every one may feel by voluntarily holding the breath unto the longest moment possible, is the first symptom. The feelings of distress are attended with involuntary spasmodic efforts of the dia- 


920 
NERVOUS FORMS OF DISEASE. 
phragm and the associated muscles of respiration, betokening the most urgent desire for fresh air. The writer once succeeded in voluntarily suspending respiration for the space of sixty seconds by the ticking of the clock, lying upon the sofa. This was only accomplished after repeated efforts, and so distressing was the feeling referable to the lungs and diaphragm that the effort was never repeated. It is said that divers engaged in the pearl-fishery remain submerged two, three, and even five minutes ; but this seems incredible, though it is probable that repeated and practiced trials, under a state of presence of mind, bodily training, and the hope of gain in this perilous employment, may enable the adventurers to remain submerged a few minutes. The exact time, therefore, that respiration may be suspended without jeopardizing life depends upon circumstances ; and the longest period at which it is proper to desist from efforts to recover persons from a state of suspended animation, or asphyxia, is by no means a settled point. It depends upon age, and the circumstances and mode of production. The writer has succeeded in restoring infants to life born in the asphyxiated state, after an hour and some minutes' persevering efforts. But let us proceed with the more striking phenomena of sudden asphyxia. 
The distress for breath rapidly becomes agony ; deep and violent spasmodic efforts of the diaphragm, intercostal and other muscles concerned in the respiratory act, ensue; the face becomes turgid or livid ; the eyes protrude from the sockets ; torpor ensues, and quickly loss of consciousness, and then succeed irregular, convulsive movements of the trunk and extremities. A moment or two, and a state of perfect relaxation of all the muscles ensues, even to the sphincters, and involuntary discharges of urine and faeces often occur. 
When slowly produced, as under some forms of disease gradually impeding respiration, the sufferings will be more protracted, and beside the painful anxiety for fresh air, there is vertigo, with other symptoms indicating oppression of the brain, such as fiery sparks, ring-sounds, and tendency to coma. The skin gradually becomes cold and livid 


ASPHYXIA. 
921 
in patches, and the lips blue. Spasms or convulsions seldom appear, and death is gradual. 
The Game of death, in asphyxia, is ascribed to the deleterious effects of vicious blood sent to the brain ; for loss of sense and consciousness ensues before the heart ceases to beat. In recovery from asphyxia, the heart may be brought to beat for an hour before the other phenomena of life faintly begin to be manifested, first by a sigh, then by an audible expiratory moan, etc. 
The loss of sense, and the convulsions that ensue, points to the brain and spinal cord as the seat of the mischief, produced by the circulation through these nervous textures of carbonaceous or unoxygenized blood, and the patient dies, as has been strongly but quaintly expressed, poisoned by Ms own blood. The correctness of this theory is corroborated by the suddenly-poisonous effects produced by the inhalation of carburetted hydrogen, and other gases into which carbon enters largely; whereas, simple hydrogen and nitrogen gases operate only negatively by usurping the place of atmospheric air. The theory of the anesthetic effect of ether and chloroform inhaled, is, that they enter the circulation, and through it reach the brain and nervous system. Accounts are recorded of grave-diggers having fallen suddenly from the inhalation of the effluvia bursting from corpses dug upon. The rapid poisoning of the brain and nervous system by gases, through the blood, is undeniable. 
Treatment. —In the treatment of asphyxia, the first indi. cation is to remove the cause, if it can be discovered, which will often be the only means required. In other cases, the body should be stripped of clothing and wrapped in a warm blanket, with the head and shoulders somewhat elevated, and the patient should have free access to air. When the temperature of the body has not been diminished, cold water may be dashed over the face, shoulders, and even the spine, and artificial respiration should be at once resorted to, and persevered in for some time. 
If the body be wet or moist, it should be wiped perfectly 


922 
NERVOUS FORMS OF DISEASE. 
dry before placing it in warm flannel; and should water have entered the air-passages, the mouth should be carefully cleansed of frothy mucosities, by means of the finger or the feathered part of a quill, a catheter introduced into the larynx, and a syringe or the mouth applied to its outer extremity for the purpose of withdrawing the liquid ; and when this is accomplished, artificial respiration should be had recourse to. 
In addition to these means, stimulants must be applied to various parts of the surface for the purpose of influencing in this manner the nervous centers, but care must be had not to carry it to too great an extent, lest, when restoration ensues, violent inflammation may occur, followed by ulceration and perhaps sloughing. Stimulating enema will be found valuable in nearly every case, and frequently stimulants, introduced into the stomach by means of a tube and syringe, have proved advantageous. 
Electro-magnetism has been found a valuable auxiliary in the treatment of asphyxia; a current passed from the epigastrium to the back part of the head, has restored sensibility and vital action, when life was supposed to have become extinct. 
After restoration has taken place, it must be remembered that danger may still exist from disorder of the brain, owing to the previous congestion, or there may be inflammation of one or more organs, with more or less functional derangement, all of which require careful watching, and in the treatment of which, the practitioner should be governed by the character of the presenting symptoms. 
Species III.— Aneurism of the Aorta. 
The arteries are liable to various morbid conditions, as inflammation, and the deposition of osseous, cartilaginous, fibrous, and other formations, rendering their coats inelastic, thickened, and fragile, in portions and patches. These morbid conditions are the causes of aneurisms, or pulsating, bloody tumors and enlargements of arteries, of which the aorta is more frequently the seat than any other \ and 


ANEURISM OF THE AORTA. 
923 
aneurism of the aorta will therefore suffice as a type of this form of disease. 
Anatomical Varieties. —1. Complete or enlargement of a portion of the aorta on all sides. This is most apt to occur in the ascending portion and at the arch, but is met with also in the descending aorta. Sometimes there are several of these dilatations in the same case. The dilatation is not generally very great —not often over twice or thrice the natural size. If these weakened, inelastic, or diseased portions be distended much beyond this size, they generally burst; that is, the internal and middle coats give way at the weakest point, and the external or cellular coat is expanded into a sack, constituting a compound or mixed form of aneurism. 
2. Partial dilatation arises from a weakened or diseased patch on the side of the aorta, which, by the pressure of the blood, is expanded into a tumor, narrowest at the neck or opening from the aorta into the pouch. This form, for distinction's sake, or because the three coats are all expanded and surround the tumor, is called true aneurism. Aneurisms of the ascending aorta and arch, are, in the first stage, mostly of this variety ; but generally become of the mixed variety at a later period of their growth. Irregular coagula, adhering by peduncles to the walls of the sack, and fluid blood fill these pouches. 
3. Rupture of the internal and middle coats of the aorta, arising from ulceration or any of the before-mentioned diseased conditions, produces what is called false aneurism. The blood passing through the rent or fissure, distends the outer or cellular coat into a pouch. This is by far the most frequent form of aneurism, and frequently ingrafts itself on the two preceding varieties. Finally, the outer coat gives way, and the sack is bounded and formed by the contiguous structures and organs pressed upon becoming thicker and denser from the agglutination of surrounding cellular tissue. No structure can resist the progress of the growth of aneurism. Pressure and attrition annihilate every opposing organ and obstacle; even the 


924 
NERVOUS FORMS OF DISEASE. 
solid bones and cartilages are worn down and absorbed, and the tumor appears at last, externally. Concentric coagula are generally formed in these tumors. They sometimes burst into internal cavities, and sometimes externally. 
4. Mixed aneurism of the aorta is formed when false aneurism becomes ingrafted upon complete or partial dilatation. The aorta first becomes dilated, as in the first or second variety, and then the inner and middle coats give way at the weakest point, and aneurism of the third variety is superadded. This form constitutes a large proportion of cases. 
Symptoms, Signs, and Diagnosis.—Aneurism of the aorta, as has been observed, occurs more frequently in the ascending portion or arch, than in the descending aorta; hence thoracic aneurism is more common than abdominal, and also much more difficult of detection. There is no pathognomonic symptom or general sign for detecting a thoracic aneurism before it becomes so superficial as either to be seen or felt. Sometimes aneurism exists for years without any disturbance of the general health, and bursting, causes instant death. Generally there is functional disturbance, becoming progressively more and more severe and urgent, but of the character met with in organic affections of the heart, or severe lesions of other viscera, denoting obstruction in the circulation, such as dyspnoea, cough, livid countenance, palpitation, sudden starting from sleep, horrid dreams, oppression of the chest, as if crowded too full; the radial pulses may be dissimilar as to force, and not synchronous in beat; there may be wheezing respiration or hemoptysis, and a great variety of other symptoms, such as are met with in nervous affections, scirrhus of the stomach or liver, etc. 
It is only by uniting the auscultatory signs with the train of symptoms present, that a clear diagnosis can be made. The distinctive characteristic sound in aneurism, is a deep, hoarse tone, like that heard in rasping a board, of abrupt commencement and termination, and lasting but for a moment, following each beat of the heart or contraction of the 


925 
ANGINA PECTORIS. 
ventricles. This is most audible just above or just below the clavicles in thoracic aneurism, and decreases toward the heart. It is heard distinctly toward the right of the sternum, in aneurism of the ascending aorta, and a little to the left, in aneurism of the arch, and more distinctly on the back when the descending aorta is the seat. Pulsation is strong both above and below the clavicles, and when the tumor makes its way to the surface, the skin on the pulsating tumor becomes livid-red. When the abdominal aorta is the seat of aneurism, the pulsating tumor may be felt by the grasp, and diagnosed by the stethoscope. 
Prognosis.—Aneurism of the aorta is generally fatal, yet much may be done to prolong life, palliate suffering, and assist the efforts of nature in forming coagulation of the blood in the sack, by means of which a permanent cure is now and then effected. 
Treatment.—We would say, in regard to the treatment of this disease, very little is to be expected, and its introduction is given more to explain the peculiar phenomena which are presented, than for any other purpose. The indications are plain, but our knowledge to fulfill them is limited ; the only hope we can have is to form a fibrinous coagula in the sack, and thereby it may be obliterated. With the hope of accomplishing this, the patient should be confined to a recumbent position, avoid all stimulants and excitement, and confine himself to such diet as will not increase the quantity of the blood. 
Yarious mechanical means have been recommended, but as they have resulted in little or no benefit to the patient, we do not consider it necessary to introduce their description and application here. 
Species IY.— Angina Pectoris. 
This name was given by Dr. Heberden about seventy years ago to a paroxysmal and painful affection of the breast, deep in the throat, and shooting to the left axilla and arm. Perhaps one hundred well-marked cases have been reported through the journals since, many of which proved 


926 
NERVOUS FORMS OF DISEASE. 
fatal, and dissections have, in the majority of them, revealed disease of the heart or contiguous arteries. The subjects were generally males, over fifty years of age, occasionally under. But few females are found in the list. 
Symptoms.—Paroxysms of peculiar distress, with intervals, longer or shorter, of comfort or perfect health, mark the course of the complaint. The paroxysm comes on suddenly while the person is under exertion. The sudden distress is referable to the region of the heart, and may be an acute, dagger-like pain, or corded stricture, and seems to threaten immediate death. The sufferer pauses, seizes anything he can reach for support, is afraid to move, and sinks down pale and covered with a cold sweat. The paroxysm may last only a few minutes, and the patient recover, or the sufferings may be protracted to even an hour. The pain shoots upward from the heart, or to the right, but generally to the left shoulder axilla and arm, where it is often extremely acute. Respiration seems more disturbed from the fear to breathe, than from inability ; the arms are thrown up to aid respiration; the pulse is very variable, quick, full, slow, or suppressed, and often regular ; flatus is generally belched, which affords great relief. 
The attacks are usually mild at first, and progressively increase in severity. Sometimes only a transient, shooting pain in the heart is first noticed ; sometimes there is pain radiating to the left arm; at others, there is a sense of distention at the heart, more permanently fixed, with stoppage of its beat, and violent palpitation. 
Causes.—The exciting causes may be anything that forcibly hurries the circulation, as prolonged, or sudden, violent exercise. The remote causes will be found to depend on either organic or functional derangement of the heart and arteries, or sympathetic functional derangements of the stomach and nervous system, brought on by dyspepsia or other depressing causes — the habit of the subject and history of the case will determine. 
Treatment.—During the paroxysm, administer the Compound Tincture of Lobelia and Capsicum, in tablespoonful 


927 
HEMORRHOIDS. 
doses, which must be repeated every ten or fifteen minutes, until relief has been afforded ; if the paroxysm is not completely relieved by this, an emetic should be given as soon as the patient can swallow, for which the Common Emetic Powder will be found the most useful. This has, in all the cases which we have treated, given prompt and permanent relief. Prom its known relaxing influence over the nerves and muscles, the Tincture of Gelseminum might probably be used with advantage in this disease. 
In addition to this, when the paroxysms are severe, and there is coldness of the surface and extremities, external stimulants, as Ammonia, or Granville's Lotion, must be applied, especially over the epigastrium and along the spine, with warmth and friction to the extremities. 
In order to prevent a return of the disease, the treatment should be especially directed to the nervous system, as well as to any other disease which may be present, as gout, rheumatism, dyspepsia, etc. The condition of the stomach should be particularly watched ; acidity may be removed by Carbonate of Ammonia, and flatulence and constipation by their appropriate remedies. Moderate exercise should be advised, together with a healthy, nutritious, digestible diet, an avoidance of acids, fats, and alcoholic liquors, as well as of all excesses, and the mind should be kept perfectly free from excitement or alarm. 
Species V.— Hemorrhoids. 
Hemorrhoids, or piles, comprehend several forms of disease of the rectum, in which bleeding may or may not be an attendant symptom, as the name imports. 
1. The commonest form of hemorrhoidal tumors is produced by an eversion of a portion of the verge of the anus from standing, walking, or other long-continued exertion in the upright posture, in persons of lax constitution and fiber. The sphincter ani is incompetent to prevent this eversion of a portion of the mucous membrane, and its efforts only serve to strangulate the portion extended, which soon swells and becomes inflamed and painful. Early re- 


928 
NERVOUS FORMS OF DISEASE. 
duction of the extended portion of the gut and its retention, by lying in bed, suffice to remedy the difficulty ; but often some hours of neglect prevent reduction, or if reduced, the tumor again protrudes of itself, though the patient assumes the horizontal posture, becomes painful, livid, and inflamed, and constitutes an acute attack of hemorrhoids. 
2. Another form of hemorrhoidal tumor arises from varicose veins, or infiltration of blood into the cellular tissue between the muscular portion or walls of the rectum and its mucous membrane just within the anus, which, becoming extended, are often a source of constant irritation and discomfort, and sometimes of great suffering. They sometimes bleed, giving rise to the term, bloody piles, in contradistinction to the former variety, which is often called blind piles. These varicose sarculated tumors or cysts, in some cases, increase to a large size, and appear lobulated, are ordinarily kept reduced, but are liable to become extended at every exoneration of the bowels, and call for surgical operation. 
3. A third variety of hemorrhoids is bleeding from the rectum. This is not a very uncommon affection, and often gives no uneasiness, recurring only occasionally, and while the patient is at stool. Varicose tumors may be the source of the flux, or it may be an exudation of blood from the mucous surface. We occasionally find the discharge habitual in free-livers. When it becomes profuse and frequent, the hemorrhoidal flux is a matter of much solicitude, and occasionally brings on an anemic condition, and finally terminates fatally, unless arrested by medical treatment. 
Treatment. —The following treatment from " Eclectic Surgery," pages 369, 370-71, is that which is usually pursued by Eclectics, and which we extract from that work: 
" In the treatment of this disease, almost everything depends upon the general health. A torpid condition of the liver and derangement of the whole digestive system is a very general attendant. Hardened faeces, impeding the return of blood from the part, have been regarded as the cause. 


HEMORRHOIDS 
929 
"At times the tumors and whole anus will become externally inflamed. In such a case, evacuate the bowels freely. This is generally best done by some medicine that has a specific action on the liver, in combination with a hydragogue, so as to produce effective but thin discharges that will not irritate the rectum. Small doses of Podophyllin, from one-eighth to a quarter of a grain, taken every two hours for six or eight hours, and then followed up with from 3ss to 3j of our common cathartic powder will generally have the desired effect. 
" After the evacuation, or even before, if the pain and inflammation be severe, the local application of Tobacco will have a good effect. Take a piece of the pressed article finely cut, or a cigar, moisten it in warm water, and let it be pressed up the rectum in contact with the tumors, and confined there by a ' T ' bandage. This measure will almost invariably give temporary relief. In some instances, the application may cause a little nausea. This is not generally of much consequence. Should it, however, go to the extent of vomiting, or much nervous depression, the s plug' should be at once removed. 
" For constant use, let a salve be made of the Extracts of Stramonium and Tobacco, da 3j, and Tannin, gr. v. Let this be applied three or four times a day so as to come in contact with every tumor. It is well also to have it spread and kept on permanently during the night. Should there be much tendency to hemorrhage, increase the proportion of Tannin." 
" Cold water is generally a good palliative. 
" The patient should be directed to take regularly of the Alterative Syrup, with from one-eighth to one-half of a grain of Podophyllin every night. 
" This simple treatment will remove all recent cases. But in some instances of long-standing, the piles have become hardened and callous. In this stage they are nearly insensible unless when inflamed. I have been called on to treat many such chronic cases in which the tumors wore a very malignant appearance, and had already occasioned ul- 


930 
NERVOUS FORMS OF DISEASE. 
ceration to a very considerable extent. The course of treatment which has been successful in every such case, is this : 
" Place a ligature round the tumor, or round two or three if there are many, passing it through a cork, as recommended in the case of fistula in ano, and tightening it every day, until the strangulated tumors slough off. The patient meantime should constantly keep on a Slippery-Elm poultice, and rest as still as possible—the bowels being loosened by small portions of hydragogue physic. 
" The ligature, as a means of removing large hemorrhoidal tumors, is far preferable to the knife. It is not so alarming to the patient and gives him no pain except on the first application, and for a few moments after each tightening. It avoids all the danger of inflammation, and the still greater danger of hemorrhage. The books are full of instances where patients have sunk under or immediately after the operation. 
" The disease rarely returns after removal by ligature, even though the patient should neglect himself and become costive. But I wish you to bear in mind that no mode of local treatment—at least none short of this operation by ligature—will effect more than temporary relief, unless proper constitutional remedies are at the same time applied." 
In addition to the above, we make use of the Hydrastis and Prinos Verticellatus, as recommended in the treatment of dyspepsia ; and where there is much hemorrhage, we combine with this Geranin in sufficient quantities to arrest it. 
Species VI. — Diabetes Mellitus 
This term is applied to an excessive secretion and evacuation of sweetish-tasted urine. It occurs more often in the middle ages of life than in childhood or old age, and is the true diabetes of authors. 
History.—Hippocrates makes no mention of this form of disease. Celsus and Galen treat of it; and Areteaeus gives a clear and minute description of it. He considered 


931 
DIABETES MELLITUS. 
it a liquefaction of the body into urine. Willis first called attention to the saccharine taste of the urine, and noticed the fact that more urine was sometimes voided than the whole amount of fluids drank. Sydenham has left an accurate account of diabetes, its causes and indications of cure, but has made no mention of the saccharine quality of the urine. Cullen, and also Heberden, treat of this form of disease, since which time it has received the attention of many able men in the profession. More-extended observations prove that in some cases more urine is discharged than the whole amount of both solid and liquid aliments taken into the stomach, though generally less than the liquids taken. The urine has in some cases amounted to four or five gallons a day, always sweet to the taste, and fermenting quickly if yeast be added. 
Symptoms.—Along with an increased flow of urine, first noticed, perhaps, by being called to rise at night, thirst and a dry and clammy state of the mouth and throat are noticed. Accident may discover to the person a sweet taste in the urine. Sometimes a mawkish-sweet taste in the mouth is early complained of. The appetite, as well as desire for fluids, is craving. The tongue becomes furred with red edges. The skin is dry and rough. The bowels become costive; there is a gnawing, craving feeling in the stomach; lassitude and weariness under the least exertion ; constant aching across the loins ; uneasiness and redness of the meatus urinarius; sometimes after the passage of urine the semen flows involuntarily ; serious disturbance of the general health ensues; the pnlse, at first quicker, becomes slower than natural and without force; the feet and ankles swell; emaciation becomes extreme; hectic fever ensues ; the gums soften as in scurvy, and shooting pains and cough mark the last stage of the complaint, with a peevish, irritable state of mind and great depression of spirits. 
Nature and Cause.—Despite all the investigations of able inquirers, the pathology of diabetes is still involved in great obscurity. Post-mortem examinations generally reveal structural changes in some important organ, and 
59 


932 
NERVOUS FORMS OF DISEASE. 
more frequently, perhaps, of the kidney, than any other abdominal viscus ; but the changes of structure are so dissimilar, that it is impossible to say what is the nature and primary cause of this extraordinary affection. The stomach, liver, spleen, lungs, mesenteric glands, etc., have all in turn been found deeply implicated, and the kidneys occasionally nearly natural. Some physiologists have come to the conclusion that the stomach is the seat of the first morbid action, converting vegetable food into sugar, which the kidneys were taxed to eliminate as a foreign substance; while others have ascribed its origin to a morbid state of the liver and bile; and others again to a morbid state of the assimilatory and nutrient functions; while others have reasoned that an irritable state of the kidneys was sufficient to account for all the phenomena presented. Analysis of the urine shows that, while the solid constituents of healthy urine are nearly maintained, there is the additional introduction into the urine of the foreign substance of grape sugar in considerable quantity, by some unaccountable perversion of function. For a long time analysis of the blood of diabetic patients did not reveal the presence of sugar, but of late several respectable chemists have detected it; and Mr. McGregor has found that the dried serum of diabetic blood, re-dissolved in a small quantity of warm water, underwent fermentation on the addition of yeast, proving that the sugar is formed before it reaches the kidneys. The most rational conclusion, therefore, is, that the digestion and assimilative functions are first deranged, and that the morbid phenomena presented are the result of the grape sugar formed and thrown constantly upon the blood. 
Prognosis.—Diabetes mellitus is a very fatal form of disease. It often comes on insidiously, and has become wellestablished before advice is sought. Still, the mild forms of this formidable affection may, with unerring attention on the part of the patient to the regimen and treatment, be so governed as to enable the patient to pass through life in a comfortable condition. It is very difficult, however, for patients to control their appetites and follow the necessary 


933 
DIABETES INSIPIDUS. 
rales of living, and hence it is difficult to establish a perfect cure after the disease has been once fully developed. Dr. Prout says, of twenty cases treated, he never saw but one where the urine became natural again. Dr. Bardsley asserts that, of twenty-nine cases treated, eight recovered* perfectly. But it is asserted that a disposition to its return remains in cases reported cured, and that ultimately these cases fall victims to its return. Fortunately it is not a common form of disease ; the writer of this never met with but one case of diabetes mellitus. 
Treatment.—This is a disease, well known by all classes of medical men, to be very difficult of successful treatment. "We have, however, succeeded in effecting permanent cures in several cases by the following method: 
Podophyllin and Leptandrin, to be given in doses sufficient to arouse the hepatic functions, without active catharsis being at the same time induced. Subsequently to this, when the liver and biliary organs have been excited, diaphoretics and tonics to be given, as the Compound Powder of Ipecac, and Opium, with Hydrastin and Prussiate of Iron, and an irritating plaster over the region of the kidneys, which course is to be pursued until the excessive discharge of urine has abated. In connection with this, the spirit vapor-bath must be employed at least twice a week, and the body should often be thoroughly rubbed all over the surface. When the discharge of urine has lessened, the above means may be omitted, with the exception of the spirit vapor-bath, and the Compound Syrup of Stillingia with Iodide of Potassium, given in the usual doses, and continued until the cure is permanent. 
The diet of the patient should be exclusively of an animal character. 
Species VII.— Diabetes Insipidus. 
The term diuresis is usually employed to designate copious urinary discharges, other than that of saccharine character, which is the true diabetes of authors ; but where these forms of diuresis become confirmed, or of permanent 


934 
NERVOUS FORMS OF DISEASE. 
character, they are usually treated of as diabetes insipidus. The urine, however, though not sweet, is not always tasteless as the term imports. 
The simple forms of diabetes insipidus are of frequent occurrence in nervous, hysterical, and dyspeptic subjects, of lean habit and irritable fiber, induced by anything that disturbs their equanimity, as changes of weather, articles of food or drink, mental agitation, etc. The urine is copious, pale, and watery, but its solid constituents are unaltered. 
The complicated forms of this affection are not only marked by copiousness in quantity of urine daily passed, but the solid constituents held in solution are altered in their proportions, and thus differ from healthy urine. This state of things should also be marked by a degree of persistency of the affection in order to constitute the disease. In some cases the urea is greatly in excess, the urine heavier than natural, and characterized by acid reaction; in others the urea is greatly deficient; sometimes the urine is of albuminous character, indicative of Bright's disease of the kidney, now and then contains extractive matter, and sometimes chyle. These forms of diabetes insipidus are often marked with gnawing or morbid feelings of the stomach, debility, thirst, dull pain in the back, and an anxious expression of countenance. The causes producing the derangements under consideration are not known. The subjects are more usually men of middle age, whose constitutions have become broken by disease, intemperance, or venereal and other excesses, though all ages and both sexes are liable. If taken early the majority of cases are remediable. 
Treatment.—Diabetes insipidus may be cured by the means advised for diabetes mellitus. It is generally more easily influenced by remedial agents, does not require such active and energetic treatment, and has frequently yielded to diaphoretics alone. 


ISCHURIA RENALIS. 
935 
Species VIII.— Ischuria Renalis. 
Ischuria renalis, or suppression of urine, is either a total abolition of the secretory function of the kidneys, or so marked a diminution as to be clearly morbid. In the form of total suppression, it probably depends on paralysis of the kidneys from disease in the nervous centers, atrophy, induration, or other structural change of the kidneys being the result. In the form of partial suppression, it is symptomatic of other forms of disease, and is much more frequently met with than total suppression. 
Symptoms.—Suspension of the passage of urine first attracts observation, or notice is taken of the very minute quantity passed. It is proper to remark in this place, that retention of urine is a very different matter from suppression, and care must be taken to examine the state of the bladder, by percussion and the introduction of the catheter. The writer has seen retention of urine, resulting from paralysis of the bladder, where the urine would not flow even after the introduction of the catheter until adequate pressure was made upon the abdomen, when several quarts of urine were drawn off. This condition might be mistaken for ischuria. Obstructions to the flow of urine in the pelvis, or the kidney, or in the ureters, are not likely to be mistaken for suppression, owing to the pain and suffering in nephritic and gravelly affections. In idiopathic suppression, little or no uneasiness may be felt for the first few days, save anxiety as to the suspension of the flow of urine, or perhaps slight pains in the lumbar region, which is all the history the patient can give on applying for advice. Nausea and perhaps vomiting come on in a day or two, with torpor and sleepiness. The pulse is slower than natural. When roused, the patient seems surprised that any concern should be manifested in his case. In five or six days coma supervenes, and convulsions usually set in before death, which happens within the week after total suppression is established. The case may run longer if small quantities of urine are from time to time passed. 


936 
NERVOUS FORMS OF DISEASE. 
Ischuria may occur at any age or period of life from infancy to old age. It has been ascribed to dentition in children, and to gouty habits in elderly people. It is perhaps more often seen in the corpulent and well-fed, who have passed the meridian of life. It is not a very common form of disease. The writer has met with two cases only of well-marked idiopathic ischuria, one in a gourmand of forty-seven years of age, and the other in a lad of seven ; both terminated fatally. 
As a symptomatic affection ischuria is often met with under various forms of acute disease, such as fevers, inflammations, dropsies, Asiatic cholera, etc., and in many cases, no doubt, greatly aggravates the primary affection by throwing the urine back upon the blood, and consequently upon the brain, inducing coma by the poisoning influence of urea upon the nervous centers—the cause of death, doubtless, in the idiopathic form. The depuration of the blood by the renal secretion is so important that it can not long be dispensed with, and hence it becomes the prominent indication in numerous forms of disease, especially in the exanthematous affections where elimination from the skin is interrupted. Symptomatic ischuria, therefore, will never escape the attention of the vigilant practitioner. Nature, it is affirmed, sometimes sets up a vicarious secretion of urine from either the stomach, bowels, skin, umbilicus, mammse, or elsewhere, in order to preserve life under a state of total suppression. The hint thus derived from nature should be acted upon, and the emunctories of the system be addressed by remedies where the kidneys are unable to maintain their function. 
Treatment. —The first indication in this disease is to restore the functions of the kidneys and the consequent secretion of urine, and secondly, to prevent a return of the attack in patients who are subject to it. To fulfil the first indication, the patient must be placed in a bath as warm as can be borne, in which he should remain until approaching syncope ; he should likewise be made to drink freely of an infusion of equal parts of Queen of the Meadow root, 


937 
ENURESIS. 
Marsh-Mallow root, and Peach leaves, or an infusion of Uva Ursi and Spirits of Nitre ; and this drink should be continued for several days after the return of the urinary discharge. Should constipation be present, the Compound Powder of Jalap, with Bitartrate of Potassa, may be given. 
To prevent a return of the attack, an irritating plaster should be applied intermittingly over the region of the kidneys, and the following pill given internally; 
R„ Eupurpurin, 9ij, 
Xanthoxylin, 9j, 
Strychnia, grs.j. Mix, 
Divide into twenty pills, of which one may be given three or four times a day. Should the disease be complicated with any other, the complication must be treated according to its peculiar character. When the disease is owing to a disorganized condition of the kidneys, palliative measures are all that can be of service. 
Species IX.— Enuresis. 
Enuresis, or incontinence of urine, may be the result of an irritable condition of the urinary bladder, or of a partial or complete paralysis of the sphincter muscle by which the discharge is usually governed. In the former case, the bladder may be either in a state of inflammation or so highly irritable that it can not tolerate the presence of even healthy urine, or suffer the least distention without painful contraction of its muscular coat ensuing, bringing on the most urgent and irresistible desire to micturate. There may exist every degree of this urgency, from the slightest nocturnal incontinence of childhood to the extreme condition presented in cystitis and strangury. In the latter case, the bladder may be perfectly healthy, but the sphincter so paralyzed as to be inoperative, and the urine therefore passes off involuntarily. 
Incontinence, as a symptom of acute or chronic inflammation or strangury, arising from the absorption of cantharides, or from other vesical irritation, as acrid urine, etc., is the offspring of totally different pathological con- 


938 
NERVOUS FORMS OF DISEASE. 
ditions from that arising from weakness or paralysis of the sphincter of the bladder, and in the investigation of these cases the curative means must be directed with reference to the causes and their removal. The causes may in some cases be obscure, as in the nocturnal incontinence of children, that sometimes seem to be perpetuated by the law of habit. In many instances, the discharge occurs only in dreams, but in the most inveterate cases of this form the patient is entirely unconscious. The habit usually ceases at puberty, but sometimes it does not, and though not seriously implicating the physical health, becomes highly important in its moral influences, and calls for the sympathy and ablest skill of the practitioner. 
Where it arises from paralysis of the muscles governing micturition, the case is often deplorable and quite beyond the resources of our art, except in a palliative point of view, or rendering the condition as comfortable as possible. This unhappy condition sometimes occurs after childbirth, in consequence of mechanical injury, or after distention of the urethra in extracting calculi from the bladder. This form of incontinence is often met with in aged persons, and frequently supervenes in various forms of disease before death. It is not unfrequently associated with paralysis of other parts depending on cerebral or spinal disease. 
Treatment.—In this disease the bowels should be kept in a soluble condition by mild laxatives ; an irritating plaster should be applied to the sacrum, and the spinal column should be douched with cold water, twice a day. Internally, we have derived the greatest benefit, in adults, from the following mixture : 
K. Comp. Syr. Stillingia, 3iv, Iodide Potassium, 3j, Tinct. Cantharides, 3j. Mix. 
Of this, give one drachm in about a wineglassful of water, three times a day, until it produces the specific effect of the Iodide upon the head, and also strangury. If theabove quantity of Cantharides should not produce this effect within a proper time, it may be necessary to increase its* 


939 
ENURESIS. 
quantity. We have usually succeeded in curing this complaint by the above course. 
We extract the following, from the Eclectic Medical Journal, Vol. I, 1853, third series, by Professor J. King, relative to this affection, more especially when it is present in children. 
" It is only for those cases in children and adults, arising from a debility of the urinary organs, produced by improper food or drink, or over exercise, straining or relaxing the parts, that I wish to lay down a mode of treatment which has been almost invariable successful. 
In a majority of cases to which I have attended, the isinglass mixture has proved effectual; it is a pleasant remedy, and well worthy a trial in every instance. It will likewise be found very beneficial in incontinence following severe rheumatic or gouty affections. 
R. Take of isinglass two drachms ; boil it in one pint of water until it is dissolved; then strain, and add one pint of sweet milk, put it again over the fire, and let it 4 just boil up ;' then sweeten with loaf sugar, and grate nutmeg upon it. When it is made, it very much resembles custard. 
Dose.—For an adult, a half-pint or a tumblerful three or four times a day. I have known this mixture to prove serviceable in many cases where all other medicines had produced no good effect whatever. 
Should the above fail, which, by the bye, will be found a very rare circumstance, the following diuretic compound will be of efficacy: 
R. Pulvis Eupatorium Pnrpureum, " Aralia Hispida, 
" Althaea Officinalis, " Epigma Repens, da 3j. 
Steep the compound in four pints of water for about four hours, then add four pints of good Holland Gin, heat it until it boils, and when cold sweeten with honey. 
This compound will also be found useful in all urinary- 


940 
NERVOUS FORMS OF DISEASE. 
difficulties, as suppression, heat, high color, difficulty in urinating, gravel, urethritis, etc. 
Dose.—In severe cases a wineglassful every hour until relief is obtained, after which, and also in mild cases, a wineglassful three or four times a day. 
In connection with the above compound, a strong tea of the following articles should be drank freely : 
R. Trillium Latifolium, 
Myrica Oerifera, 
Prunus Yirginiana; 
Of each, equal parts. If, as is sometimes the case, the complaint is occasioned by a check of perspiration, a spirit vapor-bath in addition, will be found beneficial. 
In children, this symptom is often the result of habit or carelessness, in not being made to urinate immediately before going to bed ; it will, therefore, be necessary to attend to this, and also to awaken the child at stated intervals through the night, for the purpose of evacuating the bladder. In some cases it may be found that the urine is passed during sleep while in one particular position, as, for instance, on the back; by changing this position, some benefit may at times result. 
Where children are in the habit of taking suppers, very little fluid should be allowed them, and tea and coffee must be abstained from, even for some time after a cure has been effected. The diet should be principally of boiled milk and wheat flour, with a little nutmeg and cinnamon sprinkled on it. In some cases a stimulating adhesive plaster applied from the small of the back to the sacrum, will be found a valuable auxiliary." 
Species X.— Scorbutus — Scurvy. 
The term scorbutus is said to be derived from the Danish word scorbeck, sore-mouth. There seems to be no doubt that this form of disease was known to the ancients, although the particular phenomena constituting it have not descended under a name. Writers of the sixteenth century —Krantz, Olaus, Magnus, and others —treat of it under the name of 


941 
SCORBUTUS—SCURVY. 
scurvy, as a destructive disease affecting the northern nations of Europe; and from that period until about the commencement of the eighteenth century, when its proper treatment and prevention became understood, it destroyed more sailors than the accidents of a sea-faring life and naval warfare united. On land it was formerly as fatal as an epidemic. It has sometimes been treated of under two forms, as appearing on land, and on board ships, or as land-scurvy and sea-scurvy, but there is no essential difference in the symptoms. The manner of living induces it, viz., an exemption from succulent fruits and vegetables. Before the arts of horticulture and orcharding had made much progress it was very destructive on land, and after the impulse given to navigation by the discovery of America, when long voyages at sea became common, it appeared more distructive on ship-board. It is not uncommonly met with now-a-days in the frontier settlements of the West. The writer has often encountered it toward the close of winter or during the spring season, in the frontier settlements of the western States, and has no doubt that a scorbutic tendency greatly prevails in the border settlements generally, 'greatly aggravating all the vernal attacks of malarious and other forms of disease. 
Symptoms.—The first notable symptom is paleness of the countenance. Slight scratches and bruises become troublesome sores. The patient complains of lassitude, is indisposed to make exertion, and slight efforts produce fatigue. There is feebleness and trembling of the knees ; depression of spirits ; fetid breath ; sponginess of the gums, which often bleed ; the teeth become loose; livid specks appear in patches on the arms and legs ; the mouth is complained of as sore, and frequently bleeding ulcers appear on the tongue. The constitution becomes more and more enfeebled ; hemorrhage takes place from some of the natural openings ; edema of the feet and ankles takes place ; old wounds become painful and re-open ; there are tearing pains in the belly; pains in the bones and other parts, sometimes pleuritic pains with cough; there is often syncope on rising to 


942 
NERVOUS FORMS OF DISEASE. 
the erect posture, and not unfrequently death occurs suddenly after the exertion of walking across the room. The pulse is slower than natural and feeble throughout the course of the attack ; the ulcers do not secrete healthy pus, but a thin sanious ; the appetite is generally good and a great desire for vegetable and acid food prevails. 
Such is the usual character of scorbutus, but there is every phase of complication of it with other forms of disease presented, which inexperienced practitioners are apt to overlook. For instance, women in the puerperal state, restricted in their diet and exhausted by lactation, become frequent suffers from a tendency to scorbutus. The writer has encountered many anomalous conditions at the bedside of puerperal patients that had withstood the treatment of reputable practitioners three or four months, and which yielded at once to the appropriate treatment for scurvy. 
Causes.—An altered and depraved state of the blood, occasioned by stale, salted animal diet to the exclusion of succulent vegetables, we are told by many authorities, constitutes the main or principal cause of this form of disease. But we beg leave to ask whether the condition of the blood is not, in reality, the disease ? This is our opinion ; but there are other causes that favor the production of this condition of the blood—that is, the disease ; such as, cold and humidity, an inactive life, and any debilitating circumstances to which individuals may be exposed. Hence pregnancy is a predisposing cause, and united with the almost exclusive " hog-and-hominy " fare of the frontier settlements, often induces the scorbutic diathesis. The writer has witnessed the sudden death of several delicate women, under such circumstances, after delivery, not traceable to any other cause. No hemorrhage, or other difficulty, but death ensued. This suddenly expiring after a shock of the system, is strongly characteristic of scurvy. A drooping sailor will suddenly lie down and die after the unusual exertion required of hands during a storm at sea. Of course, many diseased conditions of the system favor the production of the scorbutic diathesis, as well as the remedies in ordinary 


943 
SCORBUTUS—SCURVY 
use by the Allopathic school for their removal. A state of mercurialization is akin to the scorbutic condition. The condition brought on by an inordinate use of alkalies is also similar to that presented in scurvy. 
Diagnosis.—Purpura is the only form of disease likely to be confounded with scurvy. This is considered by some authors as a variety of scurvy. But it generally appears in autumn, when fruits and vegetables abound, and the purple patches or petecchiae are brighter when they first appear, fade away and are succeeded by another crop, whereas, in scurvy, they are dark-colored at first and persistent. There is not the same tendency to softening of the gums" and soreness of the mouth in purpura as in scurvy, nor do the remedies, lemon-juice and fresh vegetables, which cure scurvy, effect a cure of purpura. 
Prognosis.—Since the nature of scurvy has been understood, it has ceased to be considered alarming, where the remedies for its relief are to be had. It is only where the proper recourse to suitable diet and remedies can not be obtained, as in long voyages at sea, or where incurable diseases have set in, that a fatal termination may be anticipated. 
Treatment. —This disease requires but little medical attention, the principal thing being a change of diet, and a removal from the causes producing it. The patient should be placed upon a fresh vegetable diet, especially of acid fruits, oranges, lemons, limes, sour-krout, and similar articles. 
As a local application, whether it be attended with hemorrhage or ulceration, notwithstanding the great variety of remedies which have been recommended, in our opinion, nothing equals the strong decoction of Hydrastis Canadensis, very frequently applied to the parts, and at the same time, taken internally several times a day. We have succeeded in curing several cases with the Hydrastis alone, having previously removed the producing causes. 


944 
NERVOUS FORMS OF DISEASE. 
Species XI.— Chlorosis. 
This form of disease may be said to be identical with chronic anemia. From the peculiar paleness of countenance characterizing it, being of a waxen transparency, or yellowish-green hue, it has been called chlorosis or greensickness. It is most usually met with in young females, between puberty and maturity, accompanied with retention of the menses, but occasionally is met with in married women, and sometimes is seen in male youths of delicate constitution, and also workmen employed in mines. 
The idiopathic form of chlorosis is generally seen in girls of lymphatic temperament, arrived at the age of puberty, of depraved constitution and weak vital forces, insufficient to carry out and establish harmony of function, under the developments of sex. For an account of the symptoms and causes of chlorosis, or the green-sickness of girls, see "Retention of the Menses," under the head of Amenorrhea. 
Chlorosis may supervene as a consequence of repeated losses of blood, and frequently does in married females, as after frequent miscarriages, or hemorrhage incident to childbirth. It sometimes makes its appearance in delicate male youths, and is to be attributed to the same causes that give rise to it in girls. It has been known also to attack miners, confined in an impure atmosphere, deprived of the vivifying influences of insolation and fresh air. 
Nature.—The chlorotic condition may be compared to that blanched or etiolated condition of a vegetable growing in a cellar. The blood is impoverished, being nearly deprived of its red corpuscles. The indication for its removal appears to be the same from whatever cause or causes produced. 
Treatment.—The first thing to be done in this form of disease, is to remove the cause; for so long as this continues, you can expect but little from any form of treatmen —hence, it becomes necessary to make use of such means as will assist nature to remove the obstruction. All the different functional or organic derangements which are 


945 
HYDROPS. 
present, producing this peculiar condition, should be treated as referred to under their respective heads. Perhaps no class of agents possess a greater power than tonics and alteratives, the various forms of Iron, Quinine, Cornine, and Hydrastin, in such proportions as agree well with the condition of the system, avoiding such as produce irritation of the stomach. If this precaution is not strictly adhered to, the Iron will not be conveyed into the circulation, and thereby our object will be thwarted. We have, also, derived much benefit from the alkaline-bath, externally, and the Compound Syrup of Stillingia and Iodide of Patassium, in proportions as heretofore recommended. 
If there be much pain, or neuralgic symptoms, present, the Compound Powder of Ipecac, and Opium, or Quinine, should be used. The patient should be allowed moderate exercise in the open air, and avoid every cause which produces excitement of any kind. 
Species XII.— Hydrops. 
Hydrops, or dropsy, is an effusion of serum into the cellular tissue and serous cavities of the system. When the morbid accumulation is confined to a particular part, cavity, or shut sack, it is treated of as a form of local dropsy; thus we have anasarca, an infiltration of serum into the cellular tissue; hydrocephalus, dropsy of the brain; hydrothorax, dropsy of the chest; ascites, dropsy of the belly, etc.; and when most of these parts of the system are at the same time invaded, it is called a general dropsy. 
Symptoms.—General dropsy may supervene rather suddenly under a somewhat febrile condition, marked by increased frequency and force in the circulation and heat of the skin, with furred tongue and high-colored, scanty urine; or it may come on very gradually, under an opposite and broken-down, and debilitated state, characterized by depressed vascular and vital energy. Frequently its approach is not attended with marked evidences of either excitement or depression. There is often tenderness of the belly, and also of the cellular structure, indicating a low grade of 


946 
NERVOUS FORMS OF DISEASE. 
inflammatory action, but more generally the symptoms are characteristic of local irritation rather than inflammation. The appearance of the patient indicates a depraved state of system dependent on some obscure, remote, pathological condition, of which the dropsical effusion is but a symptom or effect. The face is generally pale, and a state of anemia frequently present, in which the white corpuscles of the blood prevail in undue proportion. 
As the disease progresses, the thirst becomes a prominent symptom, while the urine is always scanty, but of variable character and appearance. Sometimes it is brown, at other times, bloody, opalescent, lateritious, or bilious. In acute or febrile forms of dropsy, it is mostly of a dark and turbid appearance, containing albumen, which will be deposited in the form of curdy flakes on application of heat or tested with nitric acid. 
Perspiration is greatly deficient also in dropsy. Constipation generally attends it. The effused fluid is the serum of the blood, and consists of water mostly, but contains albumen, urea, sometimes fibrin, and the salts of soda, potash, iron, lime, etc. 
Dropsy is common to all ages and both sexes, but is more often met with in the decline of life. The most distressing symptoms of the complaint arise from obstruction to respiration and other functions, caused by pressure from the accumulations of water in the body. 
Causes. —Dropsy is caused by irritation, active congestion, and inflammation of the serous and cellular tissues which secrete serum for their lubrication in health, there existing a balance and harmony of function in health, between deposition and absorption, which harmony is destroyed by the causes producing dropsy. Debility and relaxation in the capillaries of these tissues, and consequently passive congestion, may also cause dropsy, by producing excessive exhalation and deficient absorption. An altered or diseased condition of the blood may also prove a cause of dropsy, and is probably the most common or primitive one. Scarlet fever is often a cause of dropsy 


947 
HYDROPS. 
in some form, more generally anasarca or ascites; — also measles and other eruptive forms of disease. This may be owing to neglect or inattention to depurate the blood, by diuretics in cutaneous affections, where the functions of the skin are interrupted. "Malarious fever" is frequently a cause of dropsy, as well, perhaps, by impoverishing the blood as by causing obstructions in the portal circle from enlarge ments of the liver and spleen. Diseases of the heart, liver, and kidneys, are among the most fruitful causes of dropsy, in one or another form. Indeed, Bright's disease, as it is called, of the kidneys, has been supposed to be the real or essential cause of dropsy in most cases, but the inference is unwarranted. 
Prognosis.—Dropsy is a form of disease that occasionally abates spontaneously. This might happen if the pathological condition on which it depended, was removed by the efforts of nature. Nothing is easier than to draw off the water by hydragogues and diuretics, and a portion of the cases recovers entirely, there being no return of the effusion. It often, however, returns again and again, and finally destroys the patient. The acute forms of the disease are often entirely or permanently cured, as those arising from scarlatina. In all cases arising from organic affections and irremediable obstructions, the cases admit of but palliative prospects from any course of treatment, still much may be done to soothe the passage to the grave. 
Treatment.—In all the forms of dropsy, just referred to, the general treatment will be the same, though auxiliary measures may be required somewhat varying in each. The indications are to arouse the action of the absorbent system, evacuate the fluid, and endeavor to prevent its re-accumulation. To fulfill the first of these indications, the spirit vapor-bath should be used once or twice a day, as the strength of the patient will permit, and which should be continued daily, until the removal of the fluid. Internally, hydragogue cathartics should be given, among which the Compound Powder of Jalap and Senna, with Cream of Tartar, will be found very valuable; these may be adminis- 
60 


948 
NERVOUS FORMS OF DISEASE. 
tered for the first two or three days, in sufficient quantities to produce an active hydragogue effect, after which, they should be employed only in laxative doses. Should much gastroenteric cinflammation be present, hydragogues can not be employed, and milder agents must be given, such as Leptandrin, Caulophyllin, and Podophyllin in small doses. It is also proper to administer diuretics, especially in those cases where they produce a perceptible diuretic influence; it will be found, however, that these will frequently fail in producing any effect. 
When these means have removed the effused fluid, measures must then be adopted to prevent its further return. The system must be invigorated by tonics, such as Quinine and Iron, Cornine, Hydrastin, etc., and any constitutional or local difficulties must be treated according to their respective indications. A generous, nutritious diet must be allowed, together with the use of wine, porter, or ale. 
Yariety. I. — Ascites. 
An effusion of serum within the peritoneum or shut sack, lining the abdomen, is called ascites, or abdominal dropsy. The color of the serum varies from a light yellow to a deep brown, is occasionally mixed with pus, and not unfrequently contains flakes of coagulable lymph, denoting that there has been inflammation of the peritoneum. Encysted collections of serum in the abdomen, such as are often seen attached to the liver, spleen, ovaria, and omentum, are termed encysted dropsy, ovarian dropsy, or hydatids, and are to be distinguished from true ascites by the history of the cases, and the situation and progress of the tumors. Fibrous tumors of the womb, also, as well as watery collections within its walls, polypus, and even pregnancy, may be mistaken for ascites without a careful investigation into the history of the case and skillful examination. 
Should pregnancy and ascites be combined, as sometimes happens, a case might be involved in a good deal of obscurity. Tympanites, or a collection of air in the intestines, can hardly be mistaken for a case of dropsy. Ascites may 


949 
ASCITES. 
occur under either an inflammatory or non-inflammatory condition. 
Ascites resulting f rom inflammation of the peritoneum, is accompanied with fever, pain, and tenderness of the belly, increased by pressure. In some instances the effusion is quite gradual, with little disturbance of the general health, and in others quite rapid, the abdomen becoming largely distended in a few days. Ascites, following scarlatina, is of the inflammatory type, and is generally more or less accompanied with anasarca ; the face being swollen in the morning and the feet and ankles at night. There is generally a small, wiry pulse in these acute forms of ascites, high-colored, scanty urine, furred tongue, thirst, constipation, and either clay-colored or very offensive stools. In many cases, the effusion might, perhaps, be better or more properly ascribed to a special irritation of the peritoneum than to inflammation, such a pathological condition as has received the name of congestion. Congestion of the portal circulation, from deranged conditions of the liver, retards the venous circulation in the abdomen, and throws a special irritation upon the peritoneum —ascites is the consequence. Or the special irritation may originate in the kidney, spleen, or other viscus. 
Ascites resulting from indirect debility is a consequence of previous disease, generally of some important organ. It is gradual in its development, and is usually preceded by edematous feet and ankles, and the accumulation in the abdomen is from below upward, until the diaphragm is so impeded that respiration is next to impossible. The operation of paracentesis abdominis is usually resorted to in this emergency, with, however, very variable results. As a means of affording temporary relief, and gaining time and opportunity for the administration of curative measures, it is unquestionably a proper palliative resource of the healing art. Instances are cited where it has been resorted to over two hundred times in the same case, and a permanent cure effected at last. 
This form of dropsy not unfrequently follows a broken- 


950 
NERVOUS FORMS OF DISEASE 
down condition of the constitution, resulting from malarious fever. It may follow any prostrating inroad upon the vital powers, but is most apt to succeed to those forms of disease that weaken, retard, and obstruct the portal circulation, damming up, as it were, the return of venous blood. 
Diagnosis.—In true ascites, the distention is first at the lower portion of the abdomen, and as it progresses the lateral portions widen equally, and at last the epigastrium becomes distended. This is much the case with the progress of pregnancy, and ovarian dropsy also. In pregnancy, however, an examination per vaginum will reveal a development of the neck of the womb in the latter months, or ballottement will suffice ; or holding the hand for some time in cold water and then laying it on the abdomen, will provoke movements of the child. In ovarian dropsy the tumor will roll or gravitate from side to side, as the woman changes position. The more lively thrill, or tremulous impulse under percussion, in true ascites, will assist in diagnosing difficult or obscure cases. One hand should be laid flat on one side of the abdomen, and a sudden tap or fillip made on the other. Tumors are generally detected by their inequalities under the grasp. Hydatids usually progress from above downward. In all obscure cases, the history and progress of the enlargement and attending symptoms, must be carefully inquired into. It may be fatal to the reputation of a physician to mistake a case of pregnancy for ascites, and the operation of tapping under the mistake, might be fatal to both mother and child. 
Prognosis.—Ascites resulting from functional derangements, as checked perspiration, repelled eruptions, engorgements of the liver and spleen, etc., are generally remediable. It is more often, however, dependent on changes of structure, that render it unmanageable and finally fatal. It not unfrequently disappears under the administration of remedies, and returns again and again, nntil the constitution finally succumbs. Where it exists very distinctly by itself, without effusion elsewhere, it is said to be more unmanageable than when accompanied with evidences of a 


951 
ASCITES. 
general dropsical tendency. The prognosis will, therefore, vary according to the cause, age, constitution, etc. Very rarely a spontaneous cure has taken place by the water being drained off through the urinary organs, or by the bowels. 
Treatment.—In ascites, the general treatment recommended under dropsy may be pursued, and as the water becomes evacuated, the abdomen must be supported by the use of a broad bandage, applied as tightly as the patient can bear without inconvenience. In the early stages of this disease, the use of the bandage alone, will frequently effect a cure. 
It is sometimes the case that ascites proves very obstinate, resisting all our remedial measures ; in such instances, in order to afford relief to the patient, as well as to postpone for a period the fatal termination, it will be necessary to resort to the operation of paracentesis abdominis —for a full explanation of which, see Eclectic Surgery. Notwithstanding, as a general rule, tapping only affords temporary relief, yet it sometimes happens that patients ultimately recover, even when they have undergone the operation a number of times—of which many instances are recorded. Dr. Griffith, of Virginia, reports a case in which the patient was tapped one hundred and eighty-six times in ten years, and had seven hundred and fifty-one and threefourths gallons of water removed in that time, and yet recovered. He says: 
" On the 22d of November, 1830, she was first tapped (by Dr. Dawson), when six and a half gallons of water were drawn off. She was not again tapped until the 8th of October of the following year. After this, the water continued to accumulate rapidly. In 1832 she was tapped ten times, in 1833 twenty-six times, in 1834 twenty-five times, in 1835 twenty-six times, in 1836 twenty-seven times, in 1837 twenty-six times, in 1838 twenty-six times, in 1839 seventeen times, and in March, 1840, she was tapped for the last time—in all, one hundred and eighty-six times (186), and seven hundred and fifty-one and three-fourths (751f) gallons of water, of a clear, straw color, were drawn off. The 


952 
NERVOUS FORMS OF DISEASE. 
size of the tumors gradually diminished, until they finally disappeared, but could be distinctly felt, on either side of the pelvis, for some time after the last tapping; since which time she has enjoyed almost uninterrupted good health. Indeed, during the entire period, her general health continued good, and she suffered but little except the inconvenience caused by the accumulation of water. She is now able to walk several miles without fatigue, which I have frsquently within the last few weeks, known her to do, in her benevolent attentions to the sick of her neighborhood. 
" I am aware that a number of cases have been reported, in which the operation of tapping has been borne a great number of times, and that in some, an almost incredible quantity of water has been drawn off. In the April number of this Journal, a case is referred to by Professor Peaslee, of Dartmouth College, mentioned by Burard, in which the patient was tapped 665 times in 13 years. In the case reported in the Philosophical Transactions for 1784, by Martineau, referred to by Watson, the patient, in twentysix years was tapped eighty times, and or upward of 13 hogsheads of fluid, drawn off." — Am. Jour. Medical Sciences. 
Variety II.— Hydrothorax 
Hydrothorax, or water in the chest, is treated of by some authors under three varieties, to-wit: when it occurs in the pleural cavities, when in the pericardium, and when in the substance of the lungs ; but by the most modern pathologists it is restricted to water or serum in the pleural sack, and, like most forms of dropsy, is but a symptom of disease—a result of pre-existing morbid action. Pulmonary edema, or water in the substance of the lungs and hydropericardium, or dropsy of the heart-case, are also results of previous morbid action, generally of inflammation of those immediate structures ; and though these organs are situated in the thorax, there is no propriety in considering serous effusions into their structures, forms of hydrothorax ; we 


953 
HYDROTHORAX. 
shall, therefore, restrict the terra hydrothorax, to the effusion of serum within the pleural cavities. 
Symptoms.—Viewing hydrothorax as a symptomatic form of disease, and never, strictly speaking, idiopathic, it may supervene upon almost any form of disease, either general or local, but affections of the heart, lungs, and pleura, are those that most frequently give rise to it. It has been considered by some authors as idiopathic, when it arises from such an inflamed condition of the pleura as speedily results in the effusion of serum into its cavity. This is, doubtless, its most simjJe or acute form ; but in this case the effusion is a sequent as clearly as when it results from organic disease of the heart or other viscera. 
There is no one symptom that clearly marks hydrothorax, because the effusion of serum into the cavities of the pleura occasions a train of symptoms common to other affections that greatly impede respiration and obstruct the circulation. 
The most distinctive symptom, perhaps, is difficulty of breathing— oppressive dyspnoea. But we have seen a case of hepatization of the lungs mistaken for hydrothorax by the best medical counsel, when a post-mortem examination revealed the pleural cavities entirely destitute of serum. 
One of the earliest symptoms of effusion, no matter what the primary affection, is edema of the eyelids in the morning. The progress of hydrothorax depends upon the nature of the affection causing it. In some cases it will advance slowly, as in organic affections of the heart; but from whatever cause produced, the symptoms become aggravated by the presence of the effusion, until the patient is unable to breathe, except in the sitting posture, with his arms resting on the back of a ciiair, and his face to an open window. The face becomes sallow and bloated; the lips livid; the ankles edematous; the surface and extremities cold ; the pulse feeble and fluttering. Death sometimes terminates the scene suddenly, within a few days after wellmarked symptoms of effusion have supervened; and at 


954 
NERVOUS FORMS OF DISEASE. 
other times, the sufferings are protracted for two or three weeks. 
Physical Signs.—Percussion gives a dull sound upon all parts of the chest where there is effusion. Auscultation also reveals little respiratory murmur, except at the apex of the lungs. Admeasurement frequently discloses one side of the chest larger than the other. The intercostal spaces bulge out, or at least, do not sink in as in health. 
Diagnosis.—It is not always easy to distinguish hydrothorax from other affections of the chest, such as hepatization of the lungs, empyema, etc. The most careful attention to the general history of the case is requisite as a first step. 
In hydrothorax, there will generally appear a serous diathesis or watery look in the constitution, and the puffy face in the morning and swelled ankles at evening, appear early in the stage of effusion ; whereas, in empyema, they only supervene very late. In empyema, the effusion is generally confined to one side. The early symptoms and history will generally serve to distinguish hepatization from hydrothorax. 
Prognosis.—The prognosis, in hydrothorax, is very unfavorable, because it most generally is but a symptom of some incurable malady. The effusion may be removed by appropriate treatment, and cases have occurred where the effusion has not returned ; but they are exceedingly rare. 
Treatment.—In the treatment of this form of dropsy, the practitioner will be guided by the rules laid down in the general treatment. Paracentesis thoracis is sometimes performed in this affection, but we much doubt its utility. [For an explanation of the operation, see Eclectic Surgery, page 623.] 
Variety III.— Anasarca. 
Anasarca, or an infiltration of serum into the sub-cutaneous cellular tissue, may take place under various conditions of the system, symptomatic of different forms of disease. It can hardly be said to be idiopathic, though it 


955 
ANASARCA. 
sometimes constitutes the most prominent symptom, and is treated of by some authors as a distinct form of dropsy. 
"When it occurs suddenly, and seemingly as an acute form of disease, attacking persons in the vigor of life, arising, as it mostly does, in those cases from exposure to cold after being overheated, it will generally be found to be accompanied with inflammation of some internal organ, as the lungs. There will generally be pain, increased by deep inspiration, and not unfrequently a troublesome cough. In some cases there may exist great oppression in the breathing without pain or cough, and the pulse not indicate inflammatory action, but auscultation will reveal it. The difficulty of breathing in some cases becomes very urgent, preventing the patient from lying down. The face becomes puffy and a general anasarca soon steals over the whole body. The urine is scanty and high-colored, in some cases coagulable ; and if the urgent symptoms be suffered to go on, death may occur in a week. 
When it occurs after scarlatina, or the retrocession of other eruptive forms of disease, acute or chronic, it is very analagous in character to the acute form above described, and post-mortem examinations often reveal not only the lungs, but also pleura, diaphragm, kidneys, and intestines, the seat of inflammation—clearly showing that the anasarca is the consequence of the internal disease. We always look upon anasarca from retrocession of scarlatina or measles as highly dangerous. Frequently it does not come on until three weeks subsequently to the little patient's getting about, and then insidiously steals upon the child in the form of a dry, troublesome cough at night, and puffiness of the face in the morning. 
Symptoms of extreme danger—anasarca, dyspnoea, and a distressing cough—often appear witliin three days after this edema of the face occurs, and, unless a vigorous treatment be instituted, death often results within a week. Sometimes convulsions close the scene, and at other times, effusion into the chest appears to be the immediate cause of death. Anasarca from retrocession of chronic pus- 


956 
NERVOUS FORMS OF DISEASE. 
tular eruptions is no less acute or formidable in its character. When it occurs from disordered menstruation, or suppressed hemorrhoidal discharge, the pathology is more obscure, the urgency of symptoms less acute, and the infiltration often much more gradual. It sometimes forms rapidly from suppression of the menses ; often gradually at the period of cessation; and not unfrequently is an attendant on del;ility from menorrhagia in young women, especially edema of the feet and ankles. 
When it results from organic disease of the heart, liver, uterus, enlargements of the spleen, etc., the cause of obstruction to the circulation is generally evident, and the resulting anasarca only an index of the progress of disease. It usually appears late or toward the close of life, but sometimes early in organic affections. 
When local, as in phlegmasia dolens, it depends on inflammation of the trunks of the large veins, or phlebitis. The whole matter, therefore, resolves itself into this, that anasarca is only a symptom or evidence of functional disturbance, or structural change of some important organ. 
Treatment. —In anasarca, in addition to the treatment named for general dropsy, bandages should be applied to the extremities, and kept moistened with cold water; they should be applied as tightly as the patient can bear. These will be necessary, in all cases, where there is much swelling of the limbs. 
Species XIII. — Oolica Pictonum. 
This form of disease attacks persons employed in the production of lead from its ores, white-lead manufacturers, painters, etc., and arises from the poisonous action of this metal on the system. The writer has witnessed it in a female who had been injudiciously treated with acetate of lead for bleeding piles. 
Symptoms.—A peculiar bluish tinge of the gums, sometimes showing itself in a well-marked line, a little distance from the teeth ; a sweetish styptic taste, fetid breath, sallow skin, and conjunctiva, are objective symptoms, showing 


957 
COLICA PICTONUM. 
themselves where the poison of lead has been slowly introduced into the system. Proper treatment in this stage will ward off an attack. 
The first symptoms the patient complains of, are, a loss of appetite, increased flow of saliva, restless nights, and a variety of nervous feelings. Vomiting supervenes and recurs more or less often throughout the attack. Obstinate constipation sets in, attended with pain in the belly, at first remitting, but becoming more and more constant, usually most acute at night, and not increased by pressure. The abdomen is flat and knotted, and the faeces, when discharged, dry and lumpy. Pains in the head and limbs set in, more especially in the knees, calves, ankles, and soles of the feet, and paralysis often follows. There is generally no fever, and the pulse is slower than natural. The urine is unaffected. In rare instances, peritoneal inflammation ensues late in the attack. The prostration and emaciation become extreme in cases where there is a tendency to death, but the great majority of cases recover. Subsequent torpor of the bowels, indicating a partial paralysis of their muscular coat is a common result, which may be attended by paralysis of one or more of the limbs. 
Where proper treatment is instituted, the disorder seldom proves fatal. Of five hundred cases treated in a Parisian hospital, only five terminated fatally, so that a favorable prognosis may in general be pronounced. 
Treatment. —This disease will always be spontaneously cured, if the patient will avoid further contact with the cause which produces it; yet, while the paroxysm is present, it is necessary to make use of means to allay the violent suffering. In the first place, give the patient stimulating enemas until free and copious evacuations of the bowels are produced ; as soon as this is accomplished, make use of the warm-bath or vapor-bath, then rub the patient until he is perfectly dry, and place him in bed. If, after this the pains should continue, apply hot bitter-herb fomentations over the whole abdomen, which should be as warm as the patient can bear, during the paroxysm. Apply 


958 
NERVOUS FORMS OF DISEASE. 
bottles of warm water to his feet, and give internally from one to three drachms of the Compound Tincture of Capsicum and Lobelia. 
If the above should not be sufficient to allay the pain, make use of the Compound Powder of Ipecac, and Opium. It will be well to use Podophyllin and Leptandrin, daily, until catharsis is produced. 
The above treatment has been sufficient, in our hands, to break up the disease in a short time. As there is not much tendency to a recurrence of the disease, unless the patient subjects himself to the same cause, we do not consider any further treatment necessary than—the avoidance of the cause which produces it. 
Species XIV.— Delirium Tremens — Mania h Potu. 
Dr. Watson treats of this disease in company with the inflammatory forms of cerebral disease. Drs. Wood and Eberle treat of it in association with the functional diseases of the brain ; and we include it in the class of functional forms of disease of the vegetative or ganglionic system, and our motives for so doing will be discovered in the course of this treatise. 
Delirium tremens, even now, is very imperfectly understood, and hence it becomes the duty of every investigator of it to make known his conclusions about it; for, although they may be erroneous, yet they may suggest to some one of his readers, a train of thought that may lead to the truth. 
This is our apology for the novel views we shall present — novel, in regarding this form of disease as existing in close alliance with cholera in both its cause and character. Whether right or wrong, if we shall succeed in causing others to observe and to think, we shall be amply rewarded for our labor. 
All the writers whom we have consulted describe this form of disease much in the language of Professor Eberle, as being "characterized by general inquietude, tremor, continued watchfulness, cool skin, perspiration,delirious loqua- 


959 
DELIRIUM TREMENS 
city, and sensorial illusions." It is said to occur only in habitual drunkards and inordinate opium-eaters; but as a fact, we dispute this, because we have known it to occur in those who never drank to intoxication, but only so far as to maintain a high state of excitement. Dr. Coates, Dr. Blake, and all others, so far as we have discovered, teach that delirium tremens does not result from the use of stimuli, but from the sudden disuse or abandonment of them ; and hence its beginning is manifested by " lassitude, general indisposition, a feeling of distress in the epigastrium, anorexia, nausea and vomiting, giddiness, a sense of confusion in the head, want of sleep, an anxious expression of the countenance, and tremor of the hands."— Eberle. Or, as taught by Dr. Blake, it commences with symptoms of general debility; the pulse is invariably slow, soft, and compressible, often feeble and unsteady; the hands and feet are cold and clammy. 
To the preceding account of this disease, when abstractly applied to it, we most positively object; because we have witnessed the disease under very opposite circumstances. We shall therefore contend for the existence of two distinctly-marked varieties of the disease. In those who have so long indulged in drunkenness as to have greatly crippled or broken down their vital energies, it begins as above taught—with symptoms of general debility. The other variety, to which we have alluded, takes place in the strong and vigorous—those in whom the vital energies have not been prostrated by absolute drunkenness—those who drank enough to maintain a continuous high state of nervous and vascular excitement—finally, those who continued and increased this preternatural excitement, until it became merged or lost in delirium. Of this kind of delirium, the writer has had two cases, and his friends, Professor Knapp, and Dr. Major, of Covington, Ky., assure him that they have treated similar cases, and his co-laborer, Professor R, S. Newton, informs him that he has had more cases of this kind than of the other. 
So far as the writer has observed, however, it is not de- 


960 
NERVOUS FORMS OF DISEASE. 
lirium tremens, for be has not witnessed an) r tremor in the hands of such patients ;* nevertheless it is, in his opinion, the same disease manifested in a different class of constitutions—the difference is just that which obtains between passive and active apoplexy or congestion of the brain. 
The approach of this variety of delirium is indicated by restlessness, a wildness of expression, or one of much apprehension ; the face is flushed, and the pulse is full and strong. The patient is impatient of restraint and capable of manifesting more than his ordinary muscular strength. It is attended by no stage of lassitude, and the delirium, at this stage, can only be inferred from the improbability of the patient's statements, and the incompatibility of his premises and conclusions. 
In dividing the disease, according to Dr. Blake, into three stages, we may say that there is but very little similarity between the two varieties in either of the stages ; the subjects, respectively, differ organically, and they differ in all the manifestations. 
It would appear, from some remarks of Dr. Carter (Cy. Prac. Med.), that the variety or modification of which we have been treating, had not entirely escaped his notice. He says : " In young and robust subjects, whose excesses have not been of long standing, the stage of reaction or excitement will come on much more rapidly than in persons advanced in years, and whose constitutions have been broken down by long intemperance. It is during this stage that the medical attendant is most liable to fall into error. The symptoms, many of them, are so similar to those of inflammation of the brain or its membranes, that, if he is not especially upon his guard—if he allows the pathognomonic signs of the disease to escape him, his diagnosis will be incorrect and his practice unsuccessful." 
Now, except for the description which he has given of the first stage, the preceding remarks might be a satisfac- 
* Since writing these lines, the writer has learned that some tremor has been observed. 


961 
DELIRIUM TREMENS. 
tory explanation of the whole difficulty ; hut to tell us that in the first stage the patient's " countenance is dejected and anxious; his spirits are depressed; there is frequent sighing and oppression of the preecordia;" when not one of these symptoms attends the cases embraced by his qualification, it becomes conclusive that the two forms are not one and the same—that they are as far from it, as the two forms of apoplexy before named. 
Since making the preceding extract, we have fallen upon another case, in Dr. Watson's Practice, that is more directly to our purpose. He says : " So frequently does the delirium manifest itself upon the cessation of the accustomed spree, that the continually-recurring stimulus has been regarded as the predisposing, and the privation of that stimulus the exciting cause of the affection. Sometimes, however, it comes on in men who are perpetually fuddled, even although they have not intermitted their usual indulgence in drink." 
This extract contains all that we contend for—and certainly no reasonable mind will conclude that both the use and disuse of an article — a poison, will produce the same variety of disease, after the contrary has been suggested. 
Before proceeding to give the symptoms of the second and third stages, we feel called to settle upon a conclusion as to whether the disease is really and usefully divisible into two varieties or not. By a reference to our treatise upon apoplexy and rheumatism, respectively, it will be observed we have clearly shown that apoplexy may be, and has been, entirely of a passive character; and that those who are organically liable to it, are organically exempt from the active form—and we described the organizations that occasion, respectively, the two kinds of liability. In reference to rheumatism, we made it, we think, perfectly clear, that all organizations are not, indiscriminately, liable to either form, the acute or the chronic, under any possible combination of causes—that those who have the acute can never have the chronic form, and vice versa. Now, from 


962 
NERVOUS FORMS OF DISEASE. 
what the writer has seen, and from what he has learned through his professional brethren, before named, he ventures to lay it down as a rule, that that variety of this disease, which commences with signs of debility or prostration, and in which the tongue and hands become tremulous, is confined to those of a more or less low order of vital force; or, according to Dr. Hall's Zoonomia, they possess a high dynamis—or, finally, they might have chronic rheumatism or passive apoplexy; and on the other hand, those who have the disease without a stage of prostration and without tremors, possess high vital force, or, according to Dr. Hall, high stimulus or low dynamis. The diagnosis between these two classes, organically, can be rendered obvious to the most ordinary observer. Those of the first class have thin necks, or feeble organs of muscular motion and animal sensibility ; while those of the second are precisely the reverse in all respects. Those seen by the writer were fit subjects, under other circumstances, for acute rheumatism and active congestion of the brain. 
If, in the preceding remarks, we are correct (and in accordance with the laws of analogy, they would seem to commend themselves to the careful observation of every physician), then it follows, that delirium tremens is as much and as obviously entitled to a division as rheumatism or cerebral congestion. For reasons that will appear when we come to treat of its pathology, we shall divide it into acute and chronic, and each of'these into three stages —the incipient, delirious, and prostrated. The symptoms of the first stage, in both varieties, have been sufficiently indicated in the preceding remarks. 
2. Symptoms of the second stage in the acute variety. — In this variety, there is none of the business, bustle, and anxiety which is so peculiar to this stage in the chronic variety. When the delirium becomes confirmed, which rapidly follows the incipient stage, all the manifestations are of a passionate character—that is, they indicate that all of the acting mental organs are powerfully excited; and ? as it is common for the subjects of this variety to be strong 


963 
DELIRIUM TREMENS. 
men, they are restrained and managed with great difficulty. In one case the writer had, it was necessary to bind him with ropes. The most pathognomonic manifestation of this variety is a most tormenting dread of danger, and a disposition, in some cases, to suicide to avoid it. This was particularly the case in the subject above alluded to. In another case, which the writer witnessed, the whole dread of the patient was of future torment —he, in wild and frantic calls for help, declared that the devil was dragging his soul out of him. The expression of the countenance is frightfully wild, and either desponding with pitiable lamentations, or of defiance and battle, depending entirely upon the imagined character and power of the enemy. 
The pulse is full and strong, but not remarkably frequent ; the face is flushed; the voluntary muscles have more than their normal strength; the hands are steady, and sometimes an occasional moisture appears on the surface, particularly after muscular efforts. The patient recognizes his acquaintances, and will answer correctly, in monosyllables, any question that is asked him, except with reference to the subjects of his hallucinations. 
From the beginning of the incipient stage, the patient sleeps none until he begins to mend, be the number of the days few or many—a morbid vigilance occupies his whole time. It is necessary to keep a constant watch upon such patients, for, under the impression that they are pursued by an enemy, they may quit the house and ramble off, or possibly commit suicide. The patient of the writer, before alluded to, escaped from his keeper or nurse and ran twentyfive miles in one night, without hat, coat, vest, or shoes, and when about to be arrested, he attempted suicide. 
After one or two days this stage is terminated by a sound sleep and a return to health, or else in the stage of prostration. 
The delirium of the last stage passes into incoherency— the vigilance into stupor—the pulse comes down—the skin is covered with a copious and clammy perspiration—the bowels become diarrheal, and the discharges are made 
61 


964 
NERVOUS FORMS OF DISEASE. 
involuntarily; coma succeeds, and then death, which is frequently of an apoplectic character. 
3. Second stage of the chronic form of delirium tremens. The second stage in this variety is introduced by an increase of the vertigo and mental confusion, or in other words, it may be said to commence with delirium, which is succeeded by a wild aspect of the patient's countenance, and distrust and suspicion of the nearest relatives and most sincere friends. 
In this variety there is a constant disposition to be busy— to act as though he had business of pressing importance to require his constant attention, and this leading idea of business necessity renders him exceedingly impatient under restraint. The most pathognomonic symptom of both forms of the disease is insomnia, but in this no time is squandered, for the patient is exceedingly busy—very restless, and considers it a great outrage to be prevented from discharging his obligations. 
The character of his disposition and of his illusions depends upon the structure of his mental organization; in general, however, the patient is peaceful—not even disposed to fight for his liberty, and yet he will use his utmost strength to become free, urging important business as his motive. If caution be large, and this stage well established, he will manifest the utmost dread of assassins, robbers, or other dangers, and if he be courageous, he will battle with them, otherwise he shows the utmost alarm. If marvelousness and hope are well-developed, the peculiarity of his illusions will be whimsical and laughable—he is in the midst of a swarm of insects, or he is invaded by an army of mice, and he makes battle upon them with his feet, the tongs, or broom; or he is full of ribbons, and he draws them out of his mouth, nose, or fingers. 
About this time some acceleration of his pulse may be observed—his body has become warmer, but his extremities are still cold. If no relief by this time is had, he passes into the third stage, which is indicated by a profuse and clammy perspiration, with an increase of all the other 


965 
DELIRIUM TREMENS. 
symptoms. The tremor of the hands and tongue has greatly increased ; the tongue is still moist, but more furred; the pulse is swollen, but more frequent; the countenance expresses great anxiety; the urine is pale and scanty. Thus these symptoms progress until the patient expires in convulsions; or possibly, his delirium increases, with sub sultus tendinum, and thence he becomes quiet, and dies without a struggle. 
When the disease terminates favorably, the patient passes into a sound sleep during the incipient or delirious stage, and from the latter, he usually awakes between twelve and eighteen hours in a state of convalescence, but he is pale, exceedingly feeble and tremulous. 
Cause. —The cause of the acute form of delirium tremens is the constant and unremitting use of some material stimulus upon a highly-vital organization, or, according to Hall's Zoonomia, one of such high stimulus, that more can not be borne without injury to the health. This stimulus usually consists of spirituous liquors, but it may be produced by the narcotic poisons, particularly by opium. 
In the chronic form, the cause consists of a suspension of a stimulus to which the nervous system had become accustomed, in a constitution of low stimulus, and therefore one which is constantly seeking stimulus of some kind ; and when the brain becomes accustomed to any one, it can not act normally without it. Every one who uses tobacco is a witness of the truth of this statement. But in this case, the stimulus is of the kind named, as directly producing the acute form of this disease. 
We are aware that it is taught by some that delirium tremens is not confined to tipplers and drunkards—that it may be produced in some constitutions by mental anxiety long continued. That a disease resembling the one under consideration may be thus produced, we admit to be probable, upon the authority of others, but we have some strong facts to induce us to believe that it is not and can not be the same disease. 
The writer has probably examined critically more human 


966 
NERVOUS FORMS OF DISEASE. 
crania than any other individual ever did, and in the course of his investigations he has seen the crania of many men who had been intemperate to the close of life. In those of high stimulus, intemperance in the use of ardent spirits produces a hypertrophy of the brain, atrophy of the cranium, and unmistakable marks of pericranial inflammation. He has the cranium of one unparalleled tippler and drunkard, which is remarkably thin, and in which even the temporal sutures are obliterated. Under the process of hypertrophy, the native angularity of the head is greatly rounded. He has the skull of an Indian which, by hypertrophy, wears the form of high civilization. In men of high stimulus, intemperance improves the beauty of the head, particularly in its social or coronal aspect; but it is certainly at the expense of the social and moral character. 
In those of low stimulus, intemperance produces atrophy of the brain and hypertrophy of the skull—that is, the latter becomes more dense and thick. 
The inference to be drawn from the preceding facts is, that the action of the brain, by stimulus of the kind alluded to, is increased with those of high stimulus, and decreased with those of low. 
Having now stated the cerebral condition of the two kinds of subjects of this form of disease at the time of its invasion, no one can be surprised that we are unwilling to admit that merely mental anxiety can produce it. 
Pathology of Delirium Tremens. —Dr. Armstrong, in his Lectures, supposes this disease principally depends upon some condition of the nervous system, and of this condition he acknowledges that he knows nothing. Dr. Gregory is of opinion that it depends upon " exhaustion of the nervous power." Dr. Eberle regards it as "a morbid activity of the brain, from the sudden abstraction of a habitual stimulus, by which its excitability had been long repressed or blunted;" Dr. Coates considers it as consisting in " a hightened activity of the sensorium, from the generation, as it would seem, of an inordinate degree of vital activity in the brain." Dr. Klapp thinks that it is seated in the 


967 
DELIRIUM TREMENS. 
stomach. Dr. Watson thinks that the essential nature of this disease consists in " nervous irritation" and Dr. Carter virtually confesses that he knows nothing about it, and Dr. Watson has in reality done the same. 
It must now be remembered that the preceding opinions have reference alone to what we denominate chronic delirium tremens, because no other variety has become known to the profession. With this explanation, we have a few passing remarks to make upon some of these opinions. Dr. Eberle's opinion is, to us, exceedingly inconsistent. A morbid activity from an abstraction of stimulus ! This is like making a very hot fire by abstracting its fuel. When men become drunk, and are noisy and troublesome, is it not because of a morbid activity of the brain from an excess of stimulus ? If this interrogatory be answered affirmatively, then his opinion is erroneous—absolutely inconsistent with the most acceptable doctrines of physiology. 
When a man has formed a habit of drinking, he can bear comparatively a large dose, but after having been habitually intemperate for many years, a wine-glass full inebriates him. Does this fact not prove that he has exhausted the resisting power of his system or brain ? Is it not universally conceded that a habit of intemperance long indulged, breaks down and shatters the constitution ? If this question be answered in the affirmative, then compare with it the opinion of Dr. Coates. Has drunkenness, to the extent of delirium tremens, ever been known to generate vital activity ? We leave our readers to answer this question for themselves. 
Of the preceding opinions, those of Gregory, Klapp, and Watson, are entitled to respect —each of them contains a few grains of truth. There is, in the chronic form of the disease, an " exhaustion of nervous power," and there is, also, "nervous irritability," but when admitted, what do they explain, with reference to the pathology of the disease ? They do very little more than indicate that it is not an inflammatory one. Klapp ingeniously supports the 


968 
NERVOUS FORMS OF DISEASE. 
hypothesis that the disease is of the stomach, but still, upon this conclusion, the phenomena of the disease can not be explained. 
Before proceeding to advance our opinions upon this very puzzling subject, we beg leave to premise, by placing before our readers a few facts which we esteem as having a vital bearing upon the subject. 
In commencing this treatise, it will be remembered, that we remarked that delirium tremens bore a stronger similitude to cholera, than could possibly, at first, be suspected. 
In treating of the specific cause of cholera, we considered it to consist of an abnormal quantity of carbon in the blood, which, acting like other foreign matter in the sanguiferous circulation, produced emesis and other gastro-enteritic disturbances. Now, take into consideration two facts: ardent spirits consist of carbon as their basis, and the subjects of this disease are constantly drinking them; and now for some other facts: It is well known that intemperate men are frequently afflicted with nausea and vomiting, and that more cases of cholera morbus occur among them than among any other classes of society. It is furthermore true, that when gastric disturbances are interrupted, whether spontaneously or by improper treatment, in drunkards, that delirium tremens is the result. 
Do not these facts show a coincidence between it and cholera, of a character too remarkable for either of them to occur independently of the same cause ? But we have not yet expressed the whole extent of the similitude. In all cases of cholera there is copious perspiration, and occasionally, in the absence of both puking and purging, the excess of this function alone runs the patient into fatal collapse; and one of the most marked symptoms of delirium tremens is the copiousness of the perspiration. Again, in cholera, there is a violet or leaden-color of the skin. Is not this also the case in the last stage of delirium tremens ? 
We are now prepared to come to a conclusion as to the nature of delirium tremens. 


969 
DELIRIUM TREMENS. 
In the acute form, the remote cause is a high state of cerebral action long maintained by the use of stimulating potations, and the exciting cause is such an accumulation of carbon, or what is equivalent, in this class of subjects, an interruption of the fat-producing process, whereby the carbon in the blood becomes excessive, and consequently acts as foreign matter. 
In the chronic form of this disease, the remote cause consists in that shattered or enfeebled condition of the system which makes the use of an unnatural stimulus essential to the normal discharge of its functions. The exciting cause consists of an abstraction of this stimulus, in consequence of which the depurating functions are not properly nor sufficiently carried on. Moreover, carbon has already accumulated to an excess beyond the ability of the respiratory function, which is the most essential to life. 
If an excess of carbon be the cause of delirium tremens, as it is of cholera, it may be asked why, instead of delirium, there is not cholera. We answer: this is sometimes the case, and when it is not, the condition of the brain determines otherwise. In the first class, the brain is preternaturally active, and in the second, it is much enfeebled and preternaturally irritable. But in neither case is the assault made upon the organs of external relation, or those of animal life, as every writer has maintained it to be, except Dr. Klapp ; but it is upon the ganglionic system —the organs or apparatuses of internal relation. The reflection of a moment will make this conclusion apparent. 
When the organs of external relation become functionally deranged, vegetative life and health are, comparatively, but little disturbed; as for example, in mania, monomania, catalepsy, etc. But when the functions of the vegetative or ganglionic system become deranged, the citadel of life, in the abstract, becomes endangered, as in functional derangement of the heart, lungs, stomach, etc. 
Now, inasmuch as delirium tremens is as fatal as most of the functional derangements of the vegetative /system, and inasmuch as we think that we have abso- 


970 
NERVOUS FORMS OF DISEASE. 
lutely shown that it originates in it, we must give it a place among them. 
In the production of this disease, there are two causes in operation—the action of the stimulus upon, or its withdrawal from, the apparatus of animal life, and the accumulation of carbon in the sanguiferous system. Hence, the true seat of the disease is in the ganglionic system, and when the result is not delirium, in consequence of the breach made upon the nerves of animal life, it will be cholera, or some other gastro-enteritic disturbance. The cerebral disturbance, therefore, is as much symptomatic as that of fever. Now, we have another question to solve— which portion of the nervous mass of animal life, sympathizes with the vegetative ? So far as concerns the mental manifestations, we believe that it is the mesocephalae, and with reference to the spasms, it is the medulla and the cerebello-spinal system. For a further view of this subject, see pathology of insanity. 
There is one circumstance that occurs to us as favorable to the doctrine, that long-continued mental anxiety will produce delirium tremens, which is this : mental anxiety produces mental abstraction, and consequently some neglect of the pulmonary function. The liver, too, soon becomes deranged, and this partial failure in both the lungs and liver may possibly result in a defective depuration of the venous blood. But still, there is wanting those pre-existing conditions of the brain which we have described as constant attendants upon the intemperate. 
Long-continued mental anxiety produces in the writer gastro-enteritic disturbances, which are attended with a pain in the head, that has, several times in his life, run into a high state of delirium ; and yet, every other symptom of delirium tremens was absent. These paroxysms with him have never continued longer than twenty-four hours. 
Diagnosis.—Those who are not acquainted with the manifestations of cerebral derangement, may, possibly, without some special instruction, confound this disease with meningitis, mania, or febrile delirium. The resemblance 


971 
DELIRIUM TREMENS. 
between the acute form of this disease and meningitis, is sometimes very strong, so much so, as to render the diagnosis, in many cases, very difficult; but in the latter, there is more febrile disturbance and an absence of imaginary dangers or enemies. Sometimes it is, however, conjoined with meningites, when, of course, there will be a complication of the symptoms. Indeed, we have sometimes suspected that this form is generally more or less meningitic; but our suspicion has been produced by the marks of inflammation upon the crania of this class of patients, who lived intemperate to the close of life. 
From the chronic form, mania may be distinguished by its greater incoherence, by its more gradual approach, by its less concern for business matters, and its being less tormented by imaginary enemies and dangers—tremor, too, is a much less frequent attendant upon it. 
The presence of fever, in febrile delirium, will distinguish it from the chronic form of this, more particularly when considered in connection with a much greater independence of the fantastic hallucination of the latter. As febrile mania is without that wild and frantic dread of enemies, which distinguishes acute delirium tremens, they need not to be confounded. 
But in all cases where there is a shadow of doubt, the previous habits of the patient should be ascertained if possible. 
Prognosis.—The acute form of this disease is attended with much danger, and it consists in its strong liability to run into coma or apoplexy. Another danger that attends it is suicide; and yet, when properly met in the incipient or the earlier part of the delirious stage, it is quite manageable when simple or uncomplicated. 
The chronic form of this, like the same form of other maladies, is not immediately dangerous ; but ultimately it generally proves fatal—indirectly, at least, by producing great debility, or a preparation of the system for an attack of some other disease that suddenly proves fatal. Very few cases of this form have many returns of the disease without 


972 
NERVOUS FORMS OF DISEASE. 
a great impairment of some important viscus, and the liver is the one that is most likely to suffer by the vicarious labor impc sed upon it from a failure of the lungs in its depurating function. 
Treatment.—When called in the early stage of the attack, there will usually be found delirium, or more or less spasmodic action. Should delirium only be present, administer a cathartic, place the patient in a recumbent position, and make cold applications to the head, with warmth and friction to the feet. If gastric derangement be present, treat it as heretofore referred to. 
After the operation of the cathartic, agents must be administered to quiet the nervous system, produce a determination to the surface, and cause sleep. For this purpose antispasmodics and sedatives must be given, among which we have derived much benefit from equal parts of Tincture of Valerian, Tincture of Castor, Laudanum, and Spirits of Nitre, from one to two drachms of which may be given every hour, and continued until sleep is produced. 
Should the attack commence with convulsions, give fifteen drops of the Tincture of Gelseminum every fifteen minutes or half hour, lengthening the intervals between each dose, and continue its use until spasmodic action begins to subside, when its use must be omitted, and resumed again only when the spasms re-appear or increase in severity. As soon as possible after the removal of the spasms, administer a cathartic, and subsequently pursue the same treatment as above. 
In cases where patients, after having been for some time under the influence of sedatives, or even after having slept, strongly crave liquors, it will be prudent to cautiously allow them the moderate use of some stimulants to which they have been unaccustomed, at regular intervals, which should be lengthened as far as possible, or as the case will admit. After the more active symptoms have been overcome, the patient should be placed upon tonics, among which we prefer an infusion of Hydrastis. 
It must be remembered that when sleep has been 


973 
LITHIAS1S. 
produced, the patient must, for no purpose whatever, be disturbed, unless it partake of the nature of coma, as indicated by heavy breathing, weak pulse, cold, clammy sweat, etc.; in which case he may be aroused for a few minutes at a time, and stimulauts administered. 
Species XV. — Lithiasis — Gravel — Calculous Disease. 
Those morbid conditions of the system which are embraced by the above title, are indicated by the deposition of an insoluble stony matter from the urine within the body—¦ the most usual and important of which are the three following varieties: the pulverulent, crystaline, and concretionary. " 
The pulverulent or sedimentary is found adhering to the sides and bottom of the pot, after the urine has had time to cool. Uusually it is divisible into two classes ; the sediments of the first are called pink-colored or lateritious, and consist of the lithates of soda, ammonia, and lime —they vary in color, having sometimes a brown or a yellow hue. The second class consists of the phosphates of lime, magnesia, and ammonia, and are denominated the white sediments. 
The crystalized sediments are suspended in the urine, but when it comes to rest in the vessel they sink. They are called gravel or sand—they consist of small, irregular grains of nearly pure lithic or uric acid, or a triple salt of phosphoric acid, magnesia, and ammonia, or of the oxalate of lime. The first are red, the second white, and the last are of a dark-green color. All of these varieties are not to be looked for in the same urine. 
The concretionary form results from the agglomeration of the two preceding varieties, and constitutes what is popularly understood by urinary calculi. Of these concretions, there are many varieties, which it is not necessary to consider in this place. All urinary deposits, however, may be reduced, for practical purposes, to three classes: the urates, the oxalate of lime, and the phosphates. As each of these indicate a state of disease differing from that of each of the 


974 
NERVOUS FORMS OF DISEASE. 
others, it becomes essential to give them a separate consideration. 
The urates or lithic gravel — Lithuria. —This variety of gravel is said to be the most common, and constitutes the most frequent cause of urinary calculi. It consists of uric acid and urate of ammonia, either separate or united, and in a few instances, it is said that the urate of soda becomes an element. These substances being associated with the coloring matter of the urine, have a salmon or brick-dust color, but they are sometimes yellow, and occasionally of a pink hue. Some tinge of red is always indicative of this diathesis. 
During that morbid condition of the system upon which this deposit depends, the urine is, to some extent, scanty, and generally high-colored. As a test of this diathesis, Dr. Rees states, that the deposit is dissolved by nitric acid with effervescence. "When uric acid obtains in the kidneys or bladder, it is not impossible that muriatic or acetic acid, both of which are occasionally in the stomach, may obtain access to it and occasion a deposit of calculous matter. Uric or lithic acid calculi are generally of a brown or mahogany color, and the surface may be smooth or tuberculated. 
Calculi of the urate of ammonia, though of rare occurrence, do nevertheless, occur —they have a clay-color, and are made up of concentric layers—generally smooth, but occasionally tuberculated—the fracture is fine and earthy. Infants are more liable than adults to this variety. 
Oxalate of lime calculi. —This is frequently known as the mulberry calculus, and has very much the color of the ripe mulberry—and its surface is somewhat like that of this fruit, being tuberculated. This variety does not occur so frequently as the preceding; but in many cases of it, this variety constitutes the nucleus. As oxalic acid does not obtain in healthy urine, it is imagined by some to be more difficult to account for the production of the disease; but recurring to the fact that we take into our systems, probably at every meal, all the elements of it, we should give 


975 
LITH1ASIS. 
ourselves no trouble about it until we know more about the chemical operations of the living system. 
JPhosphatic Calculi. —These consist of the phosphate of lime singly, or in combination with the double phosphate of magnesia and ammonia. The first is of rare occurrence, and the second is still less frequently met with. The two forms combined occur more frequently than either of them alone ; and this less frequently than either of the preceding varieties. In connection with this diathesis the urine is generally of a yellowish-white color. The texture of these calculi is but imperfectly laminated, and the color is of a whitish character. They are usually, but not always, soft. The surface has a crystaline appearance, and frequently this calculus is founded upon a laminated, dark-colored uric acid nucleus. 
Symptoms in General. —An aching sensation or obtuse pain in the region of the kidneys ; a burning and irritating feeling in the urethra and about the neck of the bladder ; a frequent desire to micturate, and when done a sensation remains that all is not voided. Sometimes the mucous lining of the urethra becomes irritable by the passage of small gravel, and then there is an acute smarting, and sometimes there is an acute pain in the perineum, but it is only of a momentary duration. 
Causes. —Of the uric or lithic acid diathesis, Dr. Wood thinks that the use of high-seasoned animal food, with wine or alcoholic drink combined with indolence, constitutes the most "powerful' 5 cause. It is his opinion, furthermore, that a liability to this form of disease is sometimes hereditary and apparently associated with gout. As further causes of this diathesis, he assigns sthenic fevers, and such inflammations as occasion fever; also inflammation or high irritation of the kidneys; and he says that Dr. Prout thinks inflammations of the liver and the heart are peculiarly apt to occasion a uric acid sediment. 
All this may be just and correct, but the writer has to add that there is no hereditary taint in his constitution— that he has never been a high-liver, but on the contrary he 


976 
NERVOUS FORMS OF DISEASE. 
has been most wretchedly dyspeptic, and that he has suffered considerably from this diathesis. 
Oxalic Diathesis. —This form of the disease is thought to be occasioned by derangement of the digestive apparatus, as dyspepsia, etc. It is confessed that but little is known on this subject. • 
Phosphatio Diathesis.—Upon the cause of this form of the disease, Dr. Wood says : "It has been observed that a disposition to an over-production of the phosphates is apt to accompany a nervous and irritable condition of the system, marked by general debility, paleness of complexion, impaired digestion, and a frequent, irritated, and easily excited pulse." In fine, it may attend dyspepsia, debauchery, and almost all forms of a ruined constitution. 
Pathology.—The writer is of the opinion that every variety of lithic diathesis is but symptomatic of some other form of disease, modified, more or less, by the existing constitution ; and he is surprised that lithiasis, at this day, should be treated of as an independent form of disease. 
Dr. Joy (Cy. Prac. Med.) says that " urinary calculi are formed by the diseased action of the vessels which secrete the urine, or by a deposition from urine in a morbid state." 
Are we to regard the urates which appear in the urine at the close of sthenic fevers, as a result of " diseased action " of the renal vessels ? When the other depurators of the system fail to perform their function, and calculous matter appears in the urine, are we to attribute it to renal disease ? If such calculous matter did not appear in the urine under such circumstances, then we should conclude the renal vessels were diseased; nay, more ; we should conclude that the patient could not live long. 
We do not doubt but that a long continuance of lithiasis will finally produce renal disease, just as a vicarious function imposed upon any other organ will finally enfeeble and derange its function ; but it does not follow that when the kidneys become diseased, from this cause, that their secretion will still produce lithic deposits. 


977 
LITHIASIS 
Under the head ol causes of lithiasis, we are told that blows over the region of the kidneys will occasion lithic deposits in the urine. But does this prove that they were so injured as to occasion them ? Is it not equally probable that other depurators were deranged by the blow ? The writer has frequently noticed that after a few days of mental anxiety, a copious deposition of the urates take place from his urine. Were the kidneys at fault ? 
Among the causes of the uric acid diathesis, Dr. Wood enumerates " damp places." Now we very much doubt whether a case of stone in the bladder ever obtained in the city of New Orleans, where the atmosphere is forever charged heavily with humidity. And why ? Because the bladder is always kept well washed out, and at short intervals, by a very copious secretion of urine. During many years' residence in the south, the writer was exempted from all tendency to lithiasis, but in a year after his return to this latitude, the complaint returned upon him. With these remarks we close what we have to say about the pathology of a symptom, (f) 
Treatment. —The indications in this disease are to change the character of the urine and prevent the deposition from taking place. The treatment will depend, also, upon the character of the deposit; when there is uric acid, we must endeavor to change the secretion by increasing the quantity and quality of the urine, so as to make it soluble; for this, the alkalies may be used freely. The Iodide of Potassium, the Bicarbonate of Soda, or the Bicarbonate of Potassa, should be used and continued in moderate doses until the desired effect is produced. This class of agents increases very considerably the quantity of urine. We use in connection with these the various mucilages, such as Slippery-Elm, Gum-Arabic, Flaxseed, Althea Officinalis, Uva Ursi, etc. 
In order to prevent a recurrence of this disease, the patient should use freely of the different combinations of Iron, Iodide of Potassium, and Compound Syrup of Stillingia, with the additional use of the alkaline and vapor- 


978 
NERVOUS FORMS OF DISEASE. 
bath, used alternately each day, and confine the patient entirely upon meat diet. If the phosphatic variety be present, and complicated with dyspepsia, as we usually find it, we would treat that complication as heretofore recommended under its proper head, making use, at the same time, of the same treatment referred to for uric acid, with the exception of the Bicarbonate of Soda or Potassium. The Nitro- Muriatic Acid may be used in this form of disease with advantage, by adopting both its internal and external use, according to the usual application of this remedy. 
We recommend a similar treatment in the oxalic form, with the exception of the acid application. We would advise the internal use of very little fluids of any kind, continuing the same local applications referred to in the other forms. 
Professor Powell states that during his citizenship in Baltimore, he suffered considerably from the uric acid diathesis, and became relieved by a visit of two years to the Sulphur Springs of Virginia. Thence he went south, and during many years he had no return of the disease. In connection with these circumstances he adds, that while in Baltimore his general health was much depraved—that it improved in Virginia, and became generally good in the south. Since his return to Covington his urine was frequently loaded with uric acid deposits, until he changed his residence, which was to a place that bore plenty of grapes —the eating of which arrested the diathesis. He has since experimented on the subject, and finds that the pure wine or juice of the grape made in this neighborhood, and also pickled grapes, will almost immediately arrest it, and render his urine peculiarly pure or clear. 
The remedy is simple and palatable, and those who are similarly troubled would do well to repeat his experiments. 
Species XVI. — Scrofula. 
In the catalogue of human maladies there is, perhaps, not another that is so distingushed for its capacity of appearing in so many forms and of as many grades of 


979 
SCROFULA. 
violence as scrofula. It is a tubercular form of disease, and has its location in the lymphatic system. 
Dr. Eberle says that " the most common forms of scrofula are tubercular phthisis pulmonalis, white swelling, or disease of the hip and knee joints, and opthalmia." Between phthisis pulmonalis and the other forms of tuberculous disease we are aware that writers have made no distinction. We are so far of a contrary opinion as to venture to suggest a difference. Phthisical subjects are marked with a liability to phthisis through life, but the scrofulous ones are not necessarily so marked. It as frequently occurs in persons who have not in the least a phthisical form as in those who have—if not more frequently. 
We are of opinion that children may be scrofulous and yet, in manhood, have nothing of a scrofulous character about them, and vice versa. If the liver, and even the muscles of a hog, or a rabbit, can be filled with tubercles by feeding, why may they not in children ? As a general fact, we have not been able to discover anything like a family likeness between the heads and chests of scofulous and phthisical people. When a child is the only one of the same sex in a family, it may generally be considered as liable to scrofula, and upon this principle it was, very probably, called the " King's-Evil " —too much feeding. 
We do not contend that it can be produced in all persons, and for the reason that all persons have not a cerebral organization adapted to it; and that which we have found, most frequently to be associated with it, is the reverse of that which most generally attends phthisis. 
• Writers have indulged in a very minute description of those whom they regard as being " predisposed " to it, but they do not agree among themselves in many important particulars. We have never seen one who was " predisposed " to it, but we have seen many whom we regarded as being organically liable to it, and we have seen many who had it, and yet in the circumstance of eyes, hair, complexion, etc., there existed scarcely a shade of family resemblance. We admit that there is a set of features which 
62 


980 
NERVOUS FORMS OF DISEASE. 
have a strumous indication ; but we hold them to be like the signs of rain in dry weather —they pretty generally fail. Some people say that they can always distinguish a Jew from the other classes of society, but the writer confesses that he can not, and yet he can discriminate between Whigs, Democrats, Presbyterians, Methodists, and Episcopalians, but not without a few failures—possibly five in a hundred. 
If we had found the signs of a scrofulous liability as well established as we have the sectarian, we would venture to name them. The truth is, as we believe, there is a large class of persons, particularly of children, in whose ancestry the disease never existed, who may be fed into scrofula, as certainly as a hog or a rabbit, but such is not the case with phthisis. The difference is possibly this: the former is dietetic and the latter is atmospheric. For further information, consult the introduction to the third book and the article phthisis. 
The deposition of tuberculous matter in this form of disease is of two characters; it occurs in the form of an infiltration in the tissues, or in the form of little isolated bodies, which in both cases is gray and semi-transparent, but in time becomes opake, possibly yellow, and it may become hard or merely rather soft. The matter is found, sometimes, in both conditions as to translucency and opacity ; and it has not been determined whether the difference is original, or that the former passed into the latter. 
When the tubercles are of the isolated character, and not larger than millet-seed at first, they are known as tuberculous granulations or miliary tubercles. From this diminutive size they become to be as large as a garden pea. A change at length begins—they become softer, and finally pass into a pus-like matter. Frequently these tubercles are aggregated together and form a considerably large mass. Upon this pus-like condition inflammation ensues, and consequent ulceration. The infiltrated variety develops into large, irregular masses, and then runs the same course with the other. These tubercles may be formed in almest 


981 
SCROFULA. 
any part of the system —the writer has seen them in the lungs, liver, spleen, kidneys, muscles, mesentery, and the glans penis. No age is entirely exempt from this form of disease, but the two extremes of life are the most liable. In this respect scrofula and phthisis are similar, and no doubt the rationale we have given of the latter applies equally to the former. 
Exciting Causes. —Glimate has as much to do in the production of scrofula as it has in phthisis, and in confirmation of this statement, Dr. Alison says, " that a great majority of the inhabitants of the West and East Indies, both negroes and Hindoos, are unusually prone to scrofula when they come to temperate climates."— Eberle. The reason of this is explained in the reference before made. Among the affluent we consider over feeding and the use of too much carbonaceous food as the most common cause; and among the poor, insufficient clothing, and consequently too frequent exposure to cold and dampness. The negroes of this country, in consequence of their natural inability to endure cold as well as the whites, are much more liable. In very many instances, in parts of our country, it is due to the double influence —exposure to cold and feeding on fats. 
It is said to be much more unmanageable when hereditary ; this should be expected, because to a tubercular organization is added suitable modes of organic action. 
Prognosis.—When the patient is either young or old, the prognosis is unfavorable ; in the first, because the existence of the disease indicates an insufficient viability, and in the old, because it indicates a declining viability. When the patient's residence is in a cold and humid atmosphere, the chance of a cure is improbable. When the patient is an adult, or beyond puberty, with a tolerable share of strength, a cure is rendered probable. A southern planter assured the writer that he would not insist upon a reduction of more than one hundred dollars in the price of a scrofulous negro under the circumstances last named, because he could cure him in a few weeks by the use of Burdock. 


982 
NERVOUS FORMS OF DISEASE. 
This may be true in the south and utterly fail in this Climate. 
Treatment.—If this occurs after the organization becomes complete, we can not expect to accomplish as much in the treatment as we can previous to thi3 period. And whatever is accomplished, must be done by changing the quantity and quality of the b'ood. 
When this occurs in children and is located in the glandular system, especially about the neck, there is great liability to its passing into a stage of suppuration ; this may be prevented, however, by covering the neck, where a predisposition exists, with flannel or some similar article. The fluid extract of the Walnut leaf has been used pretty extensively in the treatment of this disease. The treatment which we pursue is so similar to that which is recommended in the Eclectic Surgery, that we extract pretty fully from that work, as follows: 
" Tiie treatment must have reference to four considerations : 1st, The constitution ; 2d, The inflammatory condition or tendency in any part; 3d, The abscesses ; and 4th, The ulcerated or, perhaps, scirrhus complication. 
" To correct as much as possible the constitutional taint, give the Alterative or Scrofulous Syrup; or one I have often made for this purpose, a compound of equal parts of theRumex Crispns, Ampelopsis Quinquefolia, and Solanum Dulcamara. This preparation, taken alternately with the Scrofulous Syrup, seems to have a better effect than the continued use of either of them alone. In connection with one or both of these, a beer may be directed as a common drink, strongly charged with the Sassafras, Burdock, and Spicebush. The Menispermum Canadense and Aralia Nudicaullis in a strong syrup, is excellent; the Scrofnlaria may be added to either of the foregoing or used alone, with excellent effect. So also may the Corydalis Formosa. 
"A mild emetic, followed up with a mild cathartic, should be occasionally given during the alterative course. If the patient is inclined to acidity of the stomach, the emetic should be repeated once a week or oftener. If there 


SCROFULA. 
983 
is derangement of the liver, as there frequently will be, especially if the patient has been previously treated with Mercury, use an alterative portion of Podophyllin in connection with Leptandrin, when there is much debility; or if the bowels are already too loose, the Leptandrin alone. 
"From late experience of my own and others, I am fully convinced that no alterative or combination of alteratives that we possess, is equal to the Stillingia Sylvatica, either for the relief of scrofulous disease when developed, or the correction of the constitutional predisposition. I have recently effected cures with this article, as the only constitutional remedy, when the ulceration was very extensive, affecting even the spongy bones of the face and nose. The article may be used as infusion, decoction, or syrup, taken three or four times a day, as much as the stomach can bear. 
" The saline and alkaline baths should be used all the time in alternation, one or the other every day. 
" The diet must always be nutritious and easy of digestion—all stimulating condiments to be avoided. Never think of restricting to ' vegetable diet.' 
" To discuss any hardened tumors or enlarged glands before active inflammation or soreness is manifested, apply a poultice wet with the Comp. Tine, of Myrrh, and cloths wet with the same applied and covered with Slippery Elm. In some cases the Discutient Ointment may be more convenient. Strong alkaline lotions aid much in bringing about resolution. 
" In threatening or incipient inflammation, make a poultice of the Arum Triphyllum, by mixing the dry powder in warm water, and apply, changing it three times a day. The fresh root finely grated is still better. This article seems to have something quite specific in its influence, speedily removing scrofulous tumors when very large and highly inflamed. Whatever external means are applied in such cases must be of a stimulating character, if you expect them to aid at all in bringing about resolution. 
"If, however, your means for bringing about resolution should fail, or it is already too late for their application— 


984 
NERVOUS FORMS OF DISEASE. 
if suppuration has already taken place, the sooner the matter points to the surface and breaks out, the better for the patient. In order, then, to facilitate this result, apply emollient fomentations and poultices. But it is not best to wait for a spontaneous breaking. As soon, therefore, as any point becomes purple or discolored, and you can perceive by the fluctuation that the tumor contains matter, though it may be deep-seated, open an issue with caustic potash, pressing it in until it makes its way deep into the tumor. Let it enter the cavity if possible, the very first application. It causes little pain after passing through the skin. At all events, leave a sufficient quantity of the caustic to work its way through. Be-apply the poultices as before, continuing them so long as there is any inflammation. 
"After this, wash out the abscess once or twice a day with vegetable caustic, very weak at first, by means of a syringe, keeping the external orifice open until it fills up from below. After a few days of this alkaline washing the discharge will assume a healthy character. It should still, however, be kept up for a while, in order to prevent the fungous growths and aid the healing process. 
" If you find that the abscess contains a lymphatic gland, loose and surrounded by pus, enlarge the orifice in order that it may escape, or you may cautiously aid its expulsion by pressure, or even remove it yourself with forceps. After the removal of the gland, the sore will generally 'heal kindly.' It may, however, still need stimulating alternated with caustic applications. If the sore assume the character of a malignant ulcer, persevere with the constitutional measures before recommended, and let your local applications for a while be only such emollients and other antiphlogistics as are calculated to reduce inflammation and irritation. Against the latter a good article is a poultice of the Scrofnlaria Marylandica, with Stramonium and the Lobelia herb. 
" After allaying irritation, if there be any callous growth, which resists the vegetable caustic, use the caustic potash. Place over the ulcer also a salve composed of the roots of 


985 
EPIDEMIC CHOLERA. 
Ohelidonium or the common Irritating Plaster. This may be occasionally removed, if necessary, and the emollients re-applied. Under these means the ulcer will soon heal, all induration disappearing. 
" If the ulcer has sinuses communicating with each other, they should be joined, if possible, by ligature or the cautery, and may require injections and tents of mild caustic. These or similar means, in connection with the constitutional regimen before recommended, have succeeded in numerous instances, many of which had baffled the skill of the most celebrated practitioners. It is, no doubt, to the constitutional remedies that we are chiefly indebted, the local means being, after all, merely palliative, and never amounting to a removal of the cause. 
" In no cases of scrofula do we meet with half as much difficulty, as in those, where, beside the disease, we have to contend with the effects of previous medication. The worst influences are induced in this form of cachexia by Mercury and Sulphur. The injurious influence of this latter article is not, perhaps, as well known as the former." 
In addition to the above we have often derived much benefit from the use of Iodide of Potassium in combination with the Syrup of Stillingia, in proportion of one drachm of the former to four ounces of the latter, of which, for an adult, one drachm may be given three times a day. The different combinations of Iron should be used freely ; allow the patient plenty of exercise and a generous meat diet. 
Species XVII.—Epidemic Cholera — 
Asiatic Cholera — Spasmodic Cholera — Cholera Asphyxia. 
We have no very certain historical evidence that this form of disease was ever known before its appearance in Hindostan, in 1817; yet there is history enough to show that this was not, probably, its first visitation. In one year after its first appearance, which was at Jessore, in Hindostan, it appeared at Bombay; in 1821, it invaded Arabia, and thence, passing through Persia, it appeared at the mouth of the Volga in 1823, and nearly at the same time 


986 
NERVOUS FORMS OF DISEASE. 
it also visited Tripoli. In 1830, it re-visited the mouth of the Volga ; thence, passing through Russia, Poland, and Germany, it appeared on the coast of the Baltic in 1831, and shortly after it made its appearance in England, and thence, in 1832, it visited the United States. 
Some discussion has been had as to the name that should be adopted to designate the true nature of the disease. It is questioned whether it really belongs to the genus cholera—it is thought by some to hold a nearer relation to that of fever, and hence the appellation of epidemic cholera fever has been suggested for it. But as fever is not disease, but merely a mode of vital action to remove obstruction, we can discover no propriety in changing the name, more especially as the one it now has is universally understood. When we come to treat of its pathology it will be discovered that neither of the names expresses its true character—the one it now bears is, perhaps, the more significant. It may be defined to be a form of disease which is characterized by vomiting and purging of a colorless fluid, severe spasms of the voluntary muscles, great prostration of strength, succeeded by collapse and death or recovery. Now, except the character of the discharges, the writer has known all of these features to attend a congestive chill of an intermittent fever. It frequently happens that recovery from this disease takes place without a stage of excitement, as has been contended for, and the writer has witnessed the same in congestive chill. Under a proper mode of treatment we are not sure that a stage of excitement is essential to either form of disease. 
For the purpose of greater explicitness in giving the natural history of this form of disease, we shall divide it into four stages, viz: the premonitory, the choleric, the collapsed, and the convalescent. 
1. Premonitory stage. —During the prevalence of the epidemic, almost every member of the commuuity feels some of the effects of the specific cause of the malady— one complains of lassitude; another of costiveness ; another of diarrhea j another of anorexia \ another of dysentery; 


987 
EPIDEMIC CHOLERA- 
another of colic pains, etc. In confining our remarks to those who become the subjects of the disease, we may say, that in a great majority of the instances, diarrhea has been the most distinguished symptom of this stage. In the beginning, the diarrhea is fecal and bilious, but ultimately it takes on the peculiar or serous character of the choleric stage. This diarrhea may continue many days and greatly enfeeble the patient, and from it he may spontaneously recover; but this is not usual; most generally it passes into the next stage. In other instances the diarrhea is only a few hours in advance of the second stage, but its average duration is about forty-eight hours. In most instances the transition- from the first to the second stage is occasioned by some error or imprudence at the table. In many instances it is occasioned by fear. This premonitory stage, when prostrating from the extent of the purging, but unattended by spasms, has been denominated cholerine. Constipation very frequently precedes, and is premonitory of cholera, and the use of medicine to excite alvine action is very apt to induce the disease. Dysenteric symptoms, and more or less stricture of the large intestines, though common to society during the prevalence of the epidemic, are, by no means, so apt to be followed by an attack of the disease as diarrhea. 
2. Choleric stage. —This stage comprises those phenomena which have given character to the disease, and therefore it might be appropriately denominated the stage of action. It commences with a feeling of uneasiness in the stomach — in some instances it amounts to pain, which, in either event, is speedily succeeded by a vomiting of a white o r colorless fluid, resembling rice-water, and also a purging of the same kind of fluid ; the purging, however, may have continued from the premonitory stage, and therefore, necessarily have preceded the vomiting. The latter is very rarely so effectual as the purging—in many instances it consists of mere efforts at emesis, but in others the contents of the stomach are ejected with great force. The muscular spasms or cramps usually commence with the vomiting, 


988 
NERVOUS FORMS OF DISEASE. 
but sometimes they precede, and they constitute the greatest portion of the suffering or positive pain which the disease occasions. The alvine discharges are sometimes scanty, but generally they are copious ; and the urinary secretion is suspended or very nearly so. The pulse is feeble, most generally, and frequent; the cutaneous temperature is much below the normal standard ; the features are shrunk and of a livid or pallid hue ; the respiration is hurried, and frequently interrupted by spasms of the diaphragm and other muscles. 
Most of the reports that have come to our notice state that this stage most generally makes its assault between midnight and sunrise. As it advances the circulation sinks, the pulse becomes feeble and fluttering, and finally, in many cases, imperceptible. The tongue is pale and moist, but in other respects more or less normal. At length the skin becomes cold and of a violet or leaden-color, and so inelastic that when drawn into duplicatures, it so continues. The patient complains violently of the spasmodic contractions of the muscles, and begs to have friction applied to them. In the course of this stage he becomes very restless and complains of distress about the prcecordia, and betrays much difficulty in respiration. The mean duration of this stage varies from eight to twelve hours, but be it long or short, all the symptoms, unless arrested, increase in violence to the introduction of the stage of collapse. 
3. Stage of Collapse. —The patient has now passed the period of much suffering, but feels oppression about the praecordia and betrays that restlessness which is characteristic of high degrees of congestion. The pulse at the wrist is absent, or so nearly so as to be barely perceptible; the skin has, to the feeling of others, an icy coldness, and is of a bluish complexion, particularly on the hands and face. The tongue is moist and of less than a normal temperature, and the stomach has, so far as the fact can be ascertained, lost the whole of its irritability, for the most powerful stimulants do not seem to affect it. The urine is now entirely suspended. Spasms are not now so frequent, and when 


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EPIDEMIC CHOLERA. 
they do occur, they are too feeble to give much pain; the respiration is particularly slow; the eyes are sunken in their orbits; the conjuctivae are dry, glary, and in the inferior hemisphere injected with a dark-colored blood. The breath is but little more elevated in temperature than the atmosphere ; the voice is very feeble—frequently it becomes lost; the evacuations, if any, are passed involuntarily. If death is to close the scene, the spasms, if they have been absent, return, and after death the muscles are sometimes found in a state of rigid contraction. The intellect usually maintains its integrity to the close of life, but this does not appear to be the case with the affective faculties, for the patient appears to be incapable of any variety of emotion. Although he appears cold to those who observe his condition, yet he complains of great heat and an insupportable thirst; the respiration continues to sink until it becomes imperceptible, but finally a few gasping efforts are observed which are readily understood to announce the moment of dissolution. This is the general result of collapse, but not the uniform, for a few do recover from this low and apparently lost condition. 
4. Convalescent stage. —Whether this commences in the choleric or the collapsed stage, it begins by a return of heat to the surface ; the pulse becomes less frequent, but more full and forcible ; the sense of oppression about the prsecordia abates; the spasms become less frequent and violent; the discharges cease; the skin assumes a normal appearance, and the patient passes into a quiet and refreshing sleep. The glandular system now returns to its duty, and the patient, when he awakes, feels that he is comparatively well—and, in many instances, he is, but so feeble and delicate is his condition, that he may readily relapse. 
If the efforts of the system and of the physician have succeeded in removing the proximate cause—obstruction— then is the patient really well when secretion has become re-established. In such cases there is no stage of febrile excitement—it is simply one of nutrition ; but in some cases the obstruction has not become removed, and the system 


990 
NERVOUS FORMS OF DISEASE. 
sets up a febrile action to remove it, but in many cases this last effort fails, and death is the consequence. After reaction has been established, the patient, by imprudence or otherwise, may have a return of the disease and death may be the result; and in the event that the depuration was not rendered complete during the active stage of the disease, that obstruction which remains may ultimately produce death, notwithstanding the utmost febrile efforts the system is capable of making. 
Dr. Brown (Cy. Prac. Med.) will have a febrile stage whether the facts warrant it or not, and it is possible that in Europe such a stage did always attend the reaction, because of some peculiarity incidental to the country, or to the treatment, which we deem the most probable. We can not conceive it to be possible that after venesection and large doses of calomel, febrile action could be dispensed with in any case of reaction in this form of disease. 
In the event the reaction should be of a febrile character the patient will complain of pain in his head, the vessels of the conjunctiva become distended with blood, and light becomes distressing to the eyes, the tongue is dry and red, and the fever is of a typhous character. As the disease progresses the patient betrays stupor and possibly a muttering delirium. In this condition, more or less, he may continue a week or ten days, and then sink into coma and death, or finally recover, but his convalescence will belong and tedious. 
When the patient has been so fortunate as to escape the febrile attack, which frequently happens even in violent cases, under a judicious or a depurating treatment, he returns to good health in a few days. But in the other event he will be afflicted with gastro-intestinal derangements for months. 
Like intermittent fever, cholera sometimes appears in what may be called a masked form—that is, the attack may not be attended by either nausea or vomiting, or possibly no diarrhea attends it; or the cramps or spasms maybe very light, or possibly, entirely absent, and yet, in all other respects, it is epidemic cholera. 


EPIDEMIC CHOLERA. 
991 
Diagnosis.—Some cases of common cholera are so violent, that were they to occur during the prevalence of the epidemic, which is not possible, they would certainly be regarded as instances of it. As the treatment must be the same in both, and as both can never happen at the same time, it is useless to labor at an accurate diagnosis. The only other form of disease with which it is possible to confound epidemic cholera, is congestive chill, as it is sometimes seen in the south. But in the latter the alvine discharges consist of serum and blood, which, so far as we have learned, is never the case with cholera. 
1'rognosis.—As the writer never lost a case of congestive chill, nor one of cholera, when called to it before the stage of collapse, he is forced to regard the latter as a very manageable disease to the end of the choleric stage. That of collapse is confessedly one of danger, and so is the febrile, when it happens, for it is entirely incidental. The fact of its occurrence proves that the specific cause, more or less, is still present in the system, and it is too feeble to produce such a grade of febrile action as may be requisite for its removal. 
Causes.—Upon the subject of the exciting causes of this disease, there is a pretty general unanimity of opinion; but with reference to the specific or remote, there exists much diversity. 
The specific cause has been very extensively attributed to contagion; some have regarded the lime that is in the water we drink as being the cause; some refer it to electrical changes in the atmosphere, others to planetary influence ; some to malaria, and others to atmospheric animalculae. As no one of these supposed causes has been so explained as to account in any wise for the manifestations of the disease, they have made no impression upon the judgment of the writer. If either of these opinions has any merit, as it has been defended, he has not been able to discover it. 
At the time the disease first appeared in England the writer resided in Baltimore, and was a member of its 


992 
NERVOUS FORMS OF DISEASE. 
medical society, in which the disease was discussed at almost every meeting, during a year prior to its appearance in New York. The writer was the only member of the society who did not believe it to be contagious up to the time it appeared in that city. So firmly was he convinced that it was not contagious, that he offered himself as a subject for any experiment, by inoculation or otherwise, which the society might decide to institute. His opposition to the idea of its being contagious, was founded on the single fact that the disease did not provide, like small-pox and other contagious forms of disease, an apparatus for the elaboration of a poison. Up to the time of its appearance in Baltimore, he had formed no idea as to what the cause was, except that it was in some way atmospherical. 
Upon the appearance of the disease in that city, Mr. Baer called the writer's attention to the astonishing fact that he could not make sulphuric acid in his laboratory with sufficient success to meet the cost of materials—the chamber, as the manufacturers termed it, smoked. The writer visited with him the laboratory, and smoke it did, at every chink and crevice—a circumstance that never happens when combustion is well sustained. This phenomenon continued during the presence of the cholera. 
To conclude from this circumstance—this single coincidence, that the disease was occasioned by an atmospheric cause, may be considered as rather hazardous; but so carefully did the writer observe the coincidence and all its details, and so satisfactorily did such an atmospheric condition, admitting it to exist, account for the production of the disease, that he could not refrain from regarding the feeble combustion and the cholera as results of the same cause. 
In 1835, the writer made this coincidence and his conclusions from it, with reference to cholera, known to the medical society of the Cincinnati Medical College, and they met a very able support from Prof. Drake. Subsequently he published the tact of the coincidence in one of the Cincinnati papers, which he supposes occasioned other observers to give attention to the subject upon the next return of 


993 
EPIDEMIC CHOLERA. 
of the cholera to the city, when the same phenomenon was observed and published ; he has forgotten the authority. 
The modus operandi of this atmospheric condition in the production of cholera, will be given when we come to treat of the pathology of the disease. As to what that atmospheric condition was, we shall not inquire; for our present purpose it is enough for us to know that it was such as to afford, comparatively, but a feeble support to combustion. 
That some persons are more liable to be assailed by cholera than others, we do not doubt; and yet, in this respect, this form of disease is less influenced by differences of constitution than any other now recollected. Some organizations are entirely exempt from acute rheumatism, others from the chronic, and so with other forms of disease, the cholera excepted. "We have known it to assail some of the best and most resisting constitutions that ever distinguished the race—constitutions that had resisted every other form of epidemic, and those too, who, through life, had conformed as closely to the natural laws as man well can. Yet, as we have remarked, some organizations, particularly when under the influence of certain habits, are more liable than others ; and the most liable are the most cowardly. We do not mean by this remark, that none but cowards have the disease, but simply that more cowards have it and die of it, than of any other class, particularly among those who are able to command the essential comforts of life. In the opinion of the writer, there is, however, one organization which appears to be more exempt from cholera invasion than any other, and that is the obese. The writer has never known a fat man to have the cholera, and by inquiry of his professional brethren, he has heard of but very few. This exemption should, a priori, be expected, and for reasons that will be found under the next head. 
The exciting causes are, mostly, such as are known to develop other forms of disease. Dr. Eberle says that " the natural or constitutional predisposition to (the) disease consists, probably, in a naturally-delicate and irritable state of the mucous membrane of the alimentary canal —a condition 


994 
NERVOUS FORMS OF DISEASE 
' which may have show itself, on a former occasion, in a peculiar liability to disorders of the stomach and bowels, from slight causes, or by a habitual tendency to diarrhea and dyspepsia.'" 
We regard this opinion very much in the light of a mere supposition, and it is a very natural one to those who entertain the opinion that the mucous surface of the intestinal canal is the primary seat of the morbid impression. But the writer has known men who had, comparatively, the digestive apparatus of an ostrich, to have the disease. We do not doubt that those who have a feeble or an unsound digestive apparatus are, cceteris paribus, the most liable to die of the disease. The doctor adds, that " Exposure to a cold and humid atmosphere, particularly at night; excessive fatigue of the body; inordinate mental excitement— the abuse of spiritous liquors, and crude, indigestible, and irritating articles of food, are particularly calculated to favor the development of cholera, in persons exposed to the influence of its cause." He goes on to name those articles which have been found the most provoking in this respect, but such a detail we do not think profitable, because articles which are greatly indigestible with one person are particularly the reverse with others. It will be safe, however, to proscribe, during the prevalence of this epidemic, green peas and corn, cucumbers and watermelons ; but even these may prove very harmless with some people. The lather of the writer, in the eighty-second year of his age, had a severe attack of this disease, and yet, during the choleric stage he drank sour buttermilk and ate pickled cucumbers, and he would have them, in defiance of the remonstrance of his physician and friends. Suffice it to add—he is still living. 
Nature or Pathology of Epidemic Cholera. —Hahne- Neal, and others maintain that it is occasioned by the introduction of animalculae into the sanguiferous circulation through the medium of the lungs and the alimentary canal. We name this hypothesis, to the exclusion of others, because we conceive it to be the one that is most generally adopted. But upon this hypothesis we fall very far short 


EPIDEMIC CHOLERA. 
995 
of accounting for many of the most obvious phenomena that distinguish the disease ; as the peculiarly dark color of the blood—even the arterial, the dark-blue or violet color of the skin of the hands and face, and of the teeth and nails. 
In treating of the specific causes of cholera, we stated that during its first visit to Baltimore, the atmosphere was incapable of sustaining a normal combustion, and that upon a subsequent occasion the same fact was observed in Cincinnati. The accuracy of this observation being admitted, it follows that the pulmonary function could not have been any better sustained than was combustion. Under such a circumstance much of the carbon that ought to have been oxydized and eliminated from the lungs, continued in the blood, and therefore in the course of some days the arterial blood would partake of the venous character, become dark, and through a want of oxygen, unfit for a normal support of any of the vital functions. This carbon, then, in not having been eliminated, becomes in the blood absolutely a foreign body, and must have, more or less, the effect of foreign matter introduced into the venous system. 
Experimental physiologists have discovered that olive oil and other bland fluids injected into the venous system occasion emesis, and we think it probable that if these experiments had been pushed to the same extent of repletion of the foreign matter thus injected, which takes place with the carbon in cholera, catharsis would also have resulted. In the experiments of Drs. Manzolini and Quaglino, of Milan {Brit, and For. Med. Ghir. Rev., from Gas. Medica di Milano), it was discovered that the injection of the mineral poisons into the venous circulation occasioned gastroenteritis, and that such an injection of pus of any kind, produced very similar results. In this circumstance we have an explanation of the fact that diarrhea and gastroenteritic disturbances very generally attend suppurating forms of disease. 
It is, furthermore, shown by these experiments, that the 
03 


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NERVOUS FORMS OF DISEASE. 
mineral and animal poisons produce derangement in the organs of internal relation—the ganglionic system, and that the vegetable exert their influence upon those of external relation. We find very similar results from the administration of these substances respectively ; opium, alcohol, strychnia, etc., produce delirium, a loss of consciousness and of volition over the locomotive movements, and that such an administration of the mineral poisons manifests their morbid influence upon the mucous lining of the alimentary canal. 
As regards the animalculse hypothesis, we have no proof of their existence in the atmosphere during the prevalence of cholera, and" if we admit that they do, it can not follow that they are of the same genera and species with those discovered by post-mortem investigations ; one is atmospheric, and the other is parasitic and aquatic. Again, «we regard it as an indisputable fact that the choleric atmosphere is unfriendly to combustion, and it will scarcely be contended, we think, that this condition of it was occasioned by animalculse. 
In 1S49, and on the day that the cholera was the most fatal in Cincinnati, Prof. Newton, who was confined to his chamber at the time, has assured the writer, that all the house flies about his house died on that day. They first betrayed more or less stupor and an incapacity to fly, and then presently dropped dead. This mortality among the flies may have been occasioned by atmospheric animalculse, but we think that they died of asphyxia. 
In treating of the causes of cholera, we gave it as our opinion that fat or obese people are less liable than other persons to this disease; and the reason is now obvious. They require less oxygen than other persons, and whatever of carbon there may be in the venous blood unoxydized and eliminated, unites with hydrogen and id stored away in the form of adeps. 
Finally, our opinion is, that the first morbid impression is made upon the nerves of organic life by the abnormal condition of the blood, from the presence of foreign matter— 


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EPIDEMIC CHOLERA. 
that the nerves of external relation become affected no further than is essential to maintain the normal relation between the two systems, and that the action of the mucous membrane of the alimentary canal can no more be said to be disease or derangement, than is the action of the skin in copious diaphoresis, for the purpose of removing febrile or other obstructions. That ils action is in obedience to a law of the system to get clear of the foreign carbon that is in the blood; and when this is eliminated the patient returns to health. The disease is not the carbon, but the consequence of its influence upon the ganglionic centers. 
Prophylaxis.—When an epidemic of this disease is announced to the community, almost everybody commence some course of life which they intend shall save them from its assaults, and more frequently than otherwise more is done that is calculated to bring it on than to repel it. While we contend that a change should be made in the habits of life, yet we teach that it should not be of a character calculated to make a strong impression upon the system. All such impressions have a direct tendency to develop the disease. 
Because intemperate, but obese men usually escape the disease, the use of brandy, whisky, etc., has become to be considered by very many as an excellent prophylactic. No notice appears to be taken of the many intemperate men who die of the disease, but only of those who escape it. We admit that it would be dangerous for the intemperate to become suddenly temperate, and to those who are entirely temperate, any use of those stimuli would create, necessarily, a liability to the disease. The intemperate should continue to take his grog, and the temperate should as certainly continue so. We mean by temperance, absolute abstinence, because it is impossible to use anything temperably that is not required by the wants of the system. 
From the views we have presented concerning the nature of cholera, it follows, as a necessary inference, that all persons in cholera times should, as far as possible, abstain 


998 
NERVOUS FORMS OF DISEASE. 
from carbonaceous food and drinks, and by their pursuits avoid as far as possible any increase of demand for atmospheric air, for every inspiration but increases the danger. In obedience to these views farinaceous vegetables, sugar, butter, and all manner of fats should be, as far as practicable, avoided; because they furnish very little if any nourishment ; but being carbonaceous they increase the demand for what can not be sufficiently had—oxygen. Succulent vegetables of a digestible character, as cooked fruits, asparagus, etc., and the fresh muscle of beef and mutton and of other animals, should constitute the principal diet. These instructions are not designed for the obese, but for all others. The best prophylactics, however, are cheerfulness, patience, submission —a mind constantly occupied with its duties, and not with remote and possible danger. 
Treatment.—When called upon to treat a patient in the early stage of the disease, he should at once be placed in a recumbent position, and everything should be avoided which will have a tendency to disturb the mind, as well as the stomach and bowels. In the greater part of cases, I have found that in connection with this the administration of the Compound Pills of Camphor, introduced to the profession by myself, in 1849, is sufficient to prevent a further development of the disease. They are made as follows : 
H. Camphor, 
Opium, 
Kino, ad grs. xxxv, 
Capsicum, grs. v, 
Conserve of Roses, q. s. Mix, 
Divide into thirty pills, and give one after each discharge from the bowels, or oftener if the urgency of the case requires it. Occasionally, however, I have likewise applied a large sinapism over the whole abdomen with .advantage. Greenhow's aromatized brandy, the Aromatic Tincture of Guaiacum of the Eclectic Dispensatory, may sometimes be beneficially alternated with this pill. Should there be an overloaded condition of the alimentary canal, the Fluid Extract of Rhubarb and Potassa three parts, with Saturated 


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EPIDEMIC CHOLERA 
Tincture of Prickly-Ash berries, one part, may be administered in tablespoonful doses every hour, and continued until.the bowels are properly evacuated, after which the above astringents may be given ; but where the diarrhea is excessive, it would be imprudent to wait for catharsis, as the discharge should be checked as speedily as possible. 
In the second stage, when nausea, vomiting, and cramps are present, more active means should be pursued. To overcome the nausea or vomiting, the preparation of Dr. O. E. Newton, termed in the Eclectic Dispensatory, Compound Mixture of Camphor, may be used with excellent effect; it is prepared as follows : 
R.- Camphor "Water, 
Peppermint Water, Spearmint Water, dd f3j, 
Paregoric, f3ij. Mix. 
From a teaspoonful to a tablespoonful may be given every five or ten minutes, and in cases where this does not act sufficiently prompt, the following may be administered: 
R. Common Salt, 3j, 
Black Pepper, 3j, 
Vinegar, f3v, 
Hot Water, fgiv. Mix. 
Of this a tablespoonful may be given every ten or twenty minutes, and continued until the nausea ceases. 
To remove the cramps, hot bricks or bottles of hot water, etc., should be kept applied to the feet, legs, and arms, and cloths wet with water as hot as can be borne, must be applied over the abdomen, and changed every few minutes ; this should be perseveringly pursued until relief is obtained. Sometimes advantage will ensue from stimulant applications along the whole length of the spine. Cramps of the muscles of the limbs may be overcome by bathing with the Compound Cajuput Mixture, either alone or in combination with Chloroform, and applying friction at the same time. This course usually checks the further progress of the disease, and the patient is saved ; however, should it fail, and the stage of collapse come on, in addition to the above 


1000 
NERVOUS FORMS OF DISEASE. 
treatment, energetically pursued, the patient should be enveloped in blankets, wet with water as hot as can be borne, which should be renewed every ten or twenty minutes.; and stimulants may likewise be given—the Saturated Tincture of Prickly-Ash berries will here be found beneficial, both by mouth and by enema. 
To convey an idea of Eclectic practice in this disease, as well as its great mortality, we extract from the Eclectic Medical Journal the following report of the Eclectic Medical Society, made in 1849, and the subsequent statistics : 
" At a special meeting of the Eclectic Medical Society, held on Monday evening, September 17th, for the purpose of discussing the treatment of cholera, the following remarks were made by the members, which were reported by the secretary, for the Eclectic Medical Journal: 
" Dr. Morrow remarked, in regard to the treatment, he considered the most prominent indication to be the production of an equilibrium in the circulation and excitability. This, beyond all question, was the most important and urgent indication to be fulfilled, and the moet successful results followed its production. To fulfill this, he had found no other single preparation to have a better influence in most cases, than the Compound Tr. Guaiac, prepared by adding Gum Guaiacum, Cinnamon, and Cloves, of each pulverized one ounce to a quart of best brandy, and given in doses of from a teaspoonful to a tablespoonful in hot, sweetened water and brandy every fifteen or twenty minutes until relieved. This had been found to be an excellent stimulant and astringent, closing the mouths of the absorbents, and checking the discharges. In a few instances this preparation did not appear to answer, but as a general remedy he considered it the most useful with which he was acquainted. In some cases, where excessive nausea was the most prominent symptom, he had found it advisable to commence the treatment by giving an emetic; the operation of the emetic relieved the gastric irritability, equalized the circulation, and checked the spasms. As an emetic he preferred the Acetous Tincture of Lobelia and Sanguinaria, 


1001 
EPIDEMIC CHOLERA. 
with the addition of one-third Spiritous Tr. Aralia Spinosa. This was given in doses of from a teaspoonful to a tablespoonful every ten minutes in warm Catnip tea, sweetened. In urgent cases it was given in larger doses and frequently repeated. 
" The Saturated Tincture Xanthoxylum Fraxinifolium Bac. has been used with great benefit; he had found it an excellent and prompt remedy. When given in the early stages, it would frequently relieve in from ten to twenty minutes. He had used it in doses of from two to three tablespoonfuls. In cases of severe spasms, vomiting, prostration, and profuse rice-water discharges, he had given a tumbler half full at a dose with benefit. Of late he had used the Tr. Xanthox. Frax. Bac, and the Neutralizing Extract, equal parts of each, and had found this combination prompt and efficient. In the earlier stages of the disease, would consider it a most suitable medicine. Bottles of hot water, hot bricks, etc., were used, and if much pain or spasm, extensive sinapisms. In the advanced periods he had found it necessary to produce full, free, and copious perspiration, which would relieve in a majority of cases, say nineteen out of twenty. He thought that those who lost sight of the necessity of producing this determination to the surface, would fail in obtaining the successful results attending the practice of those who regarded it as the most important indication to be fulfilled in the treatment. 
" In eases of partial collapse, when the patients were suffering from severe spasms, he had found Hunn's Antispasmodic Mixture an excellent remedy. It is prepared by dissolving one ounce each of the oils of Cajuput, Cloves, Peppermint, and Anise, in four ounces of Alcohol. He had given this preparation in cases of violent spasms, in doses of from one to two tablespoonfuls, in hot brandy and water, sweetened, every ten minutes, with great advantage and considered it peculiarly applicable to such cases, but found that it did not succeed so well where there was great irritability of the stomach. 
" The hot blankets, notwithstanding the foolish notions 


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NERVOUS FORMS OF DISEASE. 
of some who regard their use as barbarous and improper, had been employed frequently with the most decided beneficial effect. In one case the patient was supposed to be dead—he used the blankets wrung out of scalding water, she recovered, and he got the credit of restoring one from the dead ! 
" Camphor was used beneficially in many cases. Dr. M. had succeeded in restoring patients who were pulseless, by the use of Camphor water, prepared by adding one drachm of Camphorated Spirits to half a pint of cold water. This was given in doses of a teaspoonful every three or four minutes. The external applications were always well attended to during the time of administering the Camphor. 
"Dr. J. King stated that he had used the following preparation very extensively in the treatment of cholera in the early stage. It had also been prescribed frequently by other Eclectic practitioners with advantage in cholera and dysentery. 
R. Ox Gall, 3j, 
Capsicum, 
Gm. Guaiac, dd 9iv, 
Leptandrin, 3iv. 
This was given in doses of one grain, and repeated two or three times a day. He had also succeeded in many cases with a mixture composed as follows: 
R. Sulphur sub., grs. iv, 
Gm. Guaiac, grs. ij, 
Charcoal, grs. ij, Camphor, gr. j, Opium, grs. ss. 
Dose, one to ten grains, repeated every ten minutes, until relief is obtained. In some cases, however, this compound did not appear to exert any beneficial influence. 
" He had used the spirit vapor-bath in two cases ; free perspiration was produced, and the patients expressed a great desire to sleep. Brandy and aromatics were administered, and the patients both recovered. 


EPIDEMIC CHOLERA. 
1003 
" In cases of excessive irritability of the stomach, oatmeal cake coffee was given for the purpose of allaying, and it answered the purpose admirably. 
" The Saturated Tr. Prickly-Ash berries combined 
with Tr. Opium, was used in some cases as an injection with very good effect. 
R. Saturated Tr. Xanthox. Prax. Bac, 3ss, 
Water, 3j, 
Tr. Opium, gtt. xx. 
Used as an injection after every alvine discharge. Sinapisms over the bowels and spine, as well as bottles of hot water, hot bricks, etc., were used with benefit. The preparation, made by adding one teaspoonful of fine black pepper, one teaspoonful of fine table salt, and five teaspoonfuls of vinegar to a tumbler half full of hot water, was used in the case of a young lady who was menstruating at the time, and who was rapidly approaching the stage of collapse. The injection above referred to was also used, and she recovered. This was also found beneficial in those cases, attended with stupor from the commencement of the disease, and in which cases he had always found Opium inadmissible. 
" He had also found Hunn's Antispasmodic Mixture of almost universal benefit in the spasms, pain, etc. In the incipient stage of the disease, in a number of patients, a mixture composed of Elixir Vitriol, one ounce, Tinct. Xanthox. Bac, two ounces, Ess. Lemon, one drachm, in doses of a teaspoonful in a gill of sweetened cold water, and repeated every two or three hours, removed the symptoms speedily, without any other treatment. In the more advanced stages he would not rely on it. 
" Dr. B. S. Newton observed that as to the general application of remedies, there was but little difference in his practice from other Eclectics, but he might hold different views as to the cause of the disease. He did not doubt but that there was present a redundance of acid, but thought this to be rather an effect than the cause of the disease; he believed that the cause acted primarily on the nervous 


1004 
NERVOUS FORMS OF DISEASE. 
system, that its influence passed through the circulation, causing a weakened action of the parts, relaxation, and consequent escape of the serum. He had observed symptoms in cholera patients similar to those exhibited in diseases where the exciting cause acted directly on the brain nerves, the same drowsiness, numbness, and soreness throughout the system. The symptoms were allied to those produced by Opium or some other narcotic stimulant; the patients were very generally careless about death, and had little or no apprehension of dying. Such mental derangement as this was not produced by a cause acting directly on the alimentary canal. Narcotic stimulants should, therefore, be avoided in the treatment, they had a direct tendency to increase the difficulty ; hence the fatality of the Opium practice in cholera. 
" Dr. N. tested the treatment of Dr. Hawthorne as regards Opium and brandy, to the full extent at the commencement of the epidemic. He gave one man ten grains of Opium, three pints of brandy, and Dr. Hawthorne's Stimulating Mixture. The external applications recommended were also used as well as some other powerful stimulants and astringents, but the man died. This patient had had rice-water discharges four hours before he was prescribed for. He succeeded in getting up a reaction at one time, but the Opium produced a narcotic influence subsequently, and he could neither keep up the circulation nor the perspiration. Dr. N. adopted about the same course in the treatment of another case, and he recovered. 
" He had also used a preparation composed of equal parts —Tannin, Capsicum, Camphor, and Kino, with considerable success ; to be given in doses of four grains, and repeated at short intervals until the discharges were checked. 
" He considered the Saturated Tincture Xanthoxylum Fraxinifolium Bac, the most valuable of all the remedies for cholera which he had tested. When the stomach would not retain it, he gave it as an injection. It had a peculiar influence on the system, and having taken the 


1005 
EPIDEMIC CHOLERA. 
remedy he could speak from experience of its effects. When given as an injection the effect produced was almost instantaneous : the sensation was as if he had received an electric shock ; its use was very soon followed by copious perspiration. He had more confidence in this than any other one remedy with % which he was acquainted. 
"Dr. N. further stated that he had treated one man who died without vomiting or purging. The patient was working on a boat; in the afternoon he felt a little sick; at four o'clock he had two operations, no pain, the discharges were of a natural appearance ; in the night he was feverish and restless ; at four o'clock in the morning he experienced a little nausea ; at nine o'clock he was in a collapsed condition, pulseless, eyes sunken, and he appeared to be as much wasted as if he had had copious discharges from his bowels. He tried in vain to raise his pulse or produce perspiration, and the patient died that night at nine o'clock. 
" Dr. T. J. Wright remarked that he had been more successful in the treatment of cholera toward the close of the epidemic than previously. He was not aware, when he commenced treating the disease, of the importance of removing morbid accumulations from the stomach. He afterward used emetics more frequently and with great success. He also used the Neutralizing Extract, Saturated Tr. Xanthox. Frax. Bac, and the Compound Tr. Guaiac He succeeded best with a mixture of equal parts Tinct. Prickly- Ash berries and Neutralizing Extract. He had always found it necessary to attend strictly to the surface. The best external application he found was equal parts of Capsicum, Salt, and Mustard. In the spasmodic stage he used Thompson's third preparation of Lobelia with advantage. He used injections of Neutralizing Cordial, Tinct. Opium, and Tinct. Prickly-Ash berries. He was fully convinced of the necessity of getting up a copious perspiration. In typhoid cases he pursued an entirely different course. In these cases he first gave stimulants, and failed. He afterward used mucilage of Gum-Arabic, ice and ice-water ; he 


1006 
NERVOUS FORMS OF DISEASE. 
applied externally cloths dipped in ice-water, and with these applications succeeded in bringing about reaction, after failing with ordinary hot applications. Dr. W. also remarked that many cholera cases presented symptoms similar to those described in Wood's Practice, as belonging to pernicious fever. g 
" Dr. S. H. Chase stated that the general outlines of the treatment he had pursued resembled that of other Eclectic practitioners. In the early periods of the disease he had used the Leptandrin, combined with Neutralizing Extract, very successfully. He thinks Opium can be dispensed with in the treatment of cholera altogether. He employed Leptandrin very generally in mild cases —he gave two to three grains dissolved in Camphorated Spirits of Alcohol, and then triturated with sugar, and repeated once in six hours. 
" Dr. Hunt stated that his experience was in the main the same as that of those who had preceded him ; especially was he impressed with the importance of emetics in all cases where there was any evidence of morbid accumulations in the stomach or bowels, and the patients not too much prostrated to forbid their use. He had commenced their administration in the treatment of cholera upon its first appearance, and continued to employ them- until its subsidence, and always with the happiest effect. A good thorough emetic seemed to change the whole features of the case, removing all the unfavorable symptoms, and placing the patient in a state of rapid convalescence ; he used the emetic spoken of by Dr. Morrow, composed of Acetous Emetic, three parts, Tr. Aralia, or Tr. Xanthox., one part. He was accustomed in the commencement of its administration to immerse the feet in water as hot as the patient could possibly bear, the temperature being maintained by the constant addition of more hot water. With this and the use of bottles filled with boiling water, and sinapisms, he succeeded in allaying the irritability of the stomach, removing the cramps, checking the discharges, and producing free, healthy perspiration, which was afterward maintained for eight or ten hours by using alternately a warm 


1007 
EPIDEMIC CHOLERA. 
tea of Neutralizing Mixture and Guaiac. Compound about every twenty minutes, or Tr. Xanthoxylon, Sudorific Tr., Hunn's preparation, or Tr. Camphor, as he thought most applicable. Afterward he directed the patient to be washed off with hot salt and water or weak ley and spirits, the wet clothing to be removed, the patient to be kept warm and comfortable, and the use of diuretics and mild tonics. He had found the use of tonics an important part of the treatment ; their use frequently preventing relapse. He had found much benefit result from the use of Tinct. Camphor in allaying extreme irritability * of the stomach, removing nervous depression, and promoting perspiration. When there was great irritability of stomach, no evidence of morbid accumulation and a sense of sinking or weight and oppression about the heart, he used with advantage Compound Spirits of Lavender, Tincture Camphor dd one ounce, Hoffman's Anodyne, half an ounce ; dose half to a teaspoonful every fifteen or thirty minutes in warm tea. 
" He would also commend to the attention of his professional brethren, the Plantago Cordata / he obtained a small portion of the extract, and for the purpose of ascertaining as accurately as possible its properties, had used it alone, and seemingly with benefit. Did not know whether a more extended use would justify the same conclusion ; but from its action in those cases where he had exhibited it, would judge it to be antiemetic, anodyne, and antispasmodic, and beneficial in checking diarrhea. In extreme cases, he used hot blankets or ice -bath, and has seen patients relieved by them when it seemed hoping against hope to suppose they might recover. 
" Dr. J. Milot stated, along with the various remedies that have been spoken of by Dr. Morrow and others, he had used to a very good advantage, dry cups placed along the spine, where there was a great deal of internal congestion, as well as a great determination of blood to the head. 
" * In cases of irritable stomach during the early state of the disease the Compound Mixture of Camphor (see Eclec. Dispensatoiy, p. 510) has been found lately, of much greater efficacy, and adapted to more cases than any other preparation. 


1008 
NERVOUS FORMS OF DISEASE. 
" Dr. J. R. Buchanan had relied upon the Tincture of Xanthoxylon and Compound Tincture Guaiacum, in equal parts, with a small portion of the Sudorific Tincture, and Tincture of Kino. He was pleased to observe so great a coincidence of sentiments among Eclectic practitioners, in regard to the treatment of the disease. He wished to call the attention of the members to the question, as to what extent, evacuations should be attempted. The liver was commonly supposed to be involved, and Old-School physicians were in the habit of giving large doses of Calomel to their patients, and when they had brought away dark or bilious evacuations, thought that they had accomplished an important part of the treatment. Yet the subject had been discussed in the society, and not a word had yet been said about evacuation by any one of the class of physicians who had been most successful in the treatment of the disease. This proved that the notion of evacuations was a tremendous humbug. Dr. B. thought, however, that the old doctrine was not entirely destitute of truth, that there might be necessity for purgation in some cases. He believed that some of our practitioners were in the habit of giving an efficient cholagogue after reaction had been produced ; others did not deem it important. He would consider a mild cholagogue, such as Leptandrin, desirable in a majority of cases, after efficient reaction was obtained. The kidneys were often more involved than the liver, and he believed that much of the efficacy of the alkaline treatment of cholera depended upon the diuretic properties of the alkalies employed. He thought that the cholera remedies used should combine stimulant, diaphoretic, diuretic, and cholagogue properties. These could be found in a great variety of remedies which might be successfully used. The Neutralizing Mixture used so abundantly, was gently laxative. In a large number of slight attacks, a mild aperient, or even a mild cathartic, might remove the disease, but where a decided cholera epidemic existed, the most powerful stimulants would be required. There were several valuable remedies which had not been mentioned 


1009 
EPIDEMIC CHOLERA. 
this evening. Turpentine was important in cholera as an internal as well as an external remedy; it was valuable in bowel complaints generally. He regretted that its value had not been more thoroughly tested. The simple prescription, pepper, salt, and vinegar, had been fairly tested, and might be regarded as an efficient, prompt, and excellent remedy. It is an agreeable medicine to the patient; it is similar to his every-day diet, and its use appears to restore the stomach and bowels to a natural action ; it checks the nausea and vomiting, as well as the purging, most effectually. 
" Dr. B. referred to the fact that cold applications ap. peared -to succeed better than warm in many cases ; he thought we should have some distinct idea or principle to regulate their use. In cases where the patients sunk rapidly under the use of warm applications, cold was applied, and their revived. Stimulants and external heat were used in the case of our deceased friend, Dr. Parker, without any benefit; they did not appear to rouse him, but cold applications did. Dr. P. had lived very temperately, indeed too abstemiously, and it appeared that his system had obtained such a tone, it would not bear stimulants. Stimulants to excess become sedatives to the feeble and debilitated, and he supposed that patients destitute of any considerable amount of vital power, would be injured by ordinary stimulants, in large doses, and benefited by cold applications. The use of Chloroform had been recommended in cholera, and he wished to know what experience the members had had in its use. 
" Dr Newton further remarked that he would consider the ordinary reliance upon cathartics in cholera, truly a humbug. After reaction he might use a slight laxative as Neutralizing Cordial and anti-bilious physic; when reaction had been established, he would not fear a cathartic. He had treated one case where the disease had been reproduced four times, and was not fully relieved until after the use of a cathartic. The cases requiring laxatives he should suppose were rare, as he had given them in but three cases. 


1010 
NERVOUS FORMS OF DISEASE. 
41 Dr. Morrow stated that in the early part of the epidemic he did not give any cathartic worth speaking of. In the last ten cases of cholera he treated, he gave evacuants, and they operated well. As far, however, as his experience had gone, he was convinced of the necessity of using them to any extent. Since the subsidence of the epidemic, he had used very large doses of active cathartics in dysentery, etc., with signal advantage. He had met with some cases that would not bear stimulation ; they were persons of weak constitution, who had lived poorly. Where there had been much irritability of the stomach, he found the use of icewater, in small quantities, advantageous. 
" Dr. S. H. Chase mentioned that he had met with cases of cholera in persons who were suffering from mercurial salivation, the statements of certain medical men that salivation was a preventive notwithstanding. 
" Dr. Newton informed the meeting that he had used Chloroform in one case which terminated fatally, and in three which survived. He could not rely upon it or recom • mend it; it never arrested the discharges, but acted as a gentle stimulus, increasing the circulation. 
" Dr. T. J. Wright used the Chloroform in the case of a boy, the only surviving member of a large family who died of cholera. The boy was thought to be dead ; he was cold and pulseless. After inhaling the Chloroform a short time, and taking a teaspoonful, he had several muscular contractions, his eyes rolled, the pupils dilated ; he became maniacal, and was sent to the hospital, where he remained some time. He is now going about nearly well." 
The following statistics show the number of deaths in Cincinnati, during the epidemic, in 1849 and 1850, from cholera and other disease: 
Year. Cholera. Other Diseases. Total. 
1849 4114 2345 6459 1850 1400 1355 2755 
Total, 5514 3700 9214 


TETANUS. 
1011 
Species XYIII. — Tetanus. 
A state of tonic spasm, or prolonged, rigid contraction of certain muscles, is called tetanus. When nearly all the muscles of the body are affected, the body is stiffened and the extremities extended, statue-like, and the muscles feel hardened like marble. This is the true tetanic state. 
When the muscles of the jaw are the chief seat of rigidity, it is called trismus, or locked-jaw; when the muscles of the back, throwing the body into the form of an arch, opisthotonos; when the muscles of the belly and front of body, drawing the head and knees together, emprosthotonos; and when the muscles of one side, incurvating the body sidewise, pleurothotonos. These are but symptomatic conditions of the tetanic state. 
Superadded to this tonic rigidity, clonic or convulsive spasms, alternated with more or less complete relaxation, supervene to give poignancy to the patient's sufferings, there being neither coma nor any essential disturbance of the mental faculties. Thus life is exhausted, in a majority of cases, as by torture upon the rack, with the mind clear and conscious to the last. 
Tetanus is usually treated of as idiopathic, arising without any evident cause or from common causes, and traumatic, as supervening wounds or injuries. It has also been considered as acute, sub-acute, and chronic, a refinement of but little importance. The idiopathic form is often recovered from, the traumatic variety seldom —not more than one-fourth or one-fifth of the cases probably recover. It is said to be more common or more frequently met with in hot climates. 
Symptoms.—A state of vigilance, uneasiness, languor, loss of appetite, headache, and an unusual disposition to lie with the limbs extended straight during sleep, have been noticed as precursory symptoms. Stiffness in the back of the neck, with dry and sore throat, is the first well-marked symptom. Sudden or slow contraction of the temporal muscles, locking the jaw so firmly that the teeth are some-64 


1012 
NERVOUS FORMS OF DISEASE. 
times broken, is generally the next phenomenon. If the patient attempts to suck in fluids, spasms of the throat take place forbidding the intention, so that there is generally a hydrophobic dread of repeating the attempt. This constitutes trismus, and the tetanic spasm may not extend any further, still it is equally formidable or fatal, though probably there is less suffering. 
As the disorder progresses, violent, stabbing rains seize upon the diaphragm, and the trunk and extremities become paroxysmally distorted. Respiration becomes difficult or nearly interrupted; anguish and distortion of countenance ensue; the face is turgid ; sometimes the horrid laugh called risus sardonicus becomes a symptom; relaxation of the jaws, thrusting out of the tongue and itslaceration by the teeth sometimes occur; the pupil is not particularly altered; the eyes are more generally rigidly fixed ; the trunk may be distorted backward, or doubled forward, or sidewise, or rigidly straightened; the limbs are generally firmly extended; the sphincters are usually contracted, but sometimes the urine and fasces are discharged with great impetus by the force of the abdominal muscles. Complete intervals of repose and relaxation are extremely rare, but remissions to be followed by more and more violent contractions are common. 
The mind is clear and sometimes cheerful; Mr. Abernathy says he has often known patients to express themselves as feeling better to the last; the circulation is only hurried by the muscular contractions, the animal heat, however, is higher than natural; the perspiration is generally profuse, urine not remarkable, and the bowels constipated. 
Generally at the end of twenty-four hours the patient is unable to take food or drink; emaciation ensues rapidly; the face becomes more and more frightfully distorted ; a clammy perspiration covers the skin ; there is less and less remission of the spasms; greater difficulty in breathing; the pulse becomes thread-like or imperceptible, and death more often occurs on the second day, though an average course is said by Andral to be four days. The cause of 


1013 
TETANUS. 
death is ascribed to asphyxia. So great is the suffering and so awful the spectacle that death is hailed as a blessing usually by the friends. 
Causes.—Tropical heat and transitions to cold and dampness, and wounds and injuries of any description, are the most common causes of tetanus. Peculiar organization doubtless increases liability. Negroes are said to be more liable to it than whites. A form of tetanus attacking infants, called trismus nascentium, is very common in the West Indies, much more so than among infants of white parentage, though this variety is occasionally met with in white infants of the temperate latitudes. Endemic causes favor its development, though these may be only heat, cold, and moisture. Upon this subject our views, at more length, will be found in Book III. 
By far the most frequent cause of tetanus is mechanical injuries—no matter what. According to Sir James Mc- Grigor, " it occurs in every description and in every stage of wounds, from the slightest to the most formidable, from the healthy and the sloughing, from the incised and lacerated, from the most simple and the most complicated." The locality of the injury is of almost no importance—still lacerated and punctured wounds, when of the hands, fingers, soles of the feet, and joints, are probably regarded as most apt to produce it. 
Diagnosis.—There will be no difficulty in the diagnosis in general. Hysteria sometimes partially counterfeits it, but the fickleness of spasm and warped state of mind detect it. Occasionally rheumatic affections of the muscles of the neck and jaw may sirnilate trismus, but the history of the cases, if not their febrile condition, will distinguish them from it. Poisoning by strychnine produces the same tonic character of spasm, and the same clearness of mind, but the history of the case and attending circumstances will generally lead to a correct diagnosis. 
Accession.—Idiopathic tetanus is generally sooner developed after the exciting cause has been received, than traumatic, not unfrequently supervening the next morning 


1014 
JNERVOUS FORMS OF DISEASE. 
after exposure to the cold and dampness of night. Sometimes it immediately follows bathing or falling in the water when the body is in a state of heat and perspiration. The development of the symptoms after injuries is most commonly during the second week. There is record, however, of tetanus occurring instantaneously after slight injury, and terminating fatally in fifteen minutes. It is believed never to have resulted later than a month after the injury. 
Nature.—Reasoning from the data afforded by physiology and the symptoms, in the absence of any uniformity in the post-mortem appearances, we infer that the seat of derangement is in the cerebellum and medulla oblongata. The early symptoms of stiffness about the throat and spasms of the muscles supplied with nerves from the medulla oblongata indicate it as the seat of trismus. The muscular spasms in general we are disposed to refer to the organ of muscular motion. Our observation has not been so extensive as to justify a general inference, but so far as the writer knows, tetanus has been confined to a high endowment of the above-named organ. The clearness of intellect proves that the cerebrum is not implicated. In the present state of pathological science, it is impossible to say what the nature of the morbid change may be, any more than we can tell why strychnia should produce similar phenomena, or ergot tonic contraction of the womb. 
Prognosis.—We have already remarked the greater mortality of the disease when originating from mechanical injury. Dr. O'Beirne witnessed two hundred cases in the peninsula, and not one recovered. Of forty-six traumatic cases, mentioned by Curling, ten recovered. The slower the incursion or development, the better the chance of recovery, and vice versa. Wood thinks the milder cases may terminate favorably spontaneously, which is to be borne in mind in judging of remedies. The more perfect the intermissions, the more favorable is the case to be looked upon. If the patient survives the fourth day, hopes may be entertained of his recovery. Rapid development of the symptoms, increased severity of the paroxysms, uninterrupted 


TETANUS. 
1015 
rigidity of many muscles, violent spasms of the glottis and diaphragm interrupting respiration, augur an unfavorable termination. 
Treatment.—For the treatment of this disease almost every class of remedies has been used, by different practitioners, and recommended by different authors, without producing many cures; so much so, that, at this time, the treatment for this disease is as much empirical as any we are called to treat. This being the case, every practitioner must be governed by the attending circumstances and the pathological view which he takes of the disease. 
The general indications are, to remove the exciting cause and change the condition of the nervous system, so as to prevent its recurrence, or to remove any depressing influence of the nervous system, as well as to support the vital force and enable it to resist the exhaustion produced by the muscular action during the paroxysms. 
As tetanus is frequently the result of wounds, it is necessary, in all such cases, to make use of soothing, emollient, and anodyne applications, the local use of Morphine, bathing the parts in a decoction of Stramonium leaves, Hops, and Tansy ; and as it is not a muscular disease, we are of opinion that that class of agents which produces the most immediate and permanent impression upon the brain should be used—and having failed with the treatment ordinarily recommended, we have been induced to try the virtue of one of the new remedies—the Gelseminum —in the recent cases we have had under treatment, and from the success which we have had with this agent, in almost immediately relieving the paroxysms, are fully of belief that there is not in the Materia Medica another article which possesses the same peculiar virtues. We commence its use by giving from fifteen to twenty-five drops of the tincture every fifteen to thirty minutes until the convulsions are arrested. 
Digitalis exerts a powerful influence upon the action of the heart and arteries, without producing any material change of vital action; but Gelseminum affects the whole organism, and produces a more powerful relaxant effect 


1016 
NERVOUS FORMS OF DISEASE. 
than we have ever obtained from any other agent — and since tetanus has been found to be located in the brain, and this agent acts powerfully upon that organ, we can comprehend at once its utility in that disease. 
To sustain the nervous system, and to prevent a recurrence after the exciting cause has been removed, we use Gelseminum and Quinine, in the proportion of three grains of the latter to fifteen drops of the tincture of the former, which should be given three or four times a day. 
If there be any indication of the powers of the system giving way, it will be well to omit the Gelseminum and use the Quinine, Prussiate of Iron, and Hydrastin in as large doses as the circumstances will admit. 
As this is regarded as a surgical disease, we would refer the reader for additional treatment to " Eclectic Surgery." We will here say, however, that since we have adopted the above treatment, we have found little difficulty in arresting the malady, whether idiopathic or symptomatic, after the exciting cause had been removed. 
Species XIX.— Puerperal Convulsions. 
The consideration of this form of disease properly belongs to a work exclusively devoted to obstetric practice; our observations will therefore be brief. 
Symptoms.—General convulsions coming on in the latter period of pregnancy, during parturition, or within a few days after delivery, characterize this form of disease, which is unmistakable. The incursion of the convulsions may be sudden, coming on during a parturient effort to expel the child or placenta ; or after the woman is put to bed and seemingly every way comfortable. Generally, however, there is the premonition of headache, drowsiness, flushed countenance, full, slow pulse, and partial failure of sight. Succeeding to these there may occur piercing pains in the head, fiery objects dancing before the eyes, ringing in the ears, general oppression, and sickness at the stomach. Twitching of the muscles of the face and eyes, locking of the jaws, and universal spasms and jerking of the volun- 


PUERPERAL CONVULSIONS. 
1017 
tary muscles immediately ensue with complete loss of all consciousness, and thus resembling a fit of epilepsy. There is foaming at the mouth, and while the teeth are firmly closed there is hissing inspiration and expiration. Not unfrequently the jaw is worked as in the act of grinding food, the tongue spasmodically protruded, dreadfully bitten, and bloody foaming the consequence. The countenance is horribly distorted, the eyes roll, jerk, or are fixed, the pupils are dilated, the limbs are violently agitated, and the whole body exercised as with a prolonged, universal shudder. The paroxysm, sooner or later, ends in stupor, generally after a few minutes, though repetition after repetition of the convulsions, with intervals of quiet stupor and sterterous breathing for hours and even days, are common. The patient may wake suddenly from this stupor, be perfectly rational, unconscious of anything that has passed, remain rational a shorter or longer time, and then be thrown suddenly into convulsions again, or there may be no further recurrence of spasms and the case terminate in perfect recovery. A large proportion of cases terminates fatally, however, and some of these in the apoplectic or comatose stage. According to Churchill, who has collected statistics from different observers, it appears that about one-fourth of all the cases has terminated fatally, though we are inclined to think this an over estimate of the fatality. 
Causes.—There is difficulty in the present state of pathologic science in determining the precise condition of the nervous system and centers in the convulsive forms of disease. It appears that the two opposite conditions of the sanguiferous system, viz : plethora and anemia, may give rise to convulsions. 
The immediate cause of puerperal convulsions may be either of these conditions, or it may depend on distant irritation in the womb or digestive organs. That the uterine organs are concerned in its development, is manifest, from the convulsions being peculiar to the pregnant or parturient state. Peculiar organization may be necessary. Those who have suffered one attack are more liable to another 


1018 
NERVOUS FORMS OF DISEASE. 
in subsequent confinements. The writer knew three Msters who were successively carried off in first pregnancy from the accession of puerperal convulsions at the period of parturition, which deterred a fourth and younger sister from contracting marriage. 
A disordered stomach; improper food ; sudden terror, or depressing emotions and passions may excite a paroxysm. Women brought to bed illegitimately are said to be more liable to attacks, owing to shame and mortification of feeling. Improper straining in parturient efforts, causing a rush of blood to the head, has been thought to produce an attack. It has also supervened after excessive uterine hemorrhage, and these cases are looked upon as attended with more danger. 
Treatment.—In this disease, we recommenc] the same treatment as referred to in peritonitis, which should be faithfully and energetically pursued. For the spasm which is present, we administer the Compound Tincture of Lobelia and Capsicum. 
In addition to this, it will be necessary to commence giving the patient, from the start, large doses of Quinine and Iron, which support and increase the vital force ; and, if convulsions should continue after this treatment has been pursued, we use the Tincture of Gelseminum, in combination with the Quinine, as recommended in tetanus and hydrophobia, to accomplish tiie same object. 
As there is danger of the patient dying in from twentyfour to forty-eight hours, in consequence of debility produced by the exciting cause acting upon the general system, the importance of active and energetic treatment will be seen at once. So far as our own observation extends, we have found that any depletive course of treatment increases debility by destroying the power by which the system resists the action of the disease—which being the case, the reader will at once see the necessity for adopting the treatment which we have recommended, in preference to ths antiphlogistic plan ordinarily pursued. 


1019 
HYDROPHOBIA. 
Species XX. — Hydrophobia. 
Hydrophobia is a specific form of disease arising from the bite of a mad animal, generally the dog, and hence it may not be out of place for us to briefly notice its symptoms in the dog, the better to guard the human species. 
When a dog is observed to become shy and irritable, to avoid his friends, neglect his food, droop his ears and tail, seek solitude and look sullen, it is time to confine him on suspicion of madness. Should there appear a viscid frothing at the mouth, and panting respiration, his case is still more suspicious. If he snaps at objects, and refuses his usual obedience to control, but is thrown into anger and rage at threat of the whip, he may be pronounced rabid. Some dogs only snap and bite what crosses their path, while others fly indiscriminately at every living thing, and even gnaw and tear inanimate objects. No animals escape their fury; cats, dogs, sheep, bullocks, horses, and persons, are indiscriminately attacked. Vomiting is often one of the earliest symptoms, and frequently recurs throughout the course of the disease. Respiration becomes laborious, spasms ensue, and the animal is subdued, and dies under tremors and violent convulsions. 
Not all persons who may be bitten by a rabid animal necessarily take hydrophobia—not more than one, perhaps, in a dozen. The poison is conveyed in the saliva, and clothing is a great protection by wiping the teeth. Persons bitten on the hands, or a part not protected by clothing, are much more liable to an attack. 
The time at which an attack may supervene after being bitten by a rabid animal is very various. It may come on in a short time after the healing, but seldom does in a less period than a month or six weeks, and a longer period than two years. The time during which the poison lies dormant in the S} T stem is called the stage of delitescence ; the incipient symptoms of an attack, such as pain and swelling of the scar or cicatrix, the stage of recrudescence / and the 


1020 
NERVOUS FORMS OF DISEASE. 
fully developed attack, the stage of spasm. It is convenient to follow this arrangement. 
Stage of delitescence. —In general the wound heals kindly, leaving nothing peculiar in the scar, though pains in these wounds after healing are said to be pathognomonic, but probably this may be the effect of the excited imagination. Sometimes gloomy forebodings and melancholy apprehensions weigh down the patient's mind and nearly incapacitate him for his ordinary occupation. All this is mental, however ; no outward symptoms appear, and he may never be seized with an attack. Should two years elapse, all fears may generally be dispelled. The stage of delitescence is seldom shorter than a month or six weeks, and the rationale or theory is, that the poison is absorbed into the system, and remains dormant for a longer or shorter period, analogous to other specific animal poisons, as that producing syphilis, but finally develops its effects on the nervous apparatus, according to its own peculiar laws of morbid action and tendencies. 
Stage of recrudescence. —This stage generally lasts three or four days, and is ushered in by tenderness, pain, swelling, and perhaps opening of the wound. Sometimes a sense of coldness first affects the parts, with stiffness extending up the limb. The glands of the axilla or groin ha've never been observed to swell. By far the greatest number of cases of hydrophobia occurs from the thirtieth to the fiftieth day after the bite, and after the wound, which was perhaps considerably enlarged by the surgeon, has healed, though yet tender and irritable. The exciting cause of the recrudescent stage has sometimes appeared to be a debauch, and one case is mentioned in which a pain shot into the part at the news of another person, bitten by the same dog, having died of hydrophobia. 
Stage of spasm. —The greatest anxiety prevails, of course, throughout the stage of recrudescence, and febrile symptoms not unfrequently manifest themselves prior to spasms setting in, while the symptoms of recrudescence go on increasing in the wound. Rigors may usher in the attack 


1021 
HYDROPHOBIA. 
with alternate flushings, or these may be oppression, sighing, loathing of food, or sudden nausea on sitting down to a meal, with efforts to vomit. A sense of stiffness in the back of the neck, becoming painful, and extending to the tongue and larynx supervenes. The patient soon finds it impossible to swallow, owing to spasms seizing the muscles of deglutition. Soon after, the sight of water will produce these spasms. Laborious respiration, sighing, vomiting, urgent thirst, pressure in the throat, and a burning pain down the spine from the neck, mark the progress of the alarming symptoms. The disease is now fully formed. Every attempt to allay the burning thirst brings on the most violent spasms, which at length seem to involve every muscle of the entire body and extremities. The pulse is often excited during these paroxysms to one hundred and fifty beats in the minute. There soon takes place, after the disease is fully established, a peculiar frenzied look or expression of countenance ; and all writers and observers agree that there is an alienation of the mind. It is not uncommon for the sufferer to become loquacious, and sensitively circumspect and suspicious. High delirium is seldom present. Death generally comes to the relief of the sufferer on the second or third day. The urine is natural, and the blood is not buffy. The muscles remain rigid long after death—the victim generally dying suddenly in a violent, universal spasm. 
Treatment.—This disease, like tetanus, has exhausted, in the language of Professor Wood, " the whole magazine of therapeutics," and yet the profession occupies about the same position as heretofore. During the last year, we have treated three persons who had been bitten by dogs while attacked with hydrophobia; we know this to be the case from the fact that other persons bitten by the same dogs died of the disease. On being called to each of the cases, which was immediately after the accident occurred, we cauterized the wounds which were very extensive, with a strong solution of the Chloride of Zinc, the liquid condition of which allowed it to permeate every tissue that was involved 


1022 
NERVOUS FORMS OF DISEASE. 
by being brought in contact with the teeth of the rabid animal. So soon as the parts had been thoroughly cauterized, we at once applied an Elm-poultice to facilitate the suppuration, and then administered the following : 
H. Aqua Monia, 3ij, 
Tincture Scutellaria, 3j, Syrup Ginger, 3ij. Mix. 
Of this, we gave one drachm every two hours, which was continued until the parts that had been cauterized sloughed out, with such changes of the quantity as the circumstances demanded. We subjected the patient to the daily use of the vapor-bath, and continued the suppurative action from the wound by the daily application of the Sesquicarbonate of Potassa for six weeks, and recommended the occasional use of the above prescription. Up to the present time neither of the persons have manifested any symptoms of hydrophobia. 
As the disease is so assimilated to tetanus, we would advise a similar treatment during the paroxysm. We extract the following from the " Western Medical Reformer," Vol. vi, 1816, page 83, as the treatment pursued by Professor J. King, at that time a resident of the city of New York. He says: 
" Several years since we were led to institute a series of experiments on cats and dogs, which resulted in a firm conviction that the disease depended entirely upon the absorption of a poisonous acid into the system. From this conviction we were led to employ an alkaline preparation, very diffusible and stimulating in its action, and which used in the manner we shall presently relate, has cured six persons, two in the commencement of the second stage, and four in the first stage. One of the former was Mr. John Sharpe, No. 110, Elizabeth street, New York city, who was cured in the summer of 1836, and who, we believe, is still living at said location. 
" As soon as bitten, the surest method, we conceive, would be to wash the part immediately with the alkaline liquid mentioned below, or for want of it, water will an- 


1023 
HYDROPHOBIA. 
swer, so as to remove all the saliva of the animal, and then cut out the whole wound ; after which, apply the vegetable caustic, and keep up a discharge from it for several days. In all the cases cured by us the wounds had healed, presenting a scar of a dark purplish appearance. 
" When the symptoms of hydrophobia begin to manifest themselves, or during any stage of the disease, the following is the course we invariably pursue: Take of the strongest Aqua Ammonia, one teaspoonful; finely powdered Skullcap leaves, one teaspoonful; put into a tin cup, to which add half a gill of cold water. Then holding the patient's nose, to prevent the ammoniacal vapor from being inspired therein, cause him to make as full an exhalation as possible, and immediately drink the mixture, well stirred together, while inspiring; if this can not be done at once, the operation must be repeated until the whole is taken. If from spasms, the patient is unable to swallow, then blindfold the eyes, and use all the persuasion that can be employed to induce him to force it down. Perhaps a stomach tube might be employed, covering that part of it which comes in contact with the teeth, with some strong metal; we have always succeeded without it. If the patient is attacked severely, it may be necessary to fasten his legs and arms to prevent him from injuring others. Bandaging the eyes will be found to have a soothing effect, particularly if cotton or some soft non-conducting substance is placed over them so that the patient can certainly see no light. 
" The Ammonia used by me was prepared by Dr. Chilton, a well known chemist in New York city, and was put up in glass-stoppered vials, holding two ounces each, and covered with bladder. I prefer this size, as in larger vials there is too much of the strength of the Ammonia lost while using. The only reason why we used the Skullcap was, that it had been highly recommended by others in whom, in this instance, we blindly placed confidence. 
" The above dose must be repeated every half hour for two hours. In many severe cases, the doses for the first hour, must be repeated as often as once in every fifteen minutes. 


1024 
NERVOUS FORMS OF DISEASE. 
" In an hour and a half or two hours, the more severe and distressing symptoms will generally disappear, the face and whole body will present a fiery-red appearance, and a heat nearly amounting to a sensation of burning will be experienced. The alkali has now diffused itself throughout the whole system ; but as we view it, it must at this crisis be forced, as it were, to pass even further, to the surface of the body. To accomplish this properly, we considered that an acid, between which and the alkali a great affinity or attraction exists, must be employed, and for this purpose, the following acetous vapor-bath must have been prepared, to use at the expiration of two hours: Stramonium leaves, Cicuta leaves, Hops, Skullcap, of each half a pound; good strong vinegar, four or five gallons. Boil all together for ten or fifteen minutes. Likewise, have several large stones wellheated. 
"Half an hour after the last dose, undress the patient, place him on an open-bottom chair, and completely cover and envelop him with blankets, leaving however an opportunity for him to inhale fresh atmospheric air now and then during the bath. Then place the above acetous decoction under him, and keep him there until he perspires freely and copiously. As the steam lessens, the gradual addition of the hot stones will increase it again. 
" After this vapor-bath, which must always be carried to a powerful extent, the patient must be well dried, and another dose of the Ammonia and Skullcap given, and which must be repeated every three hours for fourteen days in succession, omitting it only during the action of purgative medicine. 
"On the first night of treatment, a full dose of antibilious physic must be given, and repeated every other night for six nights, and afterward every third night, and as soon as it has operated, commence again'with the Ammonia every three hours. The acetous vapor-bath must be repeated on the second, fourth, eighth, and twelfth days of treatment. I would mention here that this active treatment, especially during the first and second days, reduces the pa- 


1025 
HYDROPHOBIA. 
tient's flesh most astonishingly. Skullcap tea must be drank freely through the whole treatment, and the diet must be light, but very nourishing, avoiding all acids, greasy or fat food, milk and liquors. 
" The bitten part must be kept constantly discharging after the first vapor-bath, by the application of vegetable caustic. Stramonium ointment may also be applied on lint. 
" In case the person is very much convulsed in the first part of the treatment, the best course to adopt is to apply the acetous vapor-bath immediately, and administer the Ammonia as soon as it can be swallowed ; in other respects pursue the same course as above. 
" This treatment should be persevered in for fourteen days, when the patient may be discharged as permanently cured.* 
" With regard to the six persons cured by the above remedy, I would remark, that they had all been recently bitten by dogs, and manifested all the phenomena of hydrophobia as it generally appears—two of the dogs were killed before it was positively known that they were rabid ; the others were well ascertained cases, particularly in the case mentioned of Mr. Sharpe, as his dog was chained at the time of the bite, and died rabid." 
" * It has been suggested that when the patient is unable to swallow the alkaline preparation, that in addition to blindfolding, the following antispasmodic tincture be given in teaspoonful doses every few minutes (by pouring it into the corners of the mouth), until the Ammonia can be taken. Also, that during the treatment the Extract of Belladonna shoqld 1 be given in doses and at intervals sufficient to keep up a gentle influence upon the system constantly. Of these I know nothing, but mention them for the benefit of your readers. 
Antispasmodic Tincture. —Mix together equal parts of the Saturated Tinctures of Lobelia seed, Capsicum, and Skunk Cabbage. I have cured three cases of lock-jaw with this preparation." 


1026 
NERVOUS FORMS OF DISEASE. 
Genus II.—Mokbid Actions in the Organs of External Relation. 
This sot of apparatuses, in a state of health, adapt man, and all other animals, to the world in which they live, and by modifications of these apparatuses all of the various modes of animal life are provided for. In some of the inferior departments of this system of organs, some of the inferior animals are superior to man ; and yet by the superior development of them as a whole he is constituted the master, the governor, the Autocrat of the animal world. All the other departments of it are subject to his will. 
By the organic arrangements that distinguish him, he is, in a state of health, capable of a variety and an extent of enjoyment which does not admit of any comparison with the most gifted of the inferior classes. By his sentiments he has the power of communicating happiness to others, and by his genius he harnesses caloric, electricity, air, and water, and forces them to labor for the command of his comforts or the aggrandizement of his ambition. 
But when these organic arrangements become deranged in their functions, he may become the most miserable, or the most helpless, or the most abject and pitiable object in the world. 
The remarkable feature of this genus consists in the fact, that however severe the attending pain may be, those functions upon which life depends, are comparatively but little disturbed. 
Species I.— Catalepsy. 
This strange form of disease of the motor system, characterized by rigidity of the muscles, either of the whole or a part of those usually designated as voluntary, has been deemed apocryphal by some of the most eminent physicians. So many well authenticated cases, however, are recorded, that, at this day, no one doubts that a state of cataleptic rigidity may seize upon a nervous subject, and fix the person statue-like for a longer or shorter period of time. The fit may last from a few minutes to many days. 


1027 
CATALEPSY. 
Cases are recorded to have continued twenty days in this condition, without food or evacuation. The attacks are mostly recovered from generally suddenly; a portion, however, passes from this state of trance to that of death. 
This condition of the muscular system is similar cr identical with that which may be induced by mesmerism. The limbs can be molded to any attitude, and remain fixed, as placed by another; the rigidity of the muscles of the shoulder, for instance, preventing the law of gravitation from bringing the hand down when the arm has been placed horizontally. 
Catalepsy is paroxysmal or intermittent, without regular periodicity; the length of the paroxysms and intervals being extremely variable. The attacks are usually sudden, though sometimes premonitory feelings, as headache, palpitation, confusion of ideas and slight spasms, usher in the paroxysms. There is usually loss of consciousness, but occasionally patients are conscious of passing events, and some are said to have witnessed the preparations for their interment in this condition, without the power to remonstrate. The countenance is in general natural and composed, the pupils dilated, the circulation feeble, the respiration scarcely preceptible, and the animal heat low. 
Causes. —Allied to the comatose forms of disease, and passing sometimes into apoplexy, mania, epilepsy, and more frequently hysteria, the causes are a great cerebral susceptibility and delicacy ot the nervous system in general, a weakened state of the system, strong emotions, depressing passions and the like. Frequent miscarriages have been known to produce it. Females of hysteric liability are the most frequent subjects of it. 
Diagnosis.—To distinguish catalepsy from death is a matter of the highest moment. If the pulse be impreceptible, and the breathing too gentle for observation, recourse should be had to auscultation for evidence of the heart's action. A small mirror held at the nose will condense any vapor from the lungs. In apoplexy the breathing is sterterous; in asphyxia the breathing and circulation are entirely 
05 


1028 
NERVOUS FORMS OF DISEASE. 
suspended, in syncope, also, with deadly paleness added, while in all three there is flexibility of the limbs. 
Treatment. —If the cause of catalepsy can be determined, it must be treated according to the indications ; and if the disease be periodical in its attacks, antiperiodics must be be given, such as Quinia and Iron. In other cases, the disease must be treated on general principles, according to the symptoms present. As regards any positive or specific treatment in catalepsy, but little is known. 
Species II. — Hysteria. 
The assemblage of morbid phenomena constituting hysteria, though not absolutely confined to the female sex, is so generally seen in women from the age of puberty to that of the cessation of the menses, that the exceptions are of little comparative importance. So diversified are its symptoms, so alarming its paroxysms to the uninitiated, and yet so seldom is there a tendency to fatal results that it has been described as " a mere ebullition on the surface of life, while its depths were undisturbed." It may similate almost every form of disease, modify and render alarming and perplexing very simple cases, thus greatly misleading inexperienced practitioners, out can hardly be said to be ever fatal of itself. Secondary forms of disease that may "be induced, or which may supervene, may prove fatal. Cases have been known to terminate fatally in apoplexy. Yery rarely males of great nervous susceptibility have exhibited the diversified and rapidly changeable groups of symptoms characterizing this disordered condition of the nervous system. 
Symptoms.—Most of the disquieting feelings, strange and wayward fancies of nervous females arise from hysteria. A paroxysm is usually preceded by general uneasiness, anxiety, and oppression ; a sensation of choking, or as if a ball were rising up from the abdomen into the throat, to which sensation the appellation of globus hystericus has been given; stiffness about the larynx, headache, and cramps. M. Georget says : " Hysteric patients in the hospital of the 


1029 
HYSTERIA. 
Salpetriere are so well accustomed to take warning by these precursory symptoms, as never to be seized unexpectedly ; they go to bed, and are tied down until the fit is over." Sometimes the paroxysm ends here ; but more generally the anxiety and sufferings increase, extreme depression of spirits, often weeping, ensues ; there is a painful sense of stiffness and coldness of the limbs ; noise in the ears ; vertigo ; confusion, and to these rapidly succeed temporary loss of sense and consciousness, and of command over the voluntary muscles, during which the most vehement struggles are alternated with moments of repose. Occasionally there is a tetanic rigidity of the muscles of the trunk or back, and the body is thrown up in the form of an arch, but the limbs are more generally contorted ; the patient often beats her breast, tears her hair, grinds the teeth, bites the tongue or lips, or otherwise injures herself. The assistants are often struck, bitten, or scratched, and have vociferous epithets heaped on them; terrific screaming, sobbing, laughing, and vacant staring may rapidly succeed each other. During the struggling the heart beats tumultuously, the countenance becomes flushed and swollen, and the breathing laborious. After a variable continuance of from a few minutes to some hours or even days, of repeated intervals of struggling and repose, as here described, the patient either falls asleep or gradually returns to a state of consciousness and her ordinary condition, save feelings of fatigue and soreness, which disappear in a few days. Such are the prominent features of the hysteric paroxysm; but it varies greatly in intensity and duration. The convulsions may be severe, with lucid intervals, and of frequent occurrence for days, or a deep, quiet sleep or coma may fill up the intervals, from which nothing can arouse the patient. In some women the paroxysms retrrn monthly or at the menstrual flow ; in others at variable intervals dependent on disturbances of the physical or mental equability. It is remarkable that plumpness of person, roseate hue of countenance, and general appearances of good health are not incompatible, but often attend the worst of sufferers from 


1030 
NERVOUS FORMS OF DISEASE. 
this affection through life, so faithfully is the nutritive function preserved amid the many and frequent storms of nervous functional derangement. 
So variable are the protean shapes which hysteria may assume, that there is scarcely an organ or its function that may not be invaded and the gravest maladies counterfeited, calculated to lead to errors in diagnosis and prognosis, compromising, if not the life and welfare of the patient, at least the reputation for close discernment of the practitioner. 
Sudden, extreme, and anomalous symptoms should not be hastily pronounced upon at the bedside of the patient. Hysteric distention of the intestines by flatus has been mistaken for pregnancy ; hysteric hiccup, for that of approaching death ; hysteric colic, for acute peritonitis ; hysteric stridulous breathing, for croup ; hysteric cough, for hooping-cough; hysteric limpid urine, for diabetes ; intense urinary irritation, for nephritis; interior irritation, for inflammation ; hysteric headache, for encephalitis ; hysteric tenderness and swelling of the knee-joint, for white-swelling ; hysteric coma, for apoplexy ; hysteric waywardness, for mania, etc. 
Diagnosis.—The suddenness of an attack of epilepsy, the cry, the fall, the distortion of the features, frothing at the mouth, livid turgescence of the face, small quantity of air admitted in inspiration, and the profound coma are sufficient to distinguish it from the hysteric paroxysm which certainly similates epilepsy more than any other affection. The want of correspondence between the violence of functional disturbance and the symptoms of organic disease will generally guide in distinguishing hysteric imitations or counterfeits. The history of the individual will aid ; examination of the spine also. 
Causes. —Whatever impairs the constitution and increases the excitability of the nervous system, may become an exciting cause of hysteria. The anemic state favors its incursion ; an irritable habit produced by errors in early physical training; early vicious practices; emotional and 


NEURALGIA. 
1031 
imaginative reading ; spinal, uterine, or gastric irritation ; strong and impassioned feelings ; startling sights, sounds, or intelligence ; grief, jealousy, or unrequited love. The ancient doctrine was that the uterus was the seat of the disease, but modern physicians regard it as seated in the nervous system or centers. 
Treatment.—In the treatment of hysteria, our principal reliance is on antispasmodics, as Valerian, Castor, Assafetida, Scutellaria, or Tincture of Lobelia and Capsicum. These means should be persevered in, and if the paroxysms are very severe the patient should be bathed in warm water, and hot fomentations applied over the region of the uterus, with sinapisms to the lumbo-sacral region. In this affection it must be remembered that although the symptoms may, apparently, be very alarming, yet serious consequences seldom ensue; and as it is generally dependent upon some other disease, as amenorrhea, dysmenorrhea, etc., these should be treated as named under their various heads. 
Species III.— Neuralgia. 
Neuralgia is a term used to designate painful local affections unattended by the evidences of inflammation or structural lesion. Literally, the term means pain in a nerve. Formerly, the term tic douloureux, literally signifying painful twitchings or twinging, was applied to this form of disease. Its most frequent seat is, perhaps, the face, supplied by the fifth nerve and its branches, but it may impinge upon any part or organ, external or internal, and its true character only become manifest from the inutility of remedies for inflammation or other forms of disease. Its seat, in a mild and familiar form, is' some spot upon the skin or scalp, exquisitely sensible to slight tough, but not to firm pressure, in which electric-like twinges of intense momentary pain occur, at intervals more or less remote. Frequently the slightest touch or movement induces the painful shock or lightning-like, acute pain. When its seat is in the face, snuffing, blowing the nose, etc., may induce the agony, and the writer has noticed a copious flow of 


1032 
NERVOUS FORMS OF DISEASE. 
tears, nasal mucus, and saliva often to result. Spasms of the muscles, and sometimes permanent distortion of features occur. The current of the shooting pain is often in the course of a nerve, and in such cases the diagnosis is plain ; but the pain is not unfrequently of more permanent and aching character and situated in an organ, as for instance, the stomach. The writer has met with a few instances of well-marked neuralgia of this organ that none of the ordinary character of remedies, opiates, carminatives, alteratives, and counter-irritation, would remove, but which yielded instantaneously to a full dose of tris-nitrate of bismuth—also, more-prolonged and agonizing neuralgia of the supra-orbital and frontal sinus regions instantaneously cured by electricity; the patient being placed in the electric bath by insulation and a current drawn off by points held near the part affected. 
The character of the pain and history of the case, together with the absence of the evidences of inflammatory action, will generally suffice to guide the practitioner in distinguishing this form of disease from all others and lead to correct treatment. 
It is to be borne in mind, in the absence of any settled convictions as to the true pathology of neuralgia, that local lesions in the branches and extremities of nerves, particularly of those distributed to the teeth, may keep up a permanent neuralgia of the face for years. The writer has known a case of great severity, and of ten years' standing, perfectly cured by the extraction of all the teeth, sound and unsound, the patient parting with fourteen sound teeth at one sitting; and from that moment to this, some twelve years, has not felt a solitary twinge of her former distressing malady. Sometimes the extraction of a single offending tooth has cured a facial neuralgia. 
Occasionally neuralgia assumes a periodic form, the paroxysms recurring at a certain hour every day or every other clay. Sometimes it assumes the rheumatic form, supervening on exposure to cold, having its seat in the fibrous and dermoid tissues. Sciatica and dermalgia are 


1033 
NEURALGIA. 
of this form. The pain experienced in organic forms of disease is often neuralgic in its character, shooting along the course of the nerves. Indeed all pain may he said to be neuralgic, or to be in the nerves, but pain arising from ordinary and obvious causes is not neuralgia in the technical sense we have defined it. Intensity of pain disproportion ed to the danger, and entire obscurity of the cause, we call neuralgia, let it be seated where it may. The writer has met with three or four instances of neuralgia of the rectum, the paroxysms of which were described by each sufferer as of the most intense character. 
Treatment.—Neuralgia is most generally dependant upon some already existing disease in the system, which it is absolutely necessary for the physician to determine and treat, before any progress toward a cure can be anticipated. During the treatment for the complication, and even when none exists, the patient should be placed upon the use of antiperiodics, among which we prefer the following: 
H. Sulphate of Quinia, Prussiate of Iron, Hydrastin, dd. Mix. 
Of this powder, about four grains may be given every four hours, in conjunction with the Compound Powder of Ipecac, and Opii, given in the same doses, three or four times a day. 
In cases where there is no other apparent disease present, we have derived considerable advantage from the use of the Compound Syrup of Stillingia and Iodide of Potassium, in connection with the above means. 
The use of the electro-magnetic battery, as a local means, has proved a powerful auxiliary in the treatment; if possible, the current should be made to pass along the course of the affected nerve. Rubefacients are sometimes used with advantage, and the local application of Chloroform has frequently been attended with the happiest results, as well as the Compound Cajuput Mixture. The bowels should be kept regular, and in many cases the occasional use of the spirit vapor-bath will be found beneficial. Belladonna, Arnica, and Aconite have been recommended, and 


1034 
NERVOUS FORMS OF DISEASE. 
we have derived much good effect from a saturated tincture of the latter article, in the proportion of one fluid drachm to eight ounces of water, of which a tablespoonful was given every hour. 
Species IV.— Mania. 
"We have treated of certain forms of disease that involved the brain as a living substance, as cerebritis, hydrocephalus, etc. We have now to treat of its functional delinquenc —of certain derangements—the results of disease, which become known to us through its manifestations. 
When we make the cerebral manifestations of the mass of society the standard of sanity, there are many, even the most gifted among the minority, whose manifestations induce the majority to consider them more or less insane. But in this variety of insanity, if such we may call it, for the present, there is a sane method about it, which has been characteristic of the individual through life. Cases of this kind depend upon peculiarities of organization, and are not to be confounded with those that result from disease. This distinction may require some illustration. We do not consider our savage tribes insane because of their mode of life, but if one of our distinguished citizens was to join them, and to adopt all their modes of life, he would certainly and very justly be regarded as more or less insane. Then why do we not regard the savages as insane ? Simply for the reason that there is a uniformity and a method in their modes of existence which is, and has been, so far as we can know, the practice of all its individuals. When we come to investigate these savages anatomically, we discover that their manifestations are physiologically normal. These remarks apply, similarly, to individuals. Nero was, confessedly, a moral monster, and yet between him and a man who should faint at seeing a fly killed, there is, in point of science, no more difference than existed between Laplace and Mr. George Combe —the first a mathematician and the second the first moral philosopher of the age, and yet does not know the multiplication table. 


MANIA 
1035 
The insanity, or departure from the standard of society, of such men as Nero and Caligula is normal, purely physiological, while that of which we have to treat is purely pathological, and yet, it will be seen, before we conclude, that they have been confounded. 
All imperfectly-constructed machines possess an inherent liability to functional derangement, and to this law the brain offers no exception. Some individuals have a brain so happily constructed that no amount, in both number and strength, of the vicissitudes of life can produce in it functional derangement, but a very large proportion of society is, more or less, differently or less perfectly constituted. Both the physiologically and the pathologically insane have had entailed upon them unfortunate organizations, which, through the aid or direction of education, the first becomes, too frequently, the inmates of our prisons, and the second, of our lunatic asylums ; and, therefore, in a legal point of view, they should be held equally responsible—the safety of society requires it, and nothing more. 
Many have been the writers who have attempted to define insanity, and all have failed, and for the reason that they attempted an impossibility. The human mind manifests, we know, about forty-seven independent functions, and it is not presumable that all of them have been discovered ; we may therefore safely assume that there are fifty—the brain, then, consists of fifty organs, each of which acts and ceases to act independently of all the others. Now, suppose the agent by which harmony of action is maintained among them, in a state of sanity, should become dethroned, would it be possible to define the confusion ? The difficulty is not yet fully expressed. No two individuals are precisely similarly organized, and hence no two cases of insanity can be exactly similar in their manifestations. 
Now suppose we define insanity to be a departure, in mental manifestation, from the standard of society—taking the majority as a standard. This definition is correct, but it is not sufficiently exclusive, because it equally applies to the normal condition of the minority of society—to those 


1036 
NERVOUS FORMS OF DISEASE. 
who are so organized as to form exceptions to the great majority. Such individuals have absolutely been medico-legally dealt with as lunatics. We have incidentally named this fact before—that some, with a healthy organization, act insanely, while others do so from disease acting upon an unfortunately constituted one. 
Insanity has been defined by some one (Oy. Prac. Med.) to be a "disordered state of the functions of the brain, which gives rise to disturbances in the operations of the mind." In this definition, " the functions of" the brain," and "the operations of the mind," seem to be regarded as two distinct entities, holding a relation of some kind to each other, while in truth, the functions of the brain are really the operations of the mind. No possible distinction can be drawn between them ; the first clause of the sentence therefore contains the whole definition, and it is as good or perfect as can be conceived of; but, as the writer, Dr. J. C. Prichard, of the article containing the definition above quoted, says "it includes a variety of other diseases, and hence it becomes necessary to render the description more particular by exclusions and restrictions." After naming some of these exclusions and restrictions, he concludes that "it is obvious a definition loses all its utility when it is found necessary to encumber it with so many particular restrictions, and it is therefore better to give up the attempt to define insanity in general terms." His article shows that he has been no more successful in the use of special ones. 
He now proceeds to notice some of the varieties of insanity for the purpose of giving us some idea of a disease which he could not define, and begins with " Moral Insanity," which he says, consists in a " morbid perversion of the feelings, affections, habits, without any hallucination or erroneous conviction impressed upon the understanding." This is moral insanity, and yet, although dogs have feelings, affections, and habits, no one regards them as moral beings. Dogs, as well as men, have this identical form of insanity; is it therefore moral insanity ? By a reference 


1037 
MANIA 
to his article it will be discovered that his moral insanity consists oi the normal actions of an unfortunately organized brain. 
If this was the place for illustrations of cerebral physiology, the writer could introduce a much more astonishing character. Every phrenologist of much experience has met with parallels of the preceding history, and he was able without any knowledge of his character, to describe accurately the peculiarities of his insanity {?). He would not confound his condition with one of disease, but as the legitimate result of organization. 
In such cases of insanity (?) as the preceding, we admit that the intellect may be sound in the absence of passion; but we deny that the intellect, in any case of insanity from disease of the affective faculties, is ever uninvolved. 
Dr. Prichard says, that when there is hallucination or erroneous judgment present, then the case is not one of moral insanity; and we add, that when no error of judg ment attends the case, It is one of organization, and not of disease. In a further effort to define moral insanity, the doctor says, that " when the morbid phenomena include merely expressions of intense malevolence, excited without ground or provocation, actual or supposed, the case is strictly one of moral insanity." "We fearlessly assert that no such case was ever witnessed, and we do it upon the principle that insane people do not and can not act without motives or causes, any more than the sane. The highest mark of insanity is shown in a want of fitness or compatibleness between the causes and the effects —the motives and the consequent actions. 
In fact, the writer, Dr. Prichard, has given us nothing on the subject of moral insanity, of a doctrinal character, which does not go to show that he has mistaken the functions of an unfortunate organization for those of a diseased one. Finally, his paper on this subject may interest those whose opportunities for becoming acquainted with mental science have been exclusively metaphysical, but in our judgment it contains scarcely a ray of scientific light. To 


1038 
NERVOUS FORMS OF DISEASE. 
treat of the functions of abstractiveness, acquisitiveness, etc., as moral faculties, can not be considered as less than a most flagrant abuse of language. Moral insanity should be understood to mean an abnormal manifestation of the moral sentiments. The same want of precision in the use of language characterizes his whole paper, thus showing that he has no clear conception of his subject. For medicolegal purposes, like other popular works of the day, it may be valuable, but not to the physiological student of medicine. 
It is customary for writers to divide functional derangement of the brain into many varieties, but as these mostly or entirely depend upon mere organic differences, we shall treat of it under two heads only, viz : mania and monomania. By the first, we mean an impairment of the cerebral functions of external relation in general; and by the second, a derangement of some one of these functions or several of them, upon one subject. 
It is usual to treat of idiotism as a variety of mental derangement, but as we consider this condition to depend upon an absolute deficiency of brain, and not upon disease, it can really have no place in a work of this kind. We are aware that some regard it as resulting sometimes from disease, but we hold it to be, in all instances, congenital. 
Dementia and fatuity are sometimes treated of as varieties, but we regard them as merely severe stages or conditions of insanity or mania. 
Imbecility is another form of mental imperfection which is frequently met with in works on this subject, and it is regarded as a modification of, or an affection that holds a close alliance with idiotism. We understand by the word an unexceptionable development of the affective portions of the brain, with more or less deficiency of the intellectual— such persons are said to be weak-minded. It is an organic condition, and therefore not a subject for present investigation. 
Our space will not permit us to pursue these introductory considerations further, nor should we have trespassed 


MANIA 
1039 
upon the reader's attention as far as we have, but for the purpose of guarding him against the metaphysical learning of the day. 
An abnormal manifestation of all the mental faculties constitutes mania ; to distinguish this form from that of monomania, it is usually denominated general mental derangement. The manifestations of maniacal patients are exceedingly various, in consequence of a difference of temperament and of cerebral organization. Our description of mania must, therefore, be esteemed as only general. 
The premonitory signs of approaching mania are usually such as to be readily observed by the family associates of the patient, inasmuch as they generally consist of a very great or even a total change of such of his mental manifestations as mostly constituted his character or mental individuality. Normally, he was confiding in his family and friends, but now he is suspicious and jealous ; he was self-governed and forbearing in his temper, but now he is irritable and easily thrown into a violent rage ; formerly rather slow in his habit or mode of thinking, but now quick and rapid ; formerly he was exceedingly frugal and circumspect, but now he is prodigal and ready to hazard under all chances of speculation ; if, normally, he was selfish, he is now liberal and philanthropic. 
When mania has become so developed as to admit of no doubt as to its existence, there are certain symptoms which are very generally present, such as sleeplessness, frightful dreams, vertigo, cephalalgia, costiveness, an inordinate appetite, a feeling of tension and throbbing in the brain, and a dull or a wild and animated expression of the countenance. In a more confirmed stage, the patient, depending upon the peculiarities of his cerebral organization, is haughty, affable, kind, or savage. When alone, he will occupy i his time in singing, whistling, swearing, praying, preaching, hallooing, walking, with rapid and wild gesticulations, or possibly he does nothing but gloomily sit still. His power to sleep leaves him for a week, or even for weeks, his appetite has become irregular, his urine is high 


1040 
NERVOUS FORMS OF DISEASE. 
colored and scanty, the bowels are constipated. The circulation appears to participate in the cerebral derangement, for it is exceedingly variable—sometimes feeble and irregular, sometimes strong and full, and at other times it is tense, or slow, or frequent and quick, and lastly it is sometimes normal. 
As an attendant upon violent grades of insanity, there is one symptom which, more than any other, claims our attention, as will more clearly appear when we come to treat of the nature or character of the disease —it is a remarkable impairment of consciousness. Every other mental faculty continues to manifest its function, though in an abnormal manner, so long as there remains evidence of mental existence, or until mania is lost in fatuity. So truly is this the case, that the patient loses all idea of his location, of his family, social, and political place, of time, and of his own personal existence. He recognizes some of the impressions that are made upon his external senses, yet even here his consciousness is exceedingly feeble—so much so that he distinguishes nothing, confounds visiters with his friends, and strangers with his relations. His affective and intellectual faculties may continue active, but they have become isolated with reference to the external senses, as is evidenced by his imagining that he hears persons talking or singing, that he sees spirits and angels, and even holds conversations with them. Among the physical phenomena that attend mania, there is a disagreeable odor, of an indefinable character, which emanates from the body and excretions of the patient (Esquiral). A suggestion:—May not this odor result from an abnormal escape of sulphur and phosphorus, two elements which are essential to sound cerebral action ? 
In the lighter shades of mania it is frequently impossible for a stranger, during a few minutes of observation and conversation, to detect any indications of its existence, and when it is detected, it is most frequently through some faulty manifestation of consciousness ; and this faculty frequently appears defective in those who are greatly liable to mania, long before the existence of the disease is suspected. 


1041 
MANIA 
The writer has particularly noted that it is about as impossible to make such persons feel conscious of error, as well before as after the maniacal invasion. 
This form of disease may appear suddenly and continue a day, a week, a month or longer, and then remit, intermit, or end fatally ; or it may appear slowly and as it were by stealth and prove continuous, or it may appear in paroxysms and observe exact periodicity, yet the intervals are not attended with sanity, but by depression or an absence of excitement. Mania may, furthermore, appear in the chronic form and continue unattended by obviously-distinct exacerbations. As this form obtains in those who have a high endowment of the organs of external relation, and a feeble one of those of internal relation, it is marked by a great absence of animation or excitement; existence seems to be one of indifference, one of neglect to every want and to every decency. 
Causes.—There are two remote causes, and without the presence of one or the other no other cause can produce mania, except mechanical violence, and they are these, viz: an unbalanced or badly-adjusted cerebral organization, and qualitative modes of cerebral action which may have been either transmitted or acquired. 
Upon this subject, Dr. Prichard (Cyc. Prac. Med.) remarks : "Among the circumstances in the previous condition of an individual which prepare him for sustaining the attack of this disease, the most important is a certain peculiarity of natural constitution. • This consists chiefly, as it is probable, in a particular organization of the brain and nervous system, rendering those individuals so constituted liable to become insane when exposed to the influence of certain agencies, which in other persons either give rise to a different train of morbid phenomena, or are, perhaps devoid of any injurious effects. The constitutional peculiarity which predisposes to madness is not distinguished by any remarkable external characters." More than seventy years since, Dr. Gall taught and demonstrated that those who are particularly liable to insanity can be " distinguished 


1042 
NERVOUS FORMS OF DISEASE. 
by" many "remarkable external characters," and every tyro among his disciples can make the distinction. Dr. Prichard, with all his learning and talent, through bigotry, writing upon a subject in both matter and manner seventy years behind his time 1 Should we not in this year, 1854, suspect an intelligent man to be of unsound mind, who should assert that there are no " remarkable external characters " by which the head of a homocidal maniac can be distinguished from that of the benevolent one, who has divided a large estate, in small portions, among the poor ? 
In happily balanced brains it is impossible for any one faculty or group of faculties, whether of internal or external relation, to become so excited as to endanger their integrity ; but with the unbalanced—the very impressible, the case is very different. We will here add an illustration, as it will not be out of place. 
During the connection of the writer with the Medical College of Louisiana, he was called to the Charity Hospital by Professor Stone, to see a raving female maniac, who had just been removed from the streets of the city to the hospital. She had about her all the indications of having held a very respectable position in society, and this circumstance caused the professor to be more than ordinarily solicitous about her. 
He desired the writer to examine her head and to give him such information touching her condition as he might thus obtain. She was Irish, and had a remarkably fine head —beautifully developed with reference to intellect and the social sentiments, but preponderating over every other compartment was the domestic. 
The examination being made, the writer informed the professor that her insanity must be attributed to some powerful shock given to her domestic affections, and suggested the immediate use of a hot pediluvium, ice to the social sentiments, and many leeches to the domestic region. This, and possibly more, but not now remembered, was done, and in the space of an hour she detailed to us much of her history relating to her mania, and as it is, in this con- 


1043 
MANIA. 
nection, particularly interesting, wo will be excused forgiving it. 
Three years previous to this event, her husband, in search of prosperity, left her with her friends in Ireland, and went to New York, and during the first two years ho sent her re. mittances of money, but during the third year she received no money nor any information of him. Sho then left her friends and went to New York to search for him ; there she learned that he was in New Orleans; she then went to New Orleans, and by the instructions sho had sho readily found Mm ; but, sad to relate, he disowned her—he denied ever having been married, and of ever having seen her before This was her history, and though brief, it was enough to drive to madness so devoted a wife. 
The reader is required to remember this case, as wo will have occasion to refer to it beforo wo conclude the subject of insanity. We regret to add that she became a contirmod maniac. 
The reader has, by this time, no doubt, discovered that a little more certainty is now had upon this subject than Dr. Prichard, Esquiral, Pinel, and many other copious writers upon it ever dreamed of. 
This unbalanced condition of the brain is the most fruitful source of insanity ; but anterior to it is another question : —what rendered such a brain common to civil society ? We answer —one of the first causes of it exists in a division of labor, and another is the revolutionary movements of the world—religioug sectarianism has been a fruitful source, and so have politics. The enthusiasm that distinguished the Whig party during the struggle that made General Harrison, President, did an immense amount of mischief. Very many of the children begotten during that struggle possess scarcely anything in common with the other members of their respective families—very many of them will be brighter ornaments of society than their sisters and brothers, if they happen to fall into a favorable current of circumstances, otherwise they will become drunkards,, gamblers, suicides, or maniacs. The writer has, with astonishment, 
06 


1044 
NERVOUS FORMS OF DISEASE. 
contemplated many of these children. Such excitement and enthusiasm, in church or state, though they may occasionally produce a great man, are of incalculable mischief to society as a whole. We have said that a division of labor has been instrumental in producing unbalanced cerebral organizations. This we have inferred from two circumstances : first, each pursuit calls into requisition only a part of the mental faculties, and secondly, in the several Indian tribes the history of an individual is that of his tribe, in kind, and all the heads of a tribe have a strong family resemblance. 
The exciting causes of mania have generally been divided into physical and moral, and yet it has neither truth, utility, nor common sense to recommend it. In the first place, we neither do nor can know anything of non-physical causes or agents; and secondly, the case of the Irish lady, above referred to, would, by those who have adopted the division, be attributed to a moral cause, when in truth the moral faculties had nothing to do with it. An outrage inflicted upon her domestic faculties or affections caused her insanity, and these faculties are as common to geese, pigeons, partridges, foxes, and some other animals, as they are to man, and certainly no one will admit that any of the inferior animals are moral beings. A more consistent division would be, into internal and external—internal, when effected through the agency of the organs of internal relation, and external, when effected through the medium of the organs of external relation. 
As internal causes of mania, we name the following, and those that most frequently produce it stand first in the catalogue, viz: apoplexy, old age, suppressed menstruation, puerperal state, worms, use of mercury, congenital injuries of the head, fever, epilepsy, pregnancy, suppressed cutaneous forms of disease, intoxication, syphilis, narcotic poisons, atmospheric influences, hemorrhage, or insufficient food, onanism, excessive indulgence of amativeness, and its unsatisfjed desire. 
Of the external causes of mania, we may name the fol- 


MANIA. 
1045 
lowing, viz: want and its consequent misery; grief, no matter how produced ; unrequited love ; fright; jealousy ; fanaticism ; long-cherished hatred; political disappointments; injured character; intense and protracted study of subjects that do not admit of certainty or demonstration ; loss of property, and disappointed ambition in general. 
We should add, in this place, that those who are liable to mania from an unbalanced cerebral organization may, very properly, be divided into two classes. Those who have had entailed upon them peculiar modes of cerebral action favorable to the production of the disease. This is the class in which mania is said to be hereditary. The second class comprises those who have not had entailed upon them such modes of cerebral action, but such an organization as is calculated to favor the production of the disease. In conclusion, we will merely add that the entailment of peculiar modes of cerebral action has become too well settled, both in'relation to men and many of our domestic animals, for it to become a question in the mind of any one. Our hunters are perfectly convinced of it with reference to the dog. The progeny of a dog that was trained to set at game will spontaneously do the same. 
Nature of Mania. —There has been considerable contrariety of opinion as to the primary source or seat of insanity. Pinel has given it as his opinion that it is in or about the stomach and intestines. With as much propriety, in our opinion, it might be contended that the true seat of gastric derangements is in or about the brain. It is true, as should be supposed, that when insanity is caused by the morbid condition of the organs of internal relation, that the general health is greatly impaired, as well preceding the insanity as afterward. But from this circumstance we are by no means entitled to the inference that when insanity results from influences exerted upon the organs of external relation, that there should exist at the time a morbid condition of the stomach, the intestines, or of any of the other viscera of the two inferior great cavities. In very many instances we know the contrary to have been the fact. The 


1046 
NERVOUS FORMS OF DISEASE. 
Irish lady, whose case we have introduced, was, apparently at least, a model of good health at the time she was stricken with insanity. This is not all. The shock upon an impressible organization may be so violent, even in a state of good general health, as to occasion the worst grade of insanity—that of amentia or fatuity. Of this kind the writer has seen one example. 
We know that visceral derangement will produce cerebral derangement, and vice versa; now, where is the point, and what is the function of it that holds the two systems in such relation to each other ? When we shall have discovered this point and its function, then, in our opinion, we shall have discovered the true seat and nature of insanity. A little further prosecution of this inquiry will probably bring us a little nearer to the object at which we aim. When the stomach, liver, intestines, etc., are sound or healthy we do not know them to exist; but when they become possessed of inflammation, then we become unequivocally informed of their being. Equally true is it, that we do not know that the brain is the organ of thought and feeling so long as it continues in a state of well-being; but a structural disease of it soon gives us to understand that these are its probable functions. Now to the question. Through what medium is it that we receive our information in both cases? Is it not through consciousness? To us it appears that physiology and pathology both answer in the affirmative, and the testimony of anatomy bears with great force upon the same question, by showing that there is a particular portion of the brain which so clearly performs the function of consciousness that Mr. Grimes, of New York, an able phrenologian, has nominated it the organ of consciousness. Vivesectionists state that in slicing down the brain, commencing with the superior surface of the hemispheres, no consciousness of the operation is manifested until the base of the brain is very nearly approached, and it is at the base of the brain we find those organs which connect consciousness with the ganglionic system, such as vitativeness, pneumativeness, gustativeness, hydra- 


1047 
MANIA, 
tiveness, etc. The independence of such a faculty as consciousness might be inferred, it would seem, from its continuing to be the only acting power of the mind in some modifications of catalepsy. Its function appears to be that of informing us as to the results of the actions of all of the organs of external relation, and to constitute the sense of ill or well-being to the organs of internal relation. 
If the preceding conclusions be well founded, it is obvious that all the phenomena of insanity are explained. In this disease the organs of external relation do not appear to be deranged, in cases of moderate violence, in their individual capacity, but in their relative actions as a whole. 
In the case of the Irish woman, before treated of, the cause of insanity was no doubt communicated through the domestic faculties, but they, in the abstract, were not injured, for if they had been, she would have displayed monomania; but as the result was insanity, the force of the shock fell upon some part, the morbid manifestations of which would be a derangement in the relations of all the organs connected with, or dependent upon it. She was conscious of having found her husband, of his having disowned her, of being three thousand miles from her friends, in the midst of a nation of strangers and without the means of providing for her necessities. If all this, in a highly refined order of organization, could not overpower and derange the organ that was the witness of it, then it must be proof against all causes. 
We have now delivered our convictions upon the seat and nature of insanity, and leave it for our readers to judge of their value. But before dismissing this division of our subject, we beg leave to make a few remarks upon microscopical investigations as they have been conducted. A few pathological anatomists deny having discovered morbid changes in brains of those who have died of insanity; but a large and preponderating majority have asserted and recorded the contrary, and with great and interesting minuteness; but, so far as we can discover, they avail nothing, because they were conducted without par- 


1048 
NERVOUS FORMS OF DISEASE. 
ticular reference to the character of the disease in each particular instance. Can it be a matter of no moment as to whether the insanity was produced through the agency of the organs of internal or external relation 2 In making a record of post-mortem appearances, should we not be informed whether the case was one of insanity, dementia, or amentia? M. Georget informs us that he found many crania among those who died of insanity to possess an irregular conformation, and most generally the right side was. more capacious than the left; in some, the lateral diameter was equal to the antero-posterior; in some, the cavities of the base were irregular; in some, the skull was partially thickened, and in others generally; some were hard and white, and without diploe; and lastly, some were very light. 
Now the medical student, and the profession at large, upon the high authority of M. Georget, must infer that all these cranial peculiarities resulted from insanity; and yet the writer can, at any moment, show all of them in the crania of individuals who never had insanity or any other form of cerebral disease. But admit them to have been occasioned by insanity, how can we render them inservient to any pathologic or therapeutic purpose, as we are left uninformed of those peculiarities under which they were severally produced \ It will be remembered that W3 named an unbalanced head, which means an irregularly formed one, to be the principal remote cause of insanity—one without which insanity could not exist, except by mechanical violence; and therefore M. Georget has mistaken the most important remote cause of insanity for an effect of it; but he is not alone, for others have done the same. 
It is true, that the cranium may become thin or thick in a state of health or disease, nevertheless they are so distinguished by other marks that they can not be confounded. A state of healthy mental activity and a state of active insanity will both be attended with a light and thin skull; and a state of mental inactivity through a want of ambition or adequate motives to, or opportunities for action, 


1049 
MANIA 
and a state of amentia succeeding to active insanity, will be associated with a thick skull; but a thin skull from disease gives evidence that inflammation existed in the duramater and pericranium at death, and the thick skull from disease discovers that these membranes had been diseased. A thin skull from insanity, and a thin one from a too full and frequent use of ardent spirits can not be certainly distinguished, but in both cases there is a preternatural excitement of the brain and its membranes—in both cases the skull becomes thin, and in both cases its normal angularities become replaced by a more full and rounded condition. 
Dementia. —The signification of this word is remarkably indefinite. It applies with equal force to that decay or absorption of the brain, and particularly of its intellectual portion, consequent upon old age, and which is in no wise allied to insanity, and also to that absorption of the brain which supervenes upon inactive insanity—with reference to both it is a mere sequent. The dementia of old age is frequently attended with a strong recollection of the events of early life, hence the aged often re-enjoy the tricks and amusements of their youth, and re-fight its battles, and yet be exceedingly forgetful of present impressions and events. The reason of all this, to us, is very obvious. In early life all the mental organs were active and vigorous, and hence all the impressions made upon consciousness were thoroughly made, and therefore enduring; but in old age the mental organs have become reduced in size and enfeebled in action —in consequence of the absorption of the perceptive convolutions and the continuous adaptation of the internal table of the cranium to it, the frontal sinuses become of enormous magnitude, and all at the expense of the perceptive organs. In this condition of these faculties a strong perceptive impression can not be made upon the organ of consciousness, and consequently no impression is distinctly retained, and frequently not even made. From the causes now stated, old people sit for days and even weeks without speaking a word, and without giving any evidence that they are in the least impressed by external 


1050 
NERVOUS FORMS OF DISEASE. 
nature ; and yet consciousness is not in the same exhausted condition, for they will smile, even laugh and possibly speak from the still existing early impressions. 
With the dementia of old people, or senile dementia, we have nothing to do further than to define it, because it is not a state of disease ; but between it and that which depends upon disease there are some points of resemblance. There is in both the same disposition to taciturnity, and non-observance of passing exents. In both there is an atrophy of the brain, and a hypertrophy of the cranium; but in senile dementia the cranium gives no evidence of pre-existing inflammation of its membranes, while that of the other always does. In the former the mental organs are worn out, not deranged, and consciousness, as an independent faculty, still preserves its integrity; but in the latter, the cerebral atrophy is attended with insanity and a greatly impaired condition of consciousness. There is another very important difference between these two forms of dementia. In the senile there is no recovery, but from the other form the patient may recover, and the brain may recover its normal size, and the cranium its normal thinness. 
In dementia, as a sequent of insanity, the patient may enjoy or rather possess good health, the appetite, the digestion, the secretions, and the excretions may all be healthy—a condition of the system that did not attend the active stage of insanity. Among patients of this denomination there are a few who have occasionally a higher state of cerebral excitement, and with it a correspondingly active state of insanity. 
Amentia or fatuity —the last stage of insanity. This appears to consist in a complete vegetative condition of the patient—those who are thus afflicted manifest no volition nor consciousness. They never call for food, and they would never eat if food was not put into their mouths. If in bed, they would never get up, and when up, they would never lie down, and neither is ever effected except by attendants. Of their excretions they take no notice. As we have 


1051 
MONOMANIA. 
remarked, they merely vegetate, and this they may do for many years, and have a pretty good state of health. 
This is regarded as the last or final stage of madness or insanity ; nevertheless, it is occasionally the first and only stage. We knew a highly-talented lawyer, who had contracted a marriage engagement with a lady, who married another gentleman very nearly about the time she had contracted to marry the other, and when he was informed of her marriage he became suddenly amentecl, and so continued many years and to the end of life, and yet the vegetative functions were not materially disturbed. It was this case that first induced the writer to reflect about the true seat of insanity. The idea of his forty or more mental faculties all becoming suddenly amented, is, to the writer, preposterous, because very many of those faculties had no more to do with the circumstance than had his external senses. But a sudden amentia or paralysis of his organ of consciousness, fully accounts for the sum total of his case. 
With these views, we have no difficulty in comprehending how it is that the vegetative functions, and some of the animal, or those which are essential to the vegetative, as the external senses, locomotion, etc., should continue, comparatively, in a normal state, when reason and consciousness are measurably dethroned. 
Species V.— Monomania. 
This is a derangement of a single mental faculty or of so many of them as may be essential to the formation of a single idea or mental conviction, while all of the other faculties continue in a normal state. The varieties of this form of disease may be as numerous as are the affective faculties and their combinations. It is more frequently to be met with than any other species of functional derangement of the organs of external relation. 
From the most careful investigation we have been able to give this subject, we have been forced to the conclusion that it is pathologically the antithesis of insanity. It will be remembered that while treating of insanity we mainr 


1052 
NERVOUS FORMS OF DISEASE. 
tained that it was primarily and essentially located in consciousness, and that it might be produced through the medium of either the organs of internal or of external relation ; but in the form of mental derangement now under consideration, the seat is in the mental organs, or organs that manifest the deranged function, that consciousness maintains its full integrity throughout the existence of the disease, and lastly, that it is never occasioned through the medium of the organs of internal relation. Furthermore, the existing liability to this form of disease is most generally indicated by the external configuration of the brain. Thus, a homicidal monomaniac has a large organ of destructiveness, and a suicidal one has watchfulness large. If we knew all the mental faculties and their modes of manifestation it is very probable that we could in all cases refer the existing delusion to its proper source. We can better teach how far we are, in a great measure, capable of certainty, and how far we are not, by the introduction of cases. 
In Tuscumbia, Alabama, there was, at the close of a phenological lecture by the writer, introduced upon the stage for public examination an old gentleman from the country. His organs of hope, reverence, marvelousness, and self-esteem were all peculiarly large, with an intellect much below mediocrity except for the plainest commonsense. The writer informed the audience that if the subject under examination should be exposed to occasions of high religious excitement, he would be liable to become a religious monomaniac, and that his self-esteem would give direction for fancying himself to be an apostle, the Savior, or the Deity ; and further, that he was even liable to such a hallucination spontaneously. At the close of the examination the lecturer and audience were informed that the old gentleman whose head had just been examined, believed himself to be the Almighty. On the day after the lecture, a member of the Tuscumbia bar informed the writer that the old gentleman above alluded to really did believe that he was God, the Governor of the universe; but that he was 


1053 
MONOMANIA. 
entirely sane upon all other subjects—managed his business and farm with much prudence. 
Some years since the writer was acquainted with an old gentleman who was deranged with reference to children — he had the organ of philoprogenitiveness decidedly large. When visited by his acquaintances of both sexes, he never failed to inform them that his wife had been pregnant nine years, and then he would ask them if they did not think the child would be a " thopper " when it came. 
Dr. Spurzheim mentions the case of a young lady of good standing, who ran into a party of ladies and gentlemen, and with much seeming satisfaction informed them that she was with child. The writer knew a black woman, some fifty years of age, who, as frequently as she got drunk, informed her mistress that her master was going to have another negro—that she was again with child. A derangement of this faculty, to some extent, is quite common to the maternal part of society. 
Thus, when the monomania is of the kind above illustrated—that is, of an affective power or faculty, the cerebral organization alwavs indicates the liability; but in the following instances it is impossible, in the present state of mental science, to determine the source of the delusive idea. 
The writer once had a female patient, who had the appearance of being in good health, but who imagined that she shook or trembled so badly that she did not, and had not for seven years, ventured to feed herself, He cured her by having five or six of her neighbor-women to visit her frequently, and assure her that she was mending, and that her physician had probably no equal in the world. By this course and bread-pills she was well in six weeks. 
44 Tissot mentions an instance, in which the patient believed himself to be a lump of butter, and would not suffer any fire near him, lest he should melt. An eminent painter imagined himself made of wax,, and avoided all contact with hard substances —(Tulpius). Zacutus Lusitanus mentions a person who believed that his posteriors were com- 


1054 
NERVOUS FORMS OF DISEASE. 
posed of glass, and would on no account sit on anything but the softest pillows. Some hypochondriacs have thought themselves dead ; others imagined that their souls formerly resided in some inferior animal, or in some fellow-creature; in short, almost every imaginable hallucination of this kind has been known to occur in this variety of mental disease.'' — Eberle. 
As that variety of monomania which is known as melancholy, depends upon a deranged condition of the prudential faculties, we are much inclined to attribute all of the preceding singular varieties of monomania to these faculties, and that false perception and reflection which they occasion. 
It should be strongly impressed upon the mind of every - body, that monomaniacs are entirely sane, and as capable as they ever were of transacting all kinds of business that does not infringe the subject of their hallucination, and that for all acts outside of this they should be held legally responsible; but for acts which come within the sphere of their special mania, they should be treated as lunatics. When a man is discovered to labor under a homicidal or a suicidal monomania, he should be constantly guarded, however sane he may be upon all other subjects. As to suicide, the writer has had the most ample evidence that it invariably results from a suicidal monomania. 
In a medico-legal point of view, the whole subject of mental derangement is one of great delicacy and importance, more especially as the whole of our criminal jurisprudence is founded in false views of human nature ; so much so that a man's life sometimes hangs upon a definition framed upon a foundation as false as that cf the jurisprudence. For instance, Dr. F. Willis says, that "a sound mind is one wholly free from delusion." Is there a member of society whom some other member does not suspect of existing at times under a delusion ? But he continues : " The man of insane mind from disease, having been once compos mentis, pertinaciously adheres to some delusive idea in opposition to the plainest evidence of its falsity, and endeavors by the 


1055 
MONOMANIA. 
most ingenious arguments, however fallacious they may be, to support his opinion." 
Under this description of sanity and insanity, the most sane and gifted of the human race could be convicted of insanity by an American jury. To illustrate this : Did not the pope and cardinals of Rome regard Galiko as laboring under a mental delusion in contending that the sun was the center of our solar system ? If they did not, why did they imprison him ? Are not all discoverers and their advocates regarded by the mass as being deluded ? We saw, recently, a newspaper statement of a man, before the time of Watis and Fulton, who was imprisoned-in France, under a supposition that he was insane, because he contended that steam could be converted into a motive power. Be the statement true or false, it is in accordance with human nature. 
We have traveled out of our legitimate sphere, but our apology is a desire to make medical students think upon the subject, because they do not know how soon th ey may be called upon to hazard an opinion which may jeopardize the reputation, the liberty, or the life of a fellow-being. 
Treatment.—Under this head we intend to have reference not only to mania, but monomania, and those mental conditions known as amentia and dementia. 
It is common for writers to divide this treatment into two kinds: therapeutic and moral. Under the first, various writers have treated of various plans of medical treatment which they, respectively, supposed to be efficacious. Some have placed much stress upon bleeding; others upon cathartics ; some upon emetics; some upon the various applications of the bath ; some upon counter irritants, etc. But as we deem it to be possible for insanity to exist with an entirely healthy condition of the organs of internal relation, we see nothing to justify the hazard of deranging them by any course of therapeutics, through a hope of effecting a salutary change in the action of those of external relation. When the insanity has resulted from a diseased or a deranged action in the organs of internal relation, then it be- 


1056 
NERVOUS FORMS OF DISEASE. 
comes the first duty of. the physician to restore these organs to health or to a normal mode of action, as the case may re. quire. But with this admission, it does not follow that we should, in this place, prescribe a course of treatment for merely supposable forms of organic disease or derangement. When the organs of internal relation cease to manifest their functions properly, it is the business of the physician, guided by the general principles of the profession, to treat them accordingly. As we can reach the organs of external relation, therapeutically, only through those of the internal; and as, upon the subject before us, we neither have, nor can have, any prescribed form of disease that has invaded the fountain of life, to guide our prescriptions, it follows very clearly that we should make none. 
We are told that the second variety of treatment embraces those " means supposed likely to exercise a beneficial influence on the mind," and which, by a most ridiculous abuse of language, is called the " moral," instead of the mental.* 
Before proceeding further with the treatment, it becomes essential that we should first place the person of the maniac in a proper condition to be treated, and this is frequently a task of great difficulty ; but as the physician is consulted on behalf of the maniac, he should decide exclusively with reference to his good—his recovery. 
Relatives and friends are usually anxious to retain the care and management of the patient; at all events they are unwilling that he should be sent to a lunatic asylum ; and yet, as a very general fact, it is far preferable that he should, because, it is-not to be supposed that he is going to obey those whom, probably, he formerly commanded. Furthermore, relatives who do not flatter his caprices, are sure to obtain his aversion and suspicion. In view of these considerations, a public institution is much to be preferred; These public establishments, furthermore, are specially pro- 
* The word mind, says Prof. Powell, embraces the whole mind—the intellect and the affections ; and in the latter is included the moral faculties. As the adjective mental refers to the whole mind, it is the proper term to use. " 


1057 
MONOMANIA. 
vided for all the contingencies that may arise—his person can be secured without harshness —the domestics have been trained to the peculiar duties of the institution, and the attending physician must be more familiar with his duty to such patients, than physicians who are engaged in general practice can be supposed to be. 
Mental treatment of insanity. —The opinions we shall advance under this head will apply to all species and varieties of the subject, unless otherwise indicated. 
Maniacs are not those who can not think and reason, but they think and reason in an unconformable manner with the laws of mind. They have not, furthermore, ceased to feel—an attachment to wife, children, and home, may still exist, and so may a proper regard for personal rights and for the good opinion of society. They may still have a proper sense of justice, of submission to authority, of hope, fear, and of kindness. The same may be true of their propensities or inferior desires; but they are all, perhaps, manifested in a manner, such as to indicate a departure from normality or the laws of mind. 
The truth of these opinions being admitted, it follows that our intercourse with them should be governed by the same laws that regulate our intercourse with society at large—discriminating the true social or official position respectively. We do not command our equals—we solicit them—induce them by motives. We should do the same with the insane, as far at least as it is practicable. To command a lunatic, who, before his misfortune, commanded others, is to insult him, and insult can not restore his faculties to a normal mode of action. We should ply the insane as we do the sane, with solicitations and motives in securing our control of them. We should neither ridicule nor laugh at their hallucinations—to do so would wound their vanity or their pride, and possibly both, and consequently lessen their regard for us. There are, in society, many sane persons whose conduct is not regulated by their moral capabilities, but by their knowledge of the consequences of violated law, and this law need not to be statutory, but consisting 


1058 
NERVOUS FORMS OF DISEASE. 
alone of social'or public opinion. Such persons, in a state of insanity, can not, perhaps, be entirely governed by the usages or address that proves sufficient with gentlemen. They must know the law, and the penalty of its violation. 
If it has been decided to place the lunatic in a public institution, then it becomes a matter of the first importance that his insane companions shall consist of those who were about his equals in society in point of gentility and intelligence. The importance of this requisition can be appreciated by every gentleman, whom circumstances may have compelled, occasionally, to be associated with the rabble— the vulgar. It is of equal importance, furthermore, that his associates should not be afflicted with the same or analogous hallucinations ; the more diversity there is among them in this respect, observation has proved to be the better. 
Hitherto, in the mental treatment of insanity, many schemes have been invented to surprise or shock the mind of the patient with a view of exposing to him the error of his hallucination, or of changing the action of his affective or intellectual faculties, as the case may have seemed to require. Such experiment can only promise possible success with monomaniacs—with the maniac none, we think. Dr. Prichard expresses some surprise that Pinel and Esquiral should give any countenance to such attempts. Our opinion is, that in many instances they would do neither good nor harm ; that in some, mischief would result, and in a few, much benefit, possibly a cure, might be the result. Now, in order that we may do good without much hazard of doing mischief, we must be able to discriminate the cases. The rule laid down by Professor Powell, in his lectures, is this : when the hallucination is such that it can be shown to be false or unfounded by a demonstration, or even true, apparently, and in such a manner as to be followed by relief, then it may be attempted. He illustrates, that a gentleman in Lexington, Kentucky, was insane upon the subject of his monetary liabilities, and was cured, by Professor Brown, by showing him by figures that his estate 


MONOMANIA. 
1059 
amounted to a greatly larger sum than his liabilities. Dr. Pritchard says that he was told that a monomaniac, who fancied that he had a serpent in his stomach, was cured by an emetic and the dropping of one in the pot, so adroitly that he believed that it came from his stomach. 
The following case, known to some of our citizens, we extract from Professor Powell's note-book, as an illustration of a form that could not be met by a demonstration. 
Cowan, who murdered his wife and children in the early part of the year 1835, was regarded by the professor as a monomaniac—his mania was jealousy, a very, frequent variety, according to his observations. But to Cowan's case: the professor called on him when in prison, and after examining his head, and finding an organic liability to such a disease, asked him what evidence he had of his wife's infidelity. He turned up his eyes, looked wildly, as though much puzzled, and answered, " I have none that I can communicate to you, but I have a consciousness of it." Now, it is obvious that such a case could not be met by a demonstration. 
There are cases that may be cured by a little address, which do not admit of a demonstration, and at the same time without any possibility of mischief of any kind. Such a case we find in Professor Powell's notes. 
In 1827, he was called to see a lady who had been confined to her armed-chair seven years, under a conviction that she shook too badly to venture to get up, walk, or feed herself. She had been attended by several physicians, who endeavored to convince her that she did not shake. Her system of internal relation was in good health. 
The professor confirmed, to her mind'-, the reality of her hallucination, and thus secured her confidence. He then induced several of her neighbors to call upon her at preconcerted times, to congratulate her upon her constantly improving appearance, to assure her that she would now soon be well, that her physician was the greatest doctor in the world. By these means and the use of bread-pills, she 
67 


1060 
NERVOUS FORMS OF DISEASE. 
was well in six weeks, and made the professor a visit at the distance of seven miles. 
Notwithstanding the low estimation in which Dr. Prichard holds such attempts, one per centum of success justifies their use in the hands of an intelligent and discreet physician. An adroit application of such means as the above would make many well persons sick, therefore it would be strange if they could not cure a sick one, occasionally. 
With reference to jealousy among men (how it is in the other sex he does not know), it is the opinion of the professor, that in a vast majority of the cases, it is monomania. He has crania of several men who were executed for wife murder, and all of them indicate the same mental liability in this respect, and in each instance it was the opinion of society that the wife was as pure as a flake of snow. 
Upon this subject, he has given this caution to society: When the wife detects the husband watching her, at the door of her chamber, from a closet, through a key-hole, or in any other sly and secret manner, the safety of her life depends upon her immediate separation from him. These, he says, are not the manifestations of a sane husband upon just causes of suspicion. 
There are yet two varieties of monomania, which through prudential considerations, require of us a passing notice. They are the homicidal and the suicidal. The first consists in a desire to kill, and without any other motive than the gratification of the desire. If space was allowed us, we could present some exceedingly interesting and instructive examples of these two forms of monomania. These two, and that of jealousy, are difficult to manage. The subjects are sane upon all other subjects, and very frequently upon these; but overtaken by desire in the form of a paroxysm, they rush to the deed. To keep men constantly confined who are capable of usefulness, and who frequently view with horror their own desire, is what we can not very readily have done, and yet without it there is no certain safety. 
Upon such forms of mania the public mind is not suffi- 


1061 
MONOMANIA. 
ciently informed as to hold a man to be irresponsible to the laws when he is generally sane and betrays much cunning and adroitness in both the commission of, and defense against the accusation of crime. Cowan was hung as a murderer, although Professor Powell did not entertain a doubt as to his mental unsoundness. Luke Manning, formerly of South Carolina, was hung in Alabama for murder, although, as the report of the case by Professor Powell shows, he had been a homicidal monomaniac nearly all his life, and the killing, for which he was executed, was committed without any other possible motive than the gratification of his destructive desire to kill. 
In such cases, it is obvious that the life of a man and the reputation of a family are made to depend upon the determination of a fact that lies at an immeasurable distance beyond the ability of the ablest mental philosopher who ever lived, viz: is the mind sound ? how unsound must it be to remove responsibility ? No thinking man can desire a stronger commentary upon our criminal legislation than this, or a stronger proof that it is not adapted to the nature of man. 
When the soundness of a steam engine becomes a question, the most competent engineers are appointed to investigate it; but when mental unsoundness is suspected, twelve hod-carriers and day-laborers are appointed to investigate and determine the fact. 
In these remarks, we admit that we have traveled out of our legitimate sphere; but our apology is our desire to set our young readers to thinking upon the grave and responsible character of this subject. 
Genus III.—Morbid Actions of the Organs of Mixed Relation. 
The organs of internal and external relation can, and do, in emasculated animals, maintain their integrity independently of those of the mixed ; but the latter holds such a relation to the two former as to modify all their actions in both health and disease; and whether we contemplate them in relation to their function—the perpetuity of the 


1062 
NERVOUS FORMS OF DISEASE. 
race, or in relation to their influence over the mental and natural history of the raqe—we are forced to regard them as of paramount importance. Such is their influence over the various forms of disease to which the other two genera are liable, that they should claim of the physician a thorough, a special, and a profound investigation. 
Species I.— Exoneirosis — Nocturnal Pollution. 
This malady is very common among boys when approaching puberty, and exceedingly ruinous to health ; but no age is necessarily exempt from it. It is more common to those who sleep in warm feather beds than to others. 
It consists of dreams of sexual intercourse, attended with stronger or more impassioned sensations of enjoyment than will ever be experienced when awake, and for the reason that all the nervous power of the system is concentrated upon this function. The desire, depending upon amativeness, is powerful; the muscular exertion is equal to the whole strength of the muscular system, stimulated to its highest capacity, and animal sensibility is so excited as to render the imagined enjoyment almost painfully exquisite. No one can now doubt that such paroxysms, concentrating all the power of the system, if frequently repeated, must prove very destructive to health; and such is really the truth, causing blindness, paralysis, apoplexy, epilepsy, and death. 
Treatment.—This, in most cases, is exceedingly simple—all that is usually requisite is to replace his bed with a matress, and his feather pillow with one made of rags or of any material that may be hard enough to force him to lie upon his side. These paroxysms never take place except when the patient is lying on his back. Break up this habit, and the disease is cured. The reason is this: when lying on the back, blood by its own gravity, accumulates in the cerebellum, which excites, not only the amatory organ, but those which co-operate with it. It may be well to accompany this treatment with light suppers for a while, and some wakeful person to sleep with him to keep him on 


MASTURPATIO. 
1063 
his side. If the case be too obstinate to yield to these means, elevate his head a little more, use cold applications to the back of it, let his diet be sufficient and nutricious, but not stimulating, keep his bowels in a normal condition by cold-water injections, and if he be already enfeebled, tone up his system with a union of some bitter tonic and iron. 
Some writers have advised that much good may be produced by exciting in his mind disgust against females. As we have never known anything but evil to result from the violation of the organic laws, we can not indorse this doctrine. The organic laws ordain that the sexes shall love each other, and therefore it is right that they should, and that too without any disgust for each other. 
This is not all—such a course can do no possible good, nor can any advice do him good, so far as regards the training of his thoughts and feelings during his waking hours. He may indulge in female society all day, and foster in his bosom the most solacious imaginings, and still he will have no sleeping dreams about them, nor emissions of semen in his sleep, if he lies upon his side. The affection is one over which he can exert no voluntary control. 
If the waking mind could prevent these paroxysms, married men would certainly be exempt from them; but this is not the case. A husband may love his wife and in an hour pollute himself, by sleeping on his back, with a soft pillow under his head. 
Species II.— Masturpatio. — Masturbation. — Voluntary 
Self-pollution. 
The practice of masturbation among boys over puberty, young men, and even among those of riper years, is much more common than is generally supposed by even the most of the profession. We but rarely take a walk through the city without meeting one or more of them. 
As there is, probably, no manifestation of irritation that is generally less understood, even by the profession, or one that is more mischievous in its results, it becomes our duty 


1064 
NERVOUS FORMS OF DISEASE. 
to shed upon it such light as our peculiar advantages may enable us. 
We are pleased to.find that some of our journals have commenced treating of this subject, and this makes it more imperious that we should present those anatomical and physiological conditions that produce the pathological manifestation usually known as self-pollution. If, in our expositions of the cerebellum, we are correct, then it follows that we alone are qualified to enlighten the profession upon the true character of this morbus, for such it is. 
Those who know nothing of Gall's doctrines, know nothing of those organic conditions which produce this form of disease; and those who understand those doctrines have been very little better provided for, inasmuch as the whole of the cerebellum has been appropriated to the sexual function. Self-pollution has not, therefore, been referred to a special organization, but to an abuse of one existing in common, except in degree, in all individuals. 
We have shown that the cerebellum comprises three organs, performs three distinct functions, and it will be discovered before we conclude that the onanic disposition results from a certain relative condition between these three organs, just as phthisis pulmonalis results from a certain relation between the medulla oblongata and the cerebellum. 
A certain equality of development between the medulla oblongata and the cerebellum is indispensable to such a balance of organization as can insu:e general good health, long life, and an equal exemption from all forms of disease. Precisely so it is, with reference to the cerebellum, in the great and important function of procreation. Animal sensibility, muscular motion, and amativeness are indispensable to the function. The last is a sine qua non; but suppose the animal to be insusceptible of irritation, or incapable of motion — muscular power and the animal would be as incapable of the procreative function, though enormously amative, as if it was emasculated. 
The cerebellum is the great elaborator of nervous power for the animal system, and when all of its parts are well 


1065 
MASTURl'ATIO 
developed, its power can be expended upon the industrial pursuits of life without any call or demand for the opposite sex ; hence it is, that a properly constituted man can live upon the ocean, year after year, if engaged in such responsibilities as will consume or demand his powers, without scarcely thinking of the other sex. This is not all—such men constitute the most chaste and temperate men, as regards the opposite sex, which society contains. 
The thoroughly constituted onanist does not want a woman—he knows that she can not relieve him, or that with her he can not relieve himself—his animal sensibility is too feeble—he will and does leave the bed of his wife for a more satisfactory indulgence with his hand—with it he can apply more pressure, produce more irritation, which is indispensable to his comparatively absent animal sensibility. Some are even forced to greater extremities—the titillation of the urethra and even its laceration, for the purpose of inducing seminal emission. Such a condition illustrates the lowest possible degree of existence in the organ or power of animal sensibility. 
There are many degrees in this capacity of animal sensibility among onanists, and it is as impossible to cure the most iuveterate as it is to save a child of a non-viable organization, or as it is impossible for the physician to create in the brain of the patient an organ of animal sensibility, or to reduce the size of the amatory —emasculation is the only remedy. 
When the cerebellum is narrow, and the central or amatory portion much developed in a downward direction, giving to the posterior cervical muscles a sharp and backward direction, we may feel sure that there exists a corresponding importunity in the sexual desire. The vital forces, as we have denominated them, are of two kinds—one exists in relation to the perpetuity of the race, and the other, consisting of two parts, in relation to the existence of the individual, and in onanists they are always feeble. 
A few cases, out of the many we have, will fully illumijaafce this subject. 


1066 
NERVOUS FORMS OF DISEASE. 
1. We have the skull of a boy who died in New Orleans at the age of sixteen years, of the consequences of onanism. He commenced the practice in the seventh year of his age. Toward the close of his life he had anesthesia of one side and acinesia of the other. The space between the mastoid processes was three and a half inches, and the amatory portion of the cerebellum was developed, downwardly, one and a quarter inch; his cerebrum was large, neck and chest small. In the substance of the cerebellum, on one side, was an encysted mass of pus as large as a pea, and in the other a tubercle of the same size. 
2. The skull of Kennedy (Table, page 20), presents the same peculiarities of organization, but not quite to the same extent. That he was an onanist before he married we have not a doubt, and according to his own confession, he had always entertained a strong desire for intercourse with female children, from which may be inferred an animal sensibility as feeble as it is indicated by his skull. 
Of illustrations differing in degree and modified in character, we have enough to make a small volume; but as we aim only at a lucid exposition of our subject, the two we have given are sufficient. 
The general opinion upon this subject is, that the practice, no matter how induced, occasions all the forms of disease that supervene. This is certainly an error. The boy above treated of would have become diseased if his hands had been tied behind him at the age of five years, and kept tied —the fault was in his organization, just as it is in cases of consumption. 
We are aw are that onanism is frequently introduced into schools; but we are equally aw r are that those bovs wdio are not organically constituted for onanists, will, while they may practice it at school as a matter of youthful sport, abandon it spontaneously when they quit the school; but those w T ho are impelled to it by organization are cured with great difficulty—we may add, that some of them are incurable, except by emasculation. 
There are other causes of onanism, beside an indispen- 


1067 
MASTUR PATIO. 
sable or necessary development. A slight preponderance of the amatory propensity over the other organs of the vitsl force, which otherwise would never have led to masturbation, may force the subject into the practice, in defiance of all his powers of resistence. We allude to irritation in the large intestines, more especially when chronic. Disease in this viscus can not exist long without producing irritation in the inferior extremity of the spinal cord, which will, in the event the amatory organ predominates over the others, no matter how slightly, react upon the testes, and these upon the amatory organ in the brain ; and thus the practice may remotely originate in intestinal worms or other causes of intestinal irritation. 
In some constitutions no known cause can produce phthisis pulmonalis—and so it is with reference to onanism; it can not be produced in very many men or boys who possess the strongest procreative ability, for in such persons muscular motion and animal sensibility preponderate. 
From our physiological exposition of this subject, it follows that the treatment must be physiological also, so far as regards a recovery. Therapeutics can only find a place so far as causes of local irritation may become to exist and to aggravate the symptom —which is masturbation. Onanists may be said to constitute a part of that family of constitutions which we denominate the aHioemic. If the onanic propensity with them, had been no stronger than the other elements of the vital force, they would die of passive congestion of the brain, phthisis pulmonalis, or some other form of tuberculosis. 
When the lateral portions of the cerebellum are fully developed, the expenditure of excitement, or irritation, in motion and sensation, prevents such an accumulation in the sexual portion, as to produce abnormal consequences. Hence the reason why we frequently see men with thin necks and small chests, who have ruined their constitutions, or are dying by inches of phthisis, or are afflicted with paralysis, or great feebleness of the spine, or amaurosis, from excessive venereal indulgence. On the other hand, we can 


1068 
NERVOUS FORMS OF DISEASE. 
see men every day, and in every walk of life, with broad necks, and large chests, with a highly developed cerebellum, whose venereal desires are never importunate, who enjoy the opposite sex as it was intended they should, as one of God's provisions for progeny and happiness. 
Indications.—These appear to be two-fold : the first is a prevention of the practice, by overcoming a desire for it, and the second is to restore a balance between the several parts of the cerebellum. 
The first can be effected by a*revulsion of the irritation by laborious exercise, continued so long as to allow barely time enough for repair through rest. The labor should be such, and so long continued, as to make rest, for the purpose of repair, absolutely imperious, and for the time allotted to it. This rest should be had upon a hard matress, with the head upon a pillow so hard that the patient will be compelled to lie upon his side. The food should be nutritious, but not stimulating. These means will affectually secure the first indication, and, to a considerable extent, if not entirely, the second, which must consist in a higher development of muscular motion and animal sensibility. 
The best mean we know for effecting a greater development of the chest, or, in other words, the lateral portions of the cerebellum, in children or young people, is dancing ; for this, we know of no substitute. For adults who are capable of it, public extemporaneous speaking, under the excitement of an audience is better, provided it be repeated every day, or every other day. 
But with reference to the affection under examination, it matters not what its cause may have been, derangement of the alimentary canal is certain to be associated with it; consequently, this must be strictly attended to in the whole treatment of the affection. 
The preceding course of treatment is only adapted to inveterate cases in lunatic asylums ; but it can be modified. Those parents who are able, can keep their boys at the dancing and fencing schools, and labor, during the 


1069 
LEUCORRHEA. 
intervals, and, also, from any more rest than may be indispensably demanded. They can also keep with the patient some one whose presence will prevent any manifestation of the onanic excitement. This training will not only overcome the vice, but render the patient more secure against consumption, and more efficient and useful. 
Those in whom the complaint is not so inveterate as to cause their separation from society, can manage their own case from the hints above given. Those of this class who are married, or have the monetary ability to indulge whereever they can, frequently become impotent, or die of some form of disease which the excess occasioned. The writer has had many examples of this kind. 
Species III.— Leucorrhea. 
By this term is generally understood increased or abnormal discharges from the vagina, not menstrual or bloody. It is not our purpose to consider in this work those forms of uterine disease that give rise to leucorrheal discharges, but to confine our remarks to vaginal leucorrhea. The vagina being the common conduit for conveying off all the discharges from the neck and cavity of the womb, as well as the abnormal and increased secretions from its own walls, the diagnosis between uterine and vaginal discharges is only, to be made by means of the speculum. Dr. Jewell has assumed that the discharges from the cavity of the womb are suspended at night, while the patient is in bed, and that a diagnosis may be made by introducing a sponge into the vagina, at bed-time, and removing it before rising. If it comes out dry, the discharge is from the womb. But it is to be borne in mind that the leucorrheal discharge sometimes amounts to a pint or more in a day, and it is not very philosophical to assume that half a pint, or even half a gill of secretion would be retained in the cavity of the uterus over night. The uterus does not tamely tolerate distention of its parietes. 
Our experience coincides with Bennet and other modern pathologists in ascribing to the neck of the womb the seat 


1070 
NERVOUS FORMS OF DISEASE. 
of the mischief in a large proportion of cases applying for advice, where leucorrhea is one of the symptoms complained of. Nothing but occular demonstration by means of the speculum will reveal these structural lesions. "We have over and over again satisfied ourself that the touch is not sufficiently acute and delicate to detect ulceration of the os, nor even a rope of mucus hanging like apples from the os—a condition often met with in inspecting leucorrheal cases arising from uterine irritation and lesions of the glandular structure of the neck. Still we are far from undervaluing the sense of touch as a means of diagnosis in leucorrhea. • The relaxed and flaccid walls of the vagina, the pasty, slimy feel of its mucous tissue, void of the rugae and tonicity that betoken health, the prolapsed neck of the uterus loosely pendulous near the floor of the pelvis, are unmistakable proofs of that abnormal condition of the vagina, accompanied by such a derangement of its secretory function as is met with in true vaginal leucorrhea. 
The discharge is, at first, but an increase of the natural lubricating mucus, of a watery appearance, that in chronic and inveterate cases becomes opake, creamy, and sometimes muco-purulent, and of very offensive odor. The discharge is generally increased by the debility incident to the menstrual periods. The general health greatly suffers. There is dragging pain in the back, heaviness and inertia of the body, and languor and indisposition of mind, pallor of countenance, feeble pulse, and irritable temper; the appetite fails, emaciation ensues, the feet become anasarcous, night-sweats set in, and the patient, after dragging out a miserable existence for years, finally sinks into the grave, unless remedial measures prevent. 
Causes.—The acute form of leucorrhea may be occasioned by vicissitudes of weather, taking cold, etc., anything that may accidentally throw an irritation amounting to, perhaps, a sub-acute form of inflammation upon the vaginal tissues, in which case there will be profuse discharge early, accompanied with heat and soreness of the 


1071 
DYSMENORRHEA. 
parts. This may end in the chronic form of the disease. Anything that debilitates the sexual system may bring on leucorrhea, miscarriages, child-bearing, excessive venereal commerce, or anything tending to break down the constitution. 
Treatment.—In this disease the treatment will have to vary according to circumstances; in those cases where there is only hyperemia or vascular injection of the membranes, attended with increased quantity of the discharge, but maintaining its characteristic transparency, abstinence from intercourse, rest, and vaginal injection, composed of an infusion of Alum, Hydrastin, and Tannin,*one drachm of each, water, one pint, are recommended. Of the infusion, one or two fluid ounces may be injected into the vagina, and repeated three times a day. 
If there is much inflammation, and attended with a green, purulent discharge, in addition to the above, we would advise the use of the cold hip-bath twice a day, with tonics and astringents internally, as infusion of Hydrastin or Macrotys, Carbonate of Iron, Quinine, Cornin, Tannin, Geranin, etc. In cases where cold local applications do not diminish the discharge, changing them to tepid will often effect immediate benefit. 
In those cases where the leucorrhea is dependent upon, or maintained by, a prolapsus of the uterus, this organ must be first permanently reduced to its proper position before the leucorrhea can be cured. 
Species IY.— Dysmenorrhea. 
Painful or difficult menstruation is the characteristic of this affection. Ordinarily, or in most women, the menstrual flow takes place without warning, or with only slight feelings of disturbance or discomfort,"such as a sensation of fullness in the pelvis, pain in the back, of a dragging or bearing-down character ; but in dysmenorrhea the monthly periods are often attended with so much suffering, as to be the perpetual dread of the woman's life. 
Symptoms.—The pain, in general,'comes on a few days 


1072 
NERVOUS FORMS OF DISEASE. 
before the menstrual discharge takes place, and ceases after the now is established, which is usually scanty. 
In other cases the pain continues throughout the discharge, the flow being -abundant, if not profuse, the pains like labor-pains, and gushes of coagula follow the pains. There is, not unfrequently, a formidable array of hysteric symptoms, belching of wind, gastric distress, and rumbling of the bowels. The pain is usually paroxysmal, resembling the grinding pains of the first stage of labor, or dilatation of the mouth of the womb, although in the intervals there is a constant aching, dragging pain from the back down to the thighs. ¦ Occasionally the suffering seems greater than the throes of child-birth, the woman rolling in agony over the bed and floor ; and even tetanic convulsions have been witnessed. Now and then a membranous bag, of the shape of the cavity of,the uterus, is expelled. Dr. Druman was of opinion that this membrane was always expelled in dysmenorrhea, but his opinion is not founded in fact; the writer has attended cases of extreme severity, but has never encountered this deciduous membrane. 
This severe affection may arise at any period of a woman's menstrual life. It may exist from puberty and cease on child-bearing, or it may supervene after the first pregnancy. It is often an attendant on barren women, and is supposed to be a cause of barrenness, but the exceptions are too numerous to justify the conclusion. 
The cause of dysmenorrhea appears to be an irritability of the uterus, that in some cases seems to border on a state of local inflammation. 
Treatment.—In the treatment of dysmenorrhea, the indications are to relieve suffering at the monthly period, and to make use of such means in the intervals, as will restore the uterus to its normal condition. To fulfill the first indication, the patient should use a warm foot-bath, or, if convenient, a general bath, after which fomentations should be applied upon the abdomen, over the region of the womb, as hot as can be borne, and continued until relief is afforded; and internally, the Compound Tincture of Virginia Snake- 


1073 
AMENORRHEA. 
root should be given in doses of from one to two fluid drachms, every hour or two. If the bowels are constipated, laxative agents must be given at an early period in the treatment. This course will be found beneficial in the neuralgic, congestive, or inflammatory varieties of the disease. Small doses of some nauseant, as Ipecacuanha, Lobelia, etc., may be given to maintain a degree of nausea and relaxation, which will be found to exert a favorable influence in relieving the suffering. To fulfill the second indication, the Compound Pill of Black Cohosh, may be given in doses of one or two pills, three times a day, and its use continued during the catamenial intervals, in connection with the use of the Compound Wine of Comfrey. In the severe and inveterate forms of the disease, the Compound Syrup of Stillingia with Iodide of Potassium, may be beneficially substituted for the above medicated wine. The patient should avoid all those causes favorable to the maintenance of that peculiar condition of the system assumed by the disease, as inflammatory, nervous, etc., and should use a nutritious but easily digestible diet. We would state here, that in some cases of the neuralgic form, we have derived much success from the use of Quinia and Prussiate of Iron. 
Species V.— Amenorrhea. 
When upon arriving at the age of puberty the menstrual secretion does not make its appearance in the human female, or if after having menstruated, this periodical discharge ceases to recur, amenorrhea exists. The former is called retention, and the latter suppression, of the menses. 
It is to be borne in mind that there is considerable difference as to the period or age at which the menstrual discharge makes its appearance, depending on climate, constitution, etc., and that every case of retention beyond the the usual developments of womanhood, does not necessarily constitute a pathological condition. The writer has known sundry instances of retention for three or four years after puberty, unattended by any derangement of the general health, and has witnessed this in families where the sisters, 


1074 
NERVOUS FORMS OF DISEASE. 
two, three, or four in number, though arriving at puberty at fourteen, did not menstruate until eighteen. In tropical regions menstruation usually occurs at ten or twelve years of age, while in northern latitudes it does not take place until the age of eighteen or twenty, and Linnseus asserts, that in Lapland, the women frequently menstruate only in the summer. 
Retention of tlie menses. —There is generally solicitude manifested on.the part of mothers where retention exists after the usual characteristics of puberty present themselves, and medical advice is often sought where nature would prove the best resource. The writer has often been consulted in cases where the only impediment seemed to be, if he may be allowed the expression, too high a state of health, or rather one of plethora, and where bleeding and purgatives would doubtless have been resorted to by many practitioners, but in which he has had the satisfaction to see all come right by the " let alone" practice, or simply interdicting animal food. 
When, however, at puberty, there is marked derangement of the general health, together with retention, the case calls for treatment. In these cases there is evidently a want of the vital forces ; the girl has been growing rapidly; is generally thin and delicate-looking; the face and hps pale; the hands and feet cold ; there is languor, lassitude, and listlessness in her look ; a little effort fatigues ; the pulse shows a feebleness in the circulation; the appetite is capricious ; the mind becomes irritable ; the bowels, costive ; the tongue, foul and imprinted with the teeth; the breath, fetid; foul eructations, and such a craving of chalk, slate-pencils, and even dirt, that they are greedily devoured when obtained ; depression of spirits and hysterical weeping occur, or decided melancholy sets in ; the feet, edematous at night and the face puffy in the morning; there are palpitation and dyspnoea on the slightest exertion, and not unfrequently a troublesome cough supervenes, and the girl is said to be going into a decline. This is the "green sickness" or chlorotic condition of female youth ; the result of a cefec- 


AMENORRHEA. 
1075 
tive organization, or original stamina; unhealthy childhood; confinement in manufactories or at school, and other depressing causes. Of course, every case is not as distinctly marked as the features here drawn, but are generally so well defined that there is no difficulty in drawing a line between retention from a want of the vital forces, and retention from plethora, where the vital forces seem to be above the secreting point. 
Suppression of the menses. —Suppression of the menses may occur at any period of a woman's life after she has menstruated, and is either acute or chronic. The acute form generally ensues from some cause acting on the system just before or during the monthly flow, as fever, exposure to wet and cold, dancing, and night air, improper food and mental agitation. Hysteria often follows acute suppression, and mania and catalepsy have been known to result. 
Chronic suppression either follows the acute form, or is a consequence of impairment of the general health. Women generally count the suppression as the cause, but it is obviously the effect, generally speaking, for we see it gradually interrupted, or become less and less in quantity, until total suppression ensues. In all cases of chronic suppression not traceable to an impaired state of the general health, the possibility of pregnancy should not be lost sight of. 
Treatment. —In amenorrhea, the treatment will vary according to the condition of the patient, that is, whether she be plethoric or debilitated. In the former condition, a depletive treatment will be required, as purgatives, diuretics, and diaphoretics, and which should be continued both during the catamenial effort and the intervals. After proper depletion by these means, the patient should be placed upon the use of Macrotin, Caulophyllin, Senecin, etc., for the purpose of acting more especially upon the reproductive organs, and imparting to them tone and energy, and which course should be persevered in until the uterus has recovered its proper condition. But after a proper time has elapsed, if no beneficial change is effected, it may then be- 
GS 


1076 
NERVOUS FORMS OF DISEASE. 
come necessary to employ some of the more active emmenagogue or forcing remedies. 
With debilitated patients, a different course must be pursued. Tonics and stimulants will here be required, and Quinia and Iron, some one of the various preparations of Iron, the Compound Wine of Comfrey, etc., may be used in connection with the agents above named, to especially influence the generative organs ; and should these fail, it will then become necessary, as in the previous instance, to resort to the active emmenagogues. In this latter case, the diet should be nutritious and generous, while, in the former, it should be light, and of easily-digested articles. 


INDEX. 
A Adhesion of the labia pudendi,. 531 Alterations of color in the skin, 422 Amativeness, organ of, 20 Amenorrhea, 1073 treatment, 1075 Amentia, . .1050 Anasarca, 954 treatment, 956 Anal worms, 601 Aneurism of the aorta, 922 anatomical varieties,... 923 symptoms and diagnosis, 924 prognosis, treatment,... 925 Angina pectoris, 925 symptoms, causes, and treatment, 926 " simplex, 552 causes, 553 treatment, 554 " inembranacea, 555 causes and treatment, 556 " tonsillaris, 557 causes, ib treatment, 558 Animal sensibility, organ of,... 22 Aorta, aneurism of, 922 Apoplexy of the brain, 255 lungs, 389 Appendix to Book I, 192 II 199 Anthritis, 850 " acute, 852 causes, 855 treatment, 856 " chronic, 857 causes, 859 ,diagnos. and treatment, 860 Ascaris lumbricoides, 600 " vermicularis, 602 Ascitis, 948 causes, 949 diagnosis and prognosis, 950 treatment, 951 Asiatic cholera, 985 Asphyxia, 918 phenomena, 919 causes of death, 921 treatment, ib 
A Asthma, 916 prognosis and treatment, 917 B Beetle grubs, 602 Bilious temperament, 49 " lymphatic do, 66 " encephalic do, . 67 " encephalo-lymphatic do, 73 " fever 679 " remittent fever, ib Bloody flux,.... 792 Blue disease of infancy, 410 Book I, 15 " II, 85 " III, 200 " IV,.... 611 Bots, 602 Brain, congestion of, acute, 256 " " passive,.. . 261 " dropsy of, 266 " inflammation of, 245-726 complicated, 250 " hypertrophy of, 272 " debility of, 285 Broad tape-worm, 601 Bronchitis, acute, 361 cau. and diag., 362 prog, and treat., 363 " chronic, 364 cau., treat.,. 365 Bulam fever, 697 BulUe, 436 C Camp fever, 655 Catalepsy, ...1026 causes and diagnosis,. 1027 treatment, 1028 Calculous disease, 973 Catarrh, 337 Catarrhal croup, 358 " ophthalmia, 865 " diarrhea, 590 Cholera infantum, 573 causes, 575 treatment, 578 " spasmodic, 985 causes, 991 pathology,... 994 treatment,... 998 


1078 
INDEX 
C Cholera asphyxia, 985 Cerebellum, opinions concerning 17 " physiological inferences from, 23 " pathological relation of the 25 " table of measurements of, 30 Cerebritis, 245-726 causes, 247-728 diag. and prog.,..ib ib treatment, ib 729 Chicken-pox, 461 Child's necessities,inattention to, 136 Child, mental injury of, 138 " vital do ib " washing of, 149 " dress of 152 " physical training of,.... 172 " mental do .... 175 Chlorosis, 944 nature and treatment,. ib Chorea, 294 causes and treatment,... 297 " sancti viti 294 Circulation, independent estabmentof, 403 Cold, 337 " in the head, 339 " " chest, 344 Colic, 5S5 Colica pictonum, symptoms,.... 956 treatment,.. .. 957 Colorectitis, 792 causes, 797 prognosis and treat., 799 Common continued synochus,... 640 Congestive fever, 690 causes and nature, 694 treatment, 695 Conjunctivitis, 865 Consumption, infantile, 375 adult, 747 Convulsions, puerperal, 1016 " infantile, 313 Coryza, 339 treatment, 342 Costiveness, 606 Cough, nervous, 395 treatment, 397 " hooping, 398 treatment 401 Cow-pox, 464 Croup, 349 Crowing disease, 390 Crusta lactae, 473 Cyanosis 410 Cyanopathy, ib Cynanche parotidtea, 769 
c Cystitis, acute, 828 causes and treat., 830 " chronic, ib caus., diag., and treatment,... ib D Death of the mouth, 558 Debility of the brain 285 Defensive faculties, training of,. 141 Delirium tremens 959 divided into two varieties, acute and chron., 962 causes, 965 pathology, 966 diagnosis, 970 prognosis 971 treatment, 972 Dementia, 1049 Dentition, irritations of, 561 Derma, remarks on, 414 " disease of, 422 " alterations of color in,... ib " excrescences on, ib Diabetes mellitus, 930 symptoms, and nature, .... 931 prognosis, 932 treatment,.... 933 " insipidus, ib simple and complicated forms, 934 treatment, ib Diarrhea, feculent, 587 causes and treat.,... 588 bilious, 589 causes, ib treatment, 590 " mucous or catarrhal,, ib causes, 591 " chylous, ib causes, 592 " lienteric, ib causes, 594 " chronic ; ib causes, 596 treatment, 597 Dilation of the ventricles, 000 Discharges from infant vagina,.. 532 Disease, never hereditary, 216 " classification of, 240 " infectious of nurses,... 135 of the cellular tissue, introduction to, 519 Dress of the child 152 Dropsy of the brain, 266 chest, 952 " " abdomen, 948 " " cellular tissue,... 954 " scrotum, 533 


INDEX 
1079 
D Dysentery .... i 792 Dysmenorrhea, 1071 symptoms, ib treatment, 1072 Dyspepsia, 580 E Ecthyma 471 causes, ib diagnosis, progno., and treatment, 472 Eczema, 876 " impetiginodes, 877 causes, 878 diagnosis and treatment, 879 Egyptian ophthalmia, 868 Encephalitis, infantile, 245 adult, 726 causes,. ... 249-728 diag., prog.,..ib— ib treatment ib-729 Encephalic temperament, 62 Encephalo-bilious do, 67 Encephalo-lymphatic do, 69 Enteritis, 786 " acute, 787 causes and diagnosis, 789 prognosis and treatment, 790 " chronic, 791 causes and treatment, 792 Enteritic fever, 640 Entero mesenteric fever, ib Enuresis, 937 treatment, 938 Epidemic cholera, 985 causes and prognosis 991 pathology, 994 prophylaxis, 997 treatment, 998 Epilepsy, 288 causes and diagnosis,, ib prognosis and treatm't, 290 Epistaxis, 898 causes 899 diag. and treatment,.. 900 Erratic worms, 602 Erysipelas, 438 causes, diagnosis and prognosis 440 treatment, 441 Erythema, 486 causes, diagno., prog., and treatment, 487 Exanthema, 483 Excrescences on the skin, 422 Exoneirosis 483-1062 treatment, ib 
F Faculties, vital, training of,.... 138 " defensive, do .... 141 " moral, do .... 142 " social, do .... 144 " intellectual, do .... 147 False croup, 358 Favus 478 Fetal openings, how obliterated, 407 Fever, what is it? 203-616 " phenomena of, 625 " continued, 634 " simple inflammatory,.... 635 " periodic, 664 " intermittent, ib " congestive, 670 " gastric, ib " malignant,. 671 " bilious, 679 " do remittent, ib " infantile remittent, 706 " petecchial, 655 " putrid, ib " scarlet, 493 " spotted, 655 " synochus, 640 " typhoid, 711 " typhous, ib " yellow, 697 " and ague, 664 Fits, infantile, 313 " puerperal, 313 Flour albus, 1071 Fluke worm, 601 Foster-mother, necessity of when, 131 Frightful dreams, 303 Functional forms of disease,.... 915 G Gangrene of infants, 521 Gastric indigestion, 580 fever, 670 Gastritis, 770 " acute, 775 causes and diagnosis, 776 prog, and treatment,. 777 " chronic, 778 causes, diagno., and treatment, 781 Glottis, infantile spasm of,.... 390 Gonorrheal ophthalmia, 871 Gout, 850 Gravel, •. 973 H Heart, inflammation of its envelopes, 412 Helminthia alva, 600 " podicis, 601 " erratica, 602 


INDEX. 
1080 
H Hematemesis, 903 causes and prog.,, ib treatment, 904 Hematuria, ib causes and diagnosis, 905 prog, and treatment,. 906 Hemorrhage from nose, 898 " " stomach, 903 " " lungs, 906 " " urinary organs, 904 " womb, 911 Hemorrhoids,.... 927 treatment, 928 Hemoptysis, 906 causes, 908 prog, and treat.,.... 909 Hepatitis, 811 " acute, ib cau., diag., and prog. 814 treatment, 815 " chronic, ib causes, 817 diag., prog., treat., . 878 Herpes, 428 " zoster, 429 " circinatus, 430 " praeputialis, 431 causes, , . ib diag., prog., treat.,... 432 Hives, 464 Hooping-cough, 398 Humid tetter, or scall, 876 Hydrocele, 533 diagnosis, ib treatment, 534 Hydrocephalus, acute, 250 causes, 253 diagnosis,.... 254 prognosis and treatment,. 255 " chronic, 266 causes, 270 diagno., prog, and treat.,. 271 Hydrops, 945 symptoms, ib causes, 946 prognosis and treatment, 947 Hydrothorax, 952 symptoms, 953 diagno., prog., and treatment, 954 Hydrophobia, 1019 treatment 1021 Hypertrophy of the brain,..... 272 Hysteria, 1028 symptoms, ib diagnosis and causes,. .1030 treatment, 1031 
H Hysteritis, 832 " acute, 833 treatment, 834 " chronic, 835 causes and treat.,... 837 I Ichthyosis, 517 Idiotism, 000 causes, 874 treatment, 875 Imperfect cicatrization of the umbilicus, 411 Impetigo larvalis, 474 causes, 474 diag., prog., and treatment,.... 476 Incontinence of urine, 937 Induration of the cellular tissue, introduction to, 519 Infantile mortality, cause of,.... 179 " " necessity and utility of,.. 185 " tetanus, 305 " fits, 313 " remote causes, 319 " exciting causes,.... 320 " prognosis, 321 " treatment, 322 " remittent fever, 706 " " acute,, ib " " slow, . 707 low,.. 708 Inflammation, what is it?.., .203-616 " of the brain, inf't 245 " adult 726 " " complica.,. 250 " " bronchia,.. 361 " " larynx,.... 344 " lungs, inf't 366 adl't 737 " " pleura, 371 " " heart's envelope,. .. 412 " " tunics of the cord, 326 " " stomach, .. 774 " parot.gld's, 769 " " kidneys,... 825 " uri. bladder 828 " " duodenum,. 785 " " large intestines, 792 " small do,.. 786 " " peritoneum, 571 " mouth, 538 " " ears, 528 " " eyes, 873 " " fauces, .... 552 " , " tonsils,.... 557 


INDEX, 
1081 
I Inflammation of the womb, 832 " " liver, 811 " " spleen, 819 " " veins, 881 Inflammatory forms of disease,. 726 general remarks on, ib Influence of maternal conditions, introduction to, 105 Intellect, development of, 147 Intestinal indigestion, 584 " worms, ... 599 Introduction to disease of the digestive system, 535 Invermination, 599 causes, 603 treatment, 604 Irritations of dentition, 561 Iritis, 873 Ischuria renalis, 935 symptoms, ib treatment, 936 J Jail fever, 655 L Laryngitis, mucous, 344 " sub-mucous, 345 diagnosis and treatment, 348 " pseudo-membranous 349 causes, 354 diag., prog., and treat.,. 355 " spasmodic, 358 predis. causes, 359 exciting do.. 360 diag. and prog, ib treatment,.... 361 Leucorrhea, 1069 causes, 1070 treatment, 1071 Lichen, 508 " simplex, ib " agrius, 509 " urticatus, 510 diagnosis, prog., ind. and treat., 511 Lithiasis, 973 symptoms and causes,. 975 treatment, 977 Long round worms, 600 Long thread do ib Lymphatic temperament, 52 Liver, inflammation of, 811 Lungs, do do 366, 737 Larynx, 344 M Madness, 1034 Malignant intermittent fever,... 671 
M Mania, 1034 causes, 1041 nature of, 1045 treatment, , 1055 Mania a potu, 959 Marriage, eligibility of, 87 improper, when, 95 Masturbation, 1063 indications of, 1068 Maternal conditions,introduc. to, 105 " impressions, influence of, on child, 106 duties to child, 127 Maw-worm, 602 Measles,.... 488 Menorrhagia, 911 causes, 913 diagnosis, 912 treatment, 913 Menses, retention of, 1074 suppression of, 1075 Menstruation, painful, 1071 Mental derangement, 1034 Mental training of children,.... 175 Miliaria, 880 Miliary eruption,. ib " vesicles, ib Milk, poison in, 134 Monomania, 1051 treatment, 1055 Moral faculties, training of, 142 Morbid actions from vascular irritation, 894 " of inter-relation, 915 Mortality, infantile causes of,... 179 " necessity and utility of 185 Mother, influence on, of childbearing, 119 " " of, on children,... 106 " foster, necessity of, when, 131 Mother's mark, 423 Mucous laryngitis, 344 Mumps, 769 Muscular motion, organ of, 21 N Nsevi materni, 423 Nephritis, 825 causes and diagnosis, 826 prognosis and treat.,.. 827 Nervous cough, 395 Neuralgia, 1031 treatment, 1033 Nettle-rash, 485 Night terrors, 303 Nocturnal pollution, 1062 Non-febrile forms of disease,.. 893 Nourishment, improper, 132 Nursery, introduction to, 164 " location and constr'n of, 165 


1082 
INDEX 
N Nursery, temperature of, 170 " physical training in,.. 173 " mental do ... , 175 Nurses, infectious disease of,... 135 Necrosis infantilis, 558 O Onanism, . 1063 Organic, action, principle of, .211,616 Ophthalmia, 865 " catarrhal, ib causes,.... 866 diagnosis, . 865 progn's and treat.,., ib purulent, 524,868 " rheumatic, 873 " scrofulous, 526 Oedema, 520 Otitis 528 Old man's itch, 512 CEstrus, 602 P Palsy, 298 Painter's colic, 956 Paralysis, ib Parental constitution, 92 " resemblance to, how told 80 " conditions, introduc. to, 85 Parents, present health of, 101 Parotitis, 772 causes and treatment,.. 773 Papula?, 503 Passive congestion of the brain,. 261 interesting case of,... 263 Pathological considerations,. 203, 615 Pathology, what, 208 Pemphygus, 436 causes, diag., prog, and treatment,... 437 Pericarditis, 412, 860 " acute 861 cau., diag., prog, and treatment, 862 " chronic, 864 causes and diag.,. ib prog, and treat.,.. 865 Periodic fever, 664 Peripneumony, 737 Petecchise. 426 treatment, 427 Petecchial fever, 655 Peritonitis, 571 diagnosis and prognos., 572 treatment, 573 Phlegmasia dolens, 881 Pityriasis,. 514 cruses, diag., prog, and treatment, 515 Phlebitis, 881 
P Piles, 927 cases of, 866 causes, 891 treatment, 892 Physical training of child, 106 Physiology, what, 21)8 Phthisis pulmonahs, 375, 747 symptoms 753 physical signs, 754 " acute, 758 " " chronic, 759 " " febrile, 761 " " latent, 762 nat. and cau. 379,766 diagnosis, 767 prognosis, 768 treatment,. .364, 769 Pleurisy, infantile, 371 Pleuritis do ib chronic 373 treatment,. 374 adult, 729 acute, 730 cau. and prog., 732 treatment, 733 " " chronic, 734 diag., prog, and treatment,... 736 Pneumonia, 366, 737 Pneumonitis, ib Poison, what is it? note, 204 Pollution, nocturnal, 1063 Porrigo, 478 " lupinosa, 479 treatment,.... 480 " scutulata, 481 causes, ib diag., pro. and treatment,.. 482 Preface to Book IV, 611 " by the authors, iii " by Prof . Powell, vi " by Prof. Newton, viii Prurigo, 512 Pruritus, ib Pseudo-membranous laryngitis,. 349 Psora, 433 Psychological influence of mother on fetus, 106 Puerperal convulsions, 1016 causes,.. .1017 treatrnent,10l8 Pulmonitis, 366, 737 causes, 741 diagnosis, 742 prognosis, 743 treatment, 369, ib Purulent ophthalmia, 868, 524 causes, 870,525 prog, treat.,...872, 526 


INDEX, 
1083 
F Putrid fever, 655 Pyrexia sthenica, 635 causes, 637 diag. and prog., 639 treatment, 662 Q Quinsy, 557 R Ramollissementdu Cerveau,.... 726 Red gum, 504 Remittent fever, 679 causes, 687 diag., prog, and treatment,....'. 688 Remitting yellow fever, 697 Respiration, imperfect, or absent, 386 Respiratory function in infants, remarks on, 333 Ring-worm, 430 Rheumatic ophthalmia, 873 Rheumatism, 838 " acute, 839 cau. and diag. 842 prog, and trea. 843 " chronic 845 cau., diag. and prog. 848 treatment,. 849 Roseola, 483 causes, diag., prog, and treatment, 484 Rose-rash, 483 Rubeola, 488 causes and diagnosis,.. 489 prognosis and treatment 490 Rupia, 442 causes, diagnosis, prognosis, indicat'n and treat., 443 S Sanguine temperament, 44 " bilious temperament,. 49 " lymphatic do 64 " encephalic do 65 " bilious lymphatic do. 69 " encephalo-bilious do. 70 " encephalo-lymphatic, 72 " bilious encephalo-lymphatic temperament.. 74 Scabies, 433 causes and diagnosis,... 434 treatment, 435 Scald-head, 479 Scalp, tumor of, 426 Scarabacus 602 Scarlatina, 493 " simplex, 495 " angincsa, 496 
S Scarlatina maligna, 497 causes, diag. and prog., 499 treatment,... 500 Scarlet fever, 493 Scorbutus, 940 symptoms, 941 causes, 942 diag., prog, and treat.,. 943 Scrofula, 978 causes and prognosis,.. 981 treatment 982 Scrofulous ophthalmia, 526 treatment,. 527 Scurvy, 940 Shingles, 429 Skin, remarks on, 414 " absence of, 425 " change of color in, 422 " excrescences on, ib Small-pox, 444 " spurious 459 Social faculties, training of,.... 144 Softening of the brain, 726 Spasmodic laryngitis, 445 Spinal meningitis, 326 post-mortem appearances of, 328 treatment, 329 Splenitis...... 819 " acute, 820 causes, diag. and prognosis,.... 821 treatment, 822 " chronic ib causes, 824 treatment,.... 825 Spotted fever, 655 Squamae 514 Stomatitis, 538 11 erythematic ib causes, treat. 539 " with altered secretion, 540 causes,.. 541 treatment 542 " follicular, v 543 " vesicular, .* 545 cau. and trea. 546 " mercurial, 549 treatment,... 551 " gangrenous, 558 cau. andtre. 560 Strofulus, 504 " intertinctus, ib " confertus, ib " volaticus, 505 " albidus 506 " candidus ib causes, i a diag pro., Ire., 5i)7 


INDEX 
1084 
s St. Vitus' dance, 394 Sub-mucous laryngitis, 345 Sudamina, 880 Suppression of urine, 935 Swine-pox, 463 Symptomatology, 233 Synochus fever, 640 causes, 649 nature and diag., 650 J3rog.,ind. andtre. 651 era, 985 T Table of contents ix Temperament, prevailing opinions on, 33 " elementary,.... 41 " binary comb, of 62 " ternaiy do 69 " quarternary do 74 " concluding remarks on,.... 75 Temperature of the nursery,.... 170 Tetanus, adult, 1011 causes anddiag.,1013 nature and prog.,1014 treatment, 1015 " infantile 305 Thread-worm 602 Tic douloureux 1031 Tinea capitis, 479 " anularis, 401 Tooth-rash, 504 Trismus nascentium, 305 cau. and tre. 306 Tubercular phthisis, 375 747 Typhoid fever, 640 " mitior, ib Typhus gravior, 655 Typhous fever, ib symptoms, 657 causes, 659 diag., and prog., 660 ind. and treat.,.. 661 
U Urticaria, 485 cau., diag., pro. and tre. ib Urine, suppression of, 935 incontinence of, 937 Uterus, inflammation of, 832 •V Vaccination, 466 " what does it imply? 468 " tests of, ! ib Vaccine protection, re-establishment of, 469 Varicella, vesicula, 461 •« lenticular, 462 " conoidal, 463 " globate, ib Variola, 444 " complications of, 450 " anatomy of the pock,.... 451 cau. and diag., 452 treatment,.... 453 " vaccina, 464 causes, 465 " " inoculated 466 Varioloid 459 causes 460 diag., prog, and treat., 461 Vital forces, training of, 138 " power, source of, 242 W Washing the child, 149 Weaning-brash, 594 Worms, intestinal, 599 Y Z Yellow fever, 697 causes, 701 diagnosis, 704 prognosis, ib indicat. and treat., 705 Zona 429 Zoster ib