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MANU
PATH
OLOGY Md'
J^afwi^
BKING THE
OUTLINE OF THE COURSE OF LECTURES DELIVERED
     S. HENRY DICKSON, M.D.,

PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE IN THE MEDICAL
      COLLEGE OF THE STATE OF SOUTH CAROLINA.
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    CHARLESTON:
PUBLISHED BY THE AUTHOR.
1842. 
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	«-v •	4 -; Q % D554>" IS 39
  Entered, according to Act of Congress, in the year 1839,
                by S. Henry Dickson,
in the Clerk's office of the District Court of South Carolina.
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      NEW  HAVEN:
PRINTED BY'B.  L. HAMLEN.
*T 
4
PATHOLOGY.
  The  science of Pathology of necessity presupposes  and is
founded upon an acquaintance with the doctrines of Physiology.
\s Physiology is the history of the  several organs of the animal
^  V and their functions, in a natural and healthy state;  so
  Pathology consists  in a knowledge of the morbid  conditions
of the organs and their functions.
  Disease has been variously defined; it always implies some
irregularity or aberration in the performance of one or more of the
functions of the body.
  This irregularity of action may be owing to obvious alterations
in the structure of some parts of the body, or it may occur with-
out our being able to detect any change in the structure of any
part.  Hence the distinction of diseases into Functional and Or-
ganic—and hence the importance  of a  close  inspection of the
condition of the parts of bodies dead from disease—a description
of which  constitutes the useful and interesting department of
morbid anatomy.
  Disease may be local or general.   It is local when the cause
producing it acts with special force upon some single part or organ,
while yet no participation in the morbid consequences is extend-
ed to other parts.   It is general when the primary local affection
has been  communicated  or  extended throughout  the  system.
Each of these  may  produce  the other.  It is plausibly argued
that all diseases are  primarily local, and afterwards  radiated or
rendered universal by nervous sympathies, and  by vitiation of
the fluids of the body.  General disease  may also produce local
affections,  as in hepatic and splenic inflammation from  the con-
cussions of fever, and in gout and scrofula.
  Causes of disease divided in the books into Remote and Prox-
imate.  I prefer to use the terms Efficient and Constituent.
  The  proximate cause  has been  absurdly enough regarded as
the disease itself.  I would denote it as being  the first essential 
4
link in the chain of morbid actions, whose results become obvious
in the symptoms of disease.  This is the constituent  condition,
upon which  depend all the circumstances which give  diseases
their characteristic and peculiar form.   The consideration of prox-
imate cause—a very complicated and obscure subject—is better
deferred, therefore, until we enter upon the consideration of mala-
dies separately.
   Remote  causes—the agents efficient in the production of dis-
ease—distinguished into the Predisposing and Exciting—terms
happily chosen as suggesting clearly enough their own meaning.
As to the specific energy of these modes of causation, I infer that
disease in the abstract  may be attributed to the disturbing influ-
ence of exciting causes,  while the mode and seat of the disease
generated will be determined by the existing predisposition upon
which the  former has acted.   Yet we cannot always draw a line
clearly between  them.  Predisposition may be so strong as  to
develope disease without the need of application of any transient
excitement—as in gout,  scrofula, &c.—and on the other hand,
an  exciting  or occasional cause shall have power  to produce
immediate  predisposition, or rather perhaps of itself to determine
the nature  of subsequent and consequent disease, as in  small pox
and other contagions.
   Brown,  Broussais, Parry, and other pathologists have taught
that the effect of all such causes is only  an increase or enhance-
ment of  the natural actions—in  other  words, that morbid differs
from healthy action merely in  intensity  or degree.   This is an
important and mischievous error.  That morbid causes occasion
difference in  nature or kind of action,  as well as in degree, I in-
fer from  the changes which take place in the secretions of disor-
dered surfaces,  which are  altered in properties, obvious  and
chemical;  and from the newness  and peculiarities of diseased
structures which are built up, as in fungus nematodes, cancer, &c.
   Predisposing  causes may be internal  or external, original  or
accidental.   Individual peculiarities of structure give predisposi-
tions, as  we see in congenital shortness of neck, which tends  to
occasion  apoplexy—narrowness of thorax, inviting respiratory dis-
order, &c.  Minuter peculiarities which  we  cannot see,  we de-
duce from the results as observed. 
5
  Predispositions, evinced by known tokens, constitute Tempera-
ments.   The consideration of these  belongs properly to Pathol-
ogy, though treated of usually among the subjects of Physiology.
Perfect health is incompatible  with  the exquisite or  notable de-
velopment of any temperament.
  Sex, Age, Color—each  exhibit well marked and  notable pre-
dispositions.
  All the individual predispositions, whether internal or external,
may be transmitted hereditarily.  Of this the examples are inde-
finitely numerous.   Idiosyncrasies are either the result of internal
peculiarity of conformation, or of sympathetic association; and
thus present instances of both original and accidental predispo-
sitions.
  Numerous farther examples of acquired or accidental predispo-
sitions may be adduced  in recurrent or paroxysmal diseases, such
as hysteria, mania, intermittent fever, &c which become habit-
ual,  as the phrase is; that is, which generate a predisposition of
irresistible strength.   It is possible also that this is often done by
effecting some minute changes of structure  in the  parts chiefly
affected,  as in rheumatism, &c.
  Among  external  sources of predisposition we  enumerate  cli-
mate, topographical peculiarities of surface, of country and soil,
6f'c.; hence national temperaments:  state of society—many dis-
eases are the product of civilization and refinement, and so abso-
lutely  artificial:  conditions of life and occupations, quantity and
quality of food.
  Exciting causes.—Among these we  instance  alternations,
changes of any kind.   Change of climate, a very familiar cause
in the  present day of emigration.   Vegetables and the lower ani-
mals are thus affected as well as man.  The evils thus occasioned
may be lessened by certain precautions, but all emigrants to dis-
tant or contrasted climates must expect to suffer more or less be-
fore they can attain a complete assimilation or adaptation to their
new circumstances.
  Heat produces apoplexy, phrenitis, inflammatory fever, hemor-
rhage.   It affects the internal viscera by  increasing the force
and  frequency of the circulation,  and by their sympathy with
the  skin, whose exhalation it increases largely; thus it gives rise
to hepatic, gastric, and intestinal derangements. 
6
  Cold causes pernio and other external inflammations, and by
constricting the surface, and  interfering thus with the  perspira-
tory function,  gives  rise to a host of diseases of undue  determi-
nation—pleurisy, enteritis, catarrh, &c.
  Alternations of temperature are proverbially injurious.   Heat
applied after  cold is perhaps the most dangerous  of  the two
changes.
  Food of improper quality, or improper quantity.  Scurvy arises
from salted meats, probably from all restricted and exclusive diet
long persevered  in under circumstances of physical  and  moral
depression; dyspepsia from  undue use of acids  and  seasoning;
colics,  &c. from  meals too large for the stomach.
  Intemperance in drinking.—Vinous and alcoholic fluids  are
dangerous in proportion to their intoxicating power.  Their im-
mediate  impression is made upon the stomach and  brain, but
acting  upon predisposition, they may occasion an infinite variety
of maladies.
  Dress, manners,  customs,  amusements, fyc, if not properly
regulated,  all  become in their turn exciting causes of disease.
The female stay or corset has been animadverted on much more
than it deserves.  Properly arranged,  it gives support as well as
adds neatness and  beauty to the form.  It may be so tightly
drawn as to interfere with locomotion and respiration, and to op-
press  the abdominal  viscera; the steel  piece  may also be  too
broad,  and thus  injure the breasts.
   Occupations are among exciting causes.  Millers, stone-cutters,
needle-grinders,  cotton-ginners, are subject to bronchial and pul-
monary inflammation from the mechanical  irritation of particles
inspired.  Painters, gilders, &c. are injured by the fumes of the
metals they employ.   Manufacturers in  general suffer both from
confinement  and from monotony of life, with utter hopelessness
of change or improvement of condition.
   The passions must be enumerated here.  I regard  them as all
stimulating in their immediate influence, and as directed prima-
rily to the sensorial organs.
   Anger, grief  and  joy, produce apoplexy, hemorrhage, phreni-
tis, hysteria, &c.
   Love—a dangerous passion even  if successful; when other-
wise, often gives rise to insanity. 
7
  Fear increases the velocity of the circulation, and  often adds
greatly to the force of muscular action ;  has been known in a few
hours to give the hair a silvery whiteness, and the whole frame
the aspect of sudden and premature old age.
  Poisons, divided into the mineral, animal and vegetable, to
which I would add a fourth, the gaseous or aerial,  as the sources
of some of them are not well known, while their form  is obvious.
   1. The vegetable poisons.—Some act  by inhalation, as the
upas and mancinella;  others by contact with the  skin, the Cer-
bera ahovai, mannarilla, cashew nut,  Rhus radicans  and Rhus
vernix,  mustard, &c.—these  irritate  and inflame ; others  still
upon the stomach and intestinal tube—these are our emetics and
cathartics; and others on the nervous system—these are the nar-
cotics, which relax, intoxicate, and produce stupor, coma and con-
vulsions ; lastly, others  require to  be introduced into the circula-
tion, as the woorara and ticunas.
   2. The animal poisons are reserved for future consideration in
another connection.
   3. The mineral poisons are multiplied in number by chemical
processes.  The metals are in their proper state harmless, but the
salts of many of them are poisonous, as of mercury, lead, arsenic
in  a high degree of intensity, copper, antimony.    The  pure
alkalies and the acids are irritating and corrosive.
   4. The aerial poisons.—Some of these are of known chemical
origin and qualities, as the several irrespirable gases; others are
in both these  respects obscure and undetected, as  epidemic'con-
taminations and malaria.   Of the first  class, the most common is
 the carbonic acid gas,  and the other combinations of  carbon and
 oxygen so often met with in mines, wells, vaults, &c.—these pro-
 duce asphyxia.   The precaution should be taken of sending into
 suspected places a lighted candle ;  if  this cease to burn, quick-
 lime should  be thrown in, in sufficient quantity to absorb, while
 slacking, the superabundant carbonic acid gas.  Charcoal burned
 in ill-ventilated apartments consumes  the oxygen,  and combines
 with it so rapidly as frequently to have thus occasioned loss of
 lives.   Air which has been breathed becomes soon unfit for respi-
 ration.  A terrible instance of the effects of confinement in  a
 close apartment, is recorded in history as having occurred in Cal- 
8
cutta upon its surrender  to the Suba of Bengal in 1756.  One
hundred and forty six of the English garrison were confined in a
narrow dungeon during a hot,  airless, and miserable night—one
hundred and twenty three perished before morning.
  Malaria.—This  term preferred in compliance  with modern
usage to the word  miasm, which has both etymologically and
in the writings of many physicians, an  extension so  wide as to
include  all aerial contamination, whether chemical, contagious or
epidemic.
  Malaria—defined as a peculiar distemperature  of the air of
certain regions,  derived from sources  to be  considered in order,
traceable only  by its effects, and as yet undetected by any chem-
ical  or  mechanical  investigations.  Its  nature is unknown—its
very existence has  been made matter of dispute—all the influ-
ences ascribed to it have  been attributed to  the  mere agency of
moisture, or  of moisture associated with heat; an error evidently
owing to the concomitance of these  exciting causes, and their
tendency to  promote its efficiency.
  The principal source of malaria is believed to  be the  decom-
position of vegetable  matter.  The  growth  and production of
vegetables, as well as their subsequent decay, are fostered by the
presence of moisture and the action of high temperatures.  Efflu-
via, thus disengaged,  produce all the forms of fever, and many
other diseases so well known as being thus generated, that  their
occurrence is regarded as proving the  presence of malaria,  an
agent capable of being every where identified by  these its effects.
Local and limited sources are, in this way, capable of originating
much evil;  thus, in a confined cellar or the hold of a ship, de-
caying vegetables create fever.  Hence,  malaria  fevers appear in
summer and autumn, and are  intense  in proportion  to the  tem-
perature of the country affected.  In  hot countries  we have the
plague,  yellow fever,  bilious remittent,  &c.—in colder  regions,
intermittents of chronic character, hepatitis, jaundice, &c.   Cold
when sufficiently intense, puts a check on the influences of malaria.
Heat promotes the  action of malaria, by generating a predispo-
sition in the system favorable to it. and by stimulating and after-
wards relaxing the  vessels of the skin and liver.  Moisture is
not only necessary to its  production,  but likewise becomes the 
9
medium  in  combination with which this poison acts upon the
body—a combination it would seem, of essential necessity to give
it effect.   Hence the known insalubrity of fogs and dews in ma-
larious regions; and hence the advantage of elevation from the
exhaling, soil.
  A certain degree of concentration, and a  certain amount of
dose, are necessary also to the efficiency of  malaria.  It is in
this property chiefly that a virus, technically so  called,  differs
from a poison ; the former being independent of both these cir-
cumstances : thus  the smallest  particle of variolous or vaccine
matter can infect the whole body.  It may indeed  be ^diluted to
inefficiency, but if it infect at  all, the degree or force of its action
has no reference to the amount or concentration.  The action of
a poison  however is always modified by the dose.
  Calms are favorable to the concentration of malaria;  winds
 and storms waft it  away, disperse and dilute it.
  Malaria  probably  acts upon  the skin  primarily.  Thus  we
account  for the insusceptibility of the  negro race, who perhaps
differ from the white more in this point  than in any other.   It
also acts more readily during sleep, when the  functions of  the
skin go  on with  energy.
   Any thing  which depresses the vital  power, may be said to
 assist its invasion—fatigue, want of food,  of rest, of clothing, &c.
   Habit diminishes in the white man rather the violence of its
 effects,  than  the susceptibility to its action.   Many residents in
 low countries have regularly annual attacks—these are  of no
 great severity, but  infallibly undermine the constitution.  A stran-
 ger is  attacked violently.   Latent period  doubtful—differs prob-
 ably in  proportion to  intensity  of cause  applied,  which  may at
 once  excite,  or may only generate  predisposition.  Trees are
 found to oppose an efficacious barrier to the invasion of malaria.
 I am uncertain whether this is owing to the  mechanical impedi-
 ment  which  they  offer to its  passage,  or  whether  it is better ac-
 counted for by the supposition of the existence of some attractive
 force, which causes the miasma to adhere to  ttteir foliage, or by
 the suggested evolution  of some efficient counter-agent." This
 last conjecture may assist us to explain  the  healthfulness of our
 pine barrens; among the favorable circumstances in whose po-
                               2 
10
sition I would enumerate the terebinthinate exhalations from the
trees, as probably balmy, tonic, and salutiferous.   The Jussieuia
grandiflora  of our southwestern bayous is maintained by  Dr.
Cartwright  to be a corrective or antidote to malaria.— Vid.  West-
ern Journal, June, 1840.
  Among other sources of malaria, the decomposition of decaying
volcanic matter has been suggested, and applies well to the phe-
nomena familiar in  Italy.   The country  about Rome  is  not
marshy but volcanic; so of Civita Castellana, &c. &c.  Ferguson
declares the only necessary condition to be, " paucity of  water
succeeding  its abundance."   Some medical philosophers would
substitute the agency of specific animalculi for all miasmatic and
epidemic influences; and Dwight has proposed animalcular pu-
trefaction as a source of malaria.
  May there not be some common product of the several  chem-
ical actions going on in these cases, aerial and of obscure nature
and qualities, whose  identity is proved  by the identity of effects
it every where gives rise to ?
  Animal  Putrefaction.—History,  both ancient and modern,
offers us frequent instances of pestilence produced by this cause.
The  burial grounds of Paris, London and New York, proved to
be injurious to the health of the vicinity.   The Catholic churches
on the continent of Europe, often require to be disinfected.
  The processes which immediately precede, and  those which
accompany or follow death, tend to generate a poisonous quality
in animal matter.  The  flesh of diseased animals is unfit to be
used as  food, and becomes injurious when so used—in one in-
stance, a specific disease is  thus communicated, " milk sick"—
a gastritis.   Among  anatomists, a  very  severe and not unfre-
quently fatal affection  is produced by puncture and inoculation
in dissection, with the scalpels, &c. imbued with the fluids of a
subject.  The absorbents inflame, and  the  glands; a cutaneous
eruption  comes on, attended with violent inflammatory  fever and
great prostration of strength.
   Animal  Poisons.—Divisible into  two  classes.   1st.  Those
which result from natural  and healthy, but  peculiar actions.
These are secretions intended for attack or defence, as the sting
of the bee, wasp, &c, the venom of the snake.  2d. Such as 
11
are produced by diseased processes—the milk and butter of a milk-
sick cow, the saliva of a rabid animal  of the  feline or canine
tribe, vaccine and variolous matter, &c.   Some of these are con-
tagious.
   Contagion.—Defined to consist in a peculiar matter given out
by a diseased surface, which possesses  the power or quality of
generating in a healthy body a diseased  condition, similar to that
whence it derived its origin.
   To prevent confusion in the use of language, I would follow
the distinction proposed by W. Philip,  in which contagion  is
pointed out  as the morbid poison, and infection as the act of com-
municating  disease.   Hydrophobia is contagious in the feline
and canine tribes, but a human subject  affected  with it, is inca-
pable of communicating it.
   The matter  of contagion may be either palpable or impalpa-
ble.   Vaccine, chancre, gonorrhoea, psora, offer examples of purely
palpable contagions.   These  are  transmissible  only by actual
contact of the morbid secretions, with some portion of absorbing
surface.
   Scarlatina, rubeola, parotitis, pertussis, give out an impercepti-
ble emanation, which affects the healthy subject, we know not
exactly how.
   Variola,  plague,  varicella, produce a virus  of palpable form,
which is capable of acting, either when directly applied, or after
having become impalpable by solution, and diffusion in air.  Yet
there are perhaps here given out two forms of contagion, the pal-
pable and impalpable.   I am doubtful of the solubility or diffusi-
bleness of any of the palpable contagions.
   Of the physical and chemical qualities of the matter of conta-
gion  but little is definitely known,  except  in a few instances.
It is not only thrown out in a distinct form, but seems to be dif-
fusible in the blood, unless we suppose  the whole mass  of blood
to become contagious matter.  For transfusion  of blood has com-
municated glanders and farcy in the horse and ass,  and Home,
Speranza, and others, have communicated measles and scarlatina
by sanguineous inoculation in the human subject.
   There are but two agents in nature which have been plausibly  #
regarded as specific disinfectors—lime and heat. Chlorine and 
12
  some  of its  combinations have  been ranked  here,  but I think
  without sufficient proof.  Vinegar  and sulphurous acid  are also
  employed.
    Contagious matter is regarded as a virus rather than a poison,
  because quantity does not modify its effects.  Hence, also, it has
  been supposed to act by contaminating the fluids of the infected
  body, and impressing on them a progressive change, or assimila-
  tion, as it has been termed.
    The matter of contagion varies in reference to its modes of
  efficient application.   It infects by
    1st. Inoculation—insertion in a wound or abrasion, either of a
  palpable matter or of diseased blood—as in vaccine, small  pox,
  herpes, tinea capitis, hydrophobia.  Under this head we place,
  of course, those propagable by sanguineous inoculation, or trans-
  fusion of blood.
    2d. Contact—favored of course by friction or protracted appli-
  cation, as in ophthalmia, psora, gonorrhoea, syphilis.
    3d. Confinement in vitiated air,  as in hospital gangrene, erysi-
  pelas, probably phthisis.
    4th. Near approach, as in typhus, scarlatina,  measles, hooping
  cough, sore throat.
    5th. Fomites.  Various articles which absorb contagious mat-
  ter are so called;  woolen and silk cloths, cottons, furs,  feathers,
  &c.   These retain it long and tenaciously,  and preserve its viru-
  lence little impaired.   The clothes  of a physician, it should be
  always remembered, may by thus entangling contagious particles
  convey them and communicate disease.
    6th. Atmospheric diffusion, as in plague, small pox, dengue,
  cholera, and numerous others.
    Contagion has no other source than the morbid action  in dis-
  eased bodies; but it is an error to  infer that  contagious diseases
  arise exclusively from the influence of contagion.   They differ
  widely in their origin.   Some are easily traceable, as psora, lues
  venerea, typhus, ophthalmia;  of others the history is obscure, as
  of measles, pertussis, &c, but indeed it is  obvious that all must
  have had a spontaneous beginning, apart from  contagious trans-
% mission. 
13
  Contagions differ in regard to their latent periods after infection.
Some of them follow a known rule, liable to exceptions.   Thus
after vaccination and variolous inoculation, about three days pass
away before any obvious results occur.   For the most part they
are indefinite.  Typhus has  been known to  assail immediately
after exposure;  the  latent  period of  measles  often extends to a
fortnight or three weeks;  and hydrophobia, it  is said, has been
postponed for six months.
   Contagions differ also in comparative force or efficiency; from
small pox,  which extends itself either by inoculation,  contact,
mere approach or aerial diffusion, to phthisis, which requires close
and protracted confinement within a vitiated atmosphere of nar-
row limit.  Scarlatina, typhus, pertussis, and cholera, will occupy
a middle place in this comparative catalogue.  It is probable that
no disease  is  contagious throughout the whole of its duration, and
it would be interesting to  know the contagious  stage of each in-
dividual malady communicable in this way.   Small pox has per-
haps two such periods;  the first being the eruptive stage, when
an impalpable matter is given out from the  whole surface;  the
second is ascribed to the maturation of the palpable virus,  which
is supposed to be soluble in the air.  I am unwilling  to confound
here the palpable and impalpable contagions.   The  latter I sup-
pose to  be  the febrile emanation,  which may arise as well in  the
secondary  as in the eruptive  stage of fever.
   The contagious periods  of febrile  diseases seem  to me to be
much more limited than is generally supposed.
   It is not easy to decide  the question of the  contagiousness of
any given  form of disease ; the  following  seem to me to  be  the
best and most reasonable tests that can be offered:—
   If, in repeated instances, under the notice and by the report of
competent observers, a single case be the forerunner of others in
the immediate  neighborhood, provided the circumstances of sea-
son and locality were sufficiently varied to remove it  from the
list of endemic affections.
   If  it exhibit an evident preference for a dense population, or
confine itself within the limits of towns, cities and villages.
   If a household or neighborhood, previously healthy, be attacked
successively from obvious communication with a sick  body, or
contact with Fbmites. 
14
   If those escape uniformly or very generally who take care to
 avoid such cases and Fomites.
   The questions concerning contagious disease are of very great
 importance, as they bear upon the commercial and ordinary inter-
 course of nations.
   Superfluous regulations of a restrictive nature have often been
 stigmatized as cruel; the imputation will lie more properly against
 such as  are  inadequate.   Every community has a right, and is
 indeed bound in duty, to establish its own quarantine regulations.
   Some  of the contagions are endowed with the property of de-
 stroying, in a system once  affected  by them,  the  tendency  or
 disposition to a recurrence or second attack—thus variola, rubeola,
 pertussis, parotitis.   From the singular fact that vaccine exhibits
 a protective influence in this  manner to shield from, or at any
 rate  to modify small-pox, some have inferred their  identity;  ex-
 plaining  the  obvious differences  upon the  conjecture,  that the
 former, in a course of successive  transmissions through the sys-
 tems of the lower order of animals, as  the horse and the cow,
 has undergone these  alterations  in external character  and symp-
 toms.  This  view is not satisfactory.   That there is a specific
 difference between them seems  proved  by the fact  that while
 vaccine protects against or notably modifies variola, it does not so
 modify or protect against itself, but may be repeated many times
 in the same subject.   The majority of contagions, and especially
 the non-febrile, give no  protection against second attacks, but
 may recur with indefinite frequency.
   Diseases are spoken of as Endemic and  Epidemic; the latter
 being divided into local and general epidemics.
   1. Endemics are of permanent prevalence in special localities,
 governed perhaps by known conditions of season and tempera-
 ture.   Intermittent fever is endemic  in Holland; bilious  re-
mittent in  all malarious  regions;  yellow fever in Havanna and
 Vera Cruz; cretinism and goitre in the Valais;  pellagra in Lom-
bardy; milk-sickness in several  portions  of  our  southwestern
country;  tumid leg in Barbadoes ; plica in Poland.
   2. Local epidemics, often confounded with the above, are
occasionally prevalent in certain  localities.  The causes of this
prevalence are  both  transient  and  obscure, their influence 
5HT«i    m&
                             15

bearing no obvious relation to seasons,  as  distinguishable from
each other.   Yellow fever sometimes prevails as a local epidemic
in situations where it is not endemic ;  so also dysentery, typhus,
&c.   Both contagious and endemic diseases may, from unknown
circumstances, become local epidemics, as bilious fever, hepatic
affections, scarlatina, plague, and pertussis.
   3. General  epidemics.  Under  this head we  comprehend all
those forms of pestilence which have at various periods spread
themselves over the world, unconfined by the limits of geograph-
ical position above referred to, and in many instances uncontrolled
by whatever conditions of season, climate,  and national pecu-
liarities.   Such was the " black death" of the fifteenth century;
such are influenza and cholera.
   Of the several  causes  of  endemics it will be best to treat in
detail under the several heads to which they belong.   Concerning
the origin of epidemics, a few observations  may be made in  this
place.
   1. Local epidemics have a definite reference, which, although
it may not be well  understood,  is uniformly observed, to  the
locality and other circumstances of the position where they occur.
   2. General  epidemics admit  of no such circumscribing con-
ditions.
   3. Endemic diseases, if of febrile character, often become local
epidemics; the non-febrile show no such power.
   4. The  febrile  contagions, however  generated,  also  become
frequently local epidemics.
   5. Endemics are  incapable  of  becoming general epidemics,
because limited, as by the description of their sources.
   6. Febrile contagions on the other hand may,  and often do
become general epidemics, spreading  on all sides, regardless of
locality, climate or season.
   7. All general epidemics are febrile—I do not hesitate to say,
febrile contagions.   None of them are  endemic;  none are to
be accounted for  by  changes of atmospheric  or  telluric con-
ditions.*  No known agent, except contagion, retains its  charac-

  * An apparent exception presents itself in influenza—epidemic catarrhal fever.
This is, perhaps, the only disease which, in its sporadic form, is regularly pro-
ducible by agents not belonging to the class of specific poisons—as where a single 
16
  teristic influence—as  does the cause of a  general epidemic, be
  it what it  may—throughout  every variety of season,  climate,
  local position,  temperature,  habits,  and modes of life, whether
  individual or national.
    The capacity for propagation or self-extension, is most notably
  different  in the different forms of epidemic disease.   Suppose a
  ship to arrive in any given sea-port town, having her hold filled
  with "infected atmosphere"—from a rice-field;  or  from a city
  where typhus is prevailing;  or from Vera Cruz or New Orleans,
  when suffering  from yellow fever; or from some seat of epidemic
  cholera.
    1. The rice-field air, however impregnated with poisonous
 malaria, would  be harmless  to all around.   If any one entered,
 he would bring away with him no poison adhering to his clothes
 or person, though he might fall sick (especially if he slept in it)
 of remittent or intermittent fever.
   2.  The typhus atmosphere may perhaps diffuse itself,  though
 this is doubtful; to  become  efficient as a cause of disease it re-
 quires that a subject remain in it some time, or labor under some
 predisposition.
   3.  The yellow fever atmosphere would probably spread itself, the
 season being favorable, and attack subjects in the neighborhood.
   4.  The cholera atmosphere would scarcely fail to diffuse itself
 on all sides:  and  in each of the three last cases, every patient
 would become  a generating  centre,  adding to the quantity of
 virus in  the air of the region into which such a ship is introduced.
   Parasitic animals should be classed among exciting causes of
 disease.  Psora  is supposed to arise from the irritating presence
 of a peculiar animal, the "itch insect;"  and some fanciful pathol-
 ogists have attributed many diseases to animalcule, as dysentery
 cholera, &c.
   Worms.—The lumbricus is  the principal, and is capable  of
producing in an infested child almost  any form of disease  accor-
ding to predisposition.   Ascarides and tami* give rise to peculiar
symptoms.
individual is exposed to cold and moisture, or many are affected by sudden atmos
phenc  changes. But this exception.is only apparent, influenza often spreading
independently of any such contingencies.                              s 
17
                DE  SEDIBUS  MORBORUM.

  The fluids of  the body preponderate very considerably, being
in a ratio of 9 to 1 to the solids, as some physiologists calculate.
This estimate I regard, however, as somewhat exaggerated.
  The primary seats  of  the vitality of the different portions of
the animal  structure, are the sensorial and circulatory systems.
Every part of every tissue, depends immediately upon its nerve,
and the blood sent to it, for its life, and these, the nerves and
blood, are dependent upon each  other.   Each  atom which is
gifted with life, receives it from nerve and blood.
  These, then, must be the primary seats of disease.
  Diseases  purely functional, may be said in the first instance to
affect exclusively the sensorial system.
  Structural diseases on the other hand, affect the vascular system.
  Sensorial and  vascular derangement intermingle together, and
produce each other.
  There are nervous affections of the whole or part of the circu-
latory system, as syncope, palpitation.
  And vascular  derangements of the whole or part of the senso-
rial system, as apoplexy, phrenitis.
  Nervous and  functional affections may run into or  produce
vascular and structural  derangements.  Too intense light will
occasion ophthalmia.   Functional  affections of the vascular sys-
tem, by continuance,  can scarcely fail to produce  structural dis-
order, as in fevers, inflammation, &c.
  It has been much disputed whether the fluids can ever be the
primary seat  of  disease—no one  can  doubt that they undergo
certain  obvious  changes  in  its progress.   Whether  any  such
changes are to be estimated as among the primary and essential
circumstances, is the true question, and I am disposed to answer
in  the  affirmative.   The ancient advocates of  the humoral
pathology,  carried  their views on this subject  quite  too far,
attributing all diseases to alterations in the qualities of the fluids,
some of which cannot be proved to occur at all, whether as cause
or effect.   But  it is fashionable in the present day of exclusive
solidism, to go equally far into the  opposite extreme. Truth lies
                             3 
18
as usual in the medium.  Chyle varies in quality, according to
the food whence it is obtained.   Blood must vary also, as derived
from  chyle.   Scurvy,  and some cutaneous affections, are the
direct result of confinement to improper diet.  Blood is also liable
to many and  important  changes of condition, referrible  to the
more  or less perfect performance of the function of respiration.
That important diseases may thus arise, which  shall depend
directly  on the state of the blood, cannot  be rationally doubted.
Typhus may take its origin in confined habitations, as well as in
impure, insufficient diet.
   Diagnosis consists in such knowledge of  the seat, nature and
history of any given disease, as shall enable us to distinguish it
from every other.  Pain will often  point out the locality of dis-
ease.   The imperfect performance of known physiological func-
tion is, however,  still  more important as a diagnostic symptom.
Sympathies of noted and recorded occurrence, whether understood
or not,  often  serve as valuable guides.  But we are liable to be
misled by each of these marks.  Some important and dangerous
diseases  occasion little or no pain.  Some  painful  affections,
imply little or no danger.  And the morbid sympathies which
connect  the organs are  in numerous instances highly irregular
and obscure.
   The  usefulness of  pathological anatomy—the examination of
bodies dead of disease, deserves to be carefully considered.
   It cannot, except in a very few, and properly accidental cases,
teach us any thing of the causes of disease.
   Among the effects of disease which it detects and developes, it
cannot  help  us  to distinguish between incidental and essential
lesions of structure.  As to  impairment of  function merely, it
gives  no information.   Nor can it  ever  aid us in  tracing the
primary locality or origin of disease ;  nor  in following up its
effects in successive series of consequences.  The true value of
morbid  anatomy, lies in connection with  observations carefully
made,  and exactly noted, during the progress of any given case
collated with  reference  to the cause of the attack, its mode of
commencement,  and  its entire and minute  history.  By  an
observation of frequent  or constant coincidences, we are taught
to direct our  attention  to organs liable to become implicated in 
19
 future cases of  similar character.  The  physician,  therefore,
 should not neglect to unite these offices; he should take careful
 and precise notes at the bedside of the  sick, nor consider himself
 to  have  performed all his duty, until he has instituted a minute
 examination of the dead body.
   The tendency of all disease is,  to  death or  disorganization.
 The old dogma of the existence of a restorative power in the con-
 stitution, a vis medicatrix natures, should be abandoned.-
   The cessation of disease (unless when brought about by reme-
 dial treatment) is owing merely to the removal  of the causes
 which produce  it.   Sometimes the exciting cause is taken away ;
 at  others,  the predisposition upon  which it acted disappears—is
 as  we say, exhausted or worn out.  The well constructed, ad-
 mirably  ordered  mechanism of the animal body, resumes  its
 natural action,  when the impeding or disturbing influence ceases
 to exert an influence upon  it.
   It is absurd to suppose  disease to be in any case a natural or
 spontaneous action of the living body, or to imagine any principle
 prepared or provided to procure  its removal: doubly absurd to
 suppose  that such principle  should act, such effort be exerted
 through, and  by means of the very processes in which disease
 consists,  and  through which it developes  itself.   Disease,  as
 Brown, and after him Rush, affirmed of life, "is a forced state."
   Morbid causes  produce  death in two ways.   Disorganization
 to a certain extent, is evidently incompatible with a subsequent
 resumption of the functions of any given system of parts.  But,
 besides this,  the mere interruption of an important function for
 a time is often  fatal, without any lesion of any part or organ, as
 in suffocation from drowning, and in some cases of syncope,  &c.
   Death from disease, must vary in its attendant circumstances,
 with direct reference to the modes in which it is brought about.
   Euthanasia, or death from old age, is owing to defect of action
 in  the organs of  supply,  and the consequent failure of all the
functions.
   Death is best defined to consist in a cessation of excitability,
 the loss  of the capacity of being impressed by, and of reacting
upon stimuli applied.   The  phenomena of death do not consti-
tute that state;  they  may be all present when animation is only 
20
suspended,  and the subject capable of resuscitation.   Interment,
in cities or  populous  towns, should be strictly prohibited; the
ancient practice of burning dead bodies, ought on many accounts,
to be preferred, wherever practicable.

               PHENOMENA OF DISEASE.

  Considered practically, diseases are mere collections of symp-
toms, the proximate or  common cause of which is exceedingly
obscure and difficult to  be traced.   These  phenomena may,  in
this place, be considered in the order of the physiological systems
and  functions which  they disturb or affect,  and their rationale
attempted to be given.
  I. Of the Digestive System.—Its disorders are shown  by
  1st.  Alterations in the appearance and condition of those por-
tions of the system which it  is in our power to examine.   The
tongue is furred, or covered with a morbid mucous coating, when
the stomach and bowels are deranged and their secretions vitia-
ted.   It is red, and sore, and ulcerated,  when they are inflamed.
In fevers it is swollen, and sodden, and variously discolored  on
the sides and surface,  if the stomach is irritated and  the hepatic
actions disturbed.   In typhoid affections it is dry and of a dark
hue;  covered with a tenacious  sordes or chapped.  It is cold in
cholera and pale.   In  purpura and the hemorrhagic state of fever
it is livid and  smooth, and exudes blood.  Its papillae protrude,
of a bright crimson tinge in scarlatina.   The gums are spongy,
swollen, and  disposed to bleed in scurvy,  purpura,  and in the
hemorrhagic states  of fever.   The  lips, cheeks,  and the whole
lining membrane of the mouth are apt to ulcerate—especially in
children—wnen the mucous tissue of the stomach and intestines
is irritated.  The teeth and gums as well as the tongue are black-
ened by sordes in typhus.
  The abdomen should  be explored.   Meteorism  is shewn by
tension or intumescence, light and resonant upon percussion ;  by
fluctuation we know the presence of fluid effusions; aneurism by
pulsatory tumor; and physconia by position, hardness, and weight.
  2d.  By functional disturbance manifested in any obvious way
as anorexia, gastric oppression, nausea.   Vomiting comes on not 
21
only to  rid the stomach of some load, but  is produced by any
mode of irritation of the alimentary tube and its inflammations;
it may arise also from gastric sympathy with other organs, as the
uterus in pregnancy, the  brain  in apoplexy, in  sea-sickness and
after  blows on  the  head.  In  fevers, it supervenes upon both
gastric and cerebral derangement.
   3d. By uneasiness or pain seated in any of the organs.   Some
abdominal pains are unaccounted for, such  as  those comprised
under the terms gastralgia and gastrodynia; others arise from
inflammation;  some from  flatulent  distension, and  some from
mechanical pressure.  Some  probably depend upon mere hype-
remia,  or vascular engorgement.  It is  usual to lay great stress
on intolerance of pressure as diagnostic of inflammation, but this
may be too much trusted to: parts forcibly distended are painful
on pressure.
   4th.  By changes in  the results of organic action, morbid secre-
 tions.  The matters vomited in disease  are exceedingly various;
 acid, oily, alkaline, bitter, white, brown, green, blue, black as in
 yellow fever,  albuminous as  in cholera, &c.  These qualities
 are not always to be accounted for; of  some the  explanation is
 obvious,  and  so are the inferences to be drawn from their occur-
 rence.
    II. Of the  Circulatory System.—Syncope, the cessation of ac-
 tion of the heart—palpitation, its convulsive action.  The pulse
 derives its importance as a symptom of disease, from the almost
 universal sympathy, which extends  diseased actions in other sys-
 tems, so as to affect more or less the circulatory.  The pulse of
 an infant newly born, beats about one hundred and forty strokes
 in a minute ; declining from that time,  the average adult pulse is
 about seventy to seventy five.
    In health,  the pulse is modified by a great variety of circum-
 stances.
    Idiosyncrasy.—In some persons it beats one hundred, in others
 not more than forty.
    Sep.—The female  pulse is somewhat more frequent than that
 of the male.
    Stature.—la. tall men it is less frequent, in dwarfs more so.
    Muscular exertion makes it beat with greater rapidity. 
22
  Sleep makes it slower.
  The passions and emotions add to  its frequency, and perhaps
its force.
  Temperature.—Heat augments, cold (continued) diminishes its
frequency.                 '
  Diurnal changes.—-The pulse is usually somewhat  more fre-
quent in the evening.
  These agents affect chiefly the frequency of the pulse in health.
  The healthy pulse is regular—that  is, the intervals between the
strokes are precisely equal;  it is vigorous—that is, it resists with
determined opposition, the influence of  force applied to  compress
it; it is full—that is,  the artery is completely,  but not unduly
distended by its blood.
  The systole of the heart occupies a given portion of time, con-
tracting steadily without harshness or hurry.
  A morbid pulse may readily be distinguished then by compar-
ison.
  It is more or less frequent than in health.
        "      "  hard or  resisting.
        "      "  quick, (abrupt or  jerking.)
        "      "  full.
  Irregular in interval.
      "      force.
  Intermittent, regularly or irregularly.
  These comparative  phrases  address  themselves to  the judg-
ment, convey a definite meaning, and are easily remembered and
referred to.
  These several morbid qualities of  the  pulse may be  variously
combined, so as to offer a great variety; the attempt to give fan-
ciful names to which has introduced some disorder and confusion.
  Plethora, in strict propriety, is always a relative term, implying
a want  of proportion between the quantity, or  the stimulating
quality  of  the blood, and  the tone of  the heart  and  vessels.
Hence it is often met with in weak and debilitated constitutions.
  I doubt the possibility of an absolute hypercemia,  o r undue
abundance  of blood.   Local  hyperemia, on the other hand, is
one of the most common conditions of  disease, being implied in
all inflammations and congestions. 
23
  Ancemia.—The deficiency of sound or nutritious blood,  often
results from hemorrhages, natural or artificial, and from disease.
The fibrine and red globules, would seem to be slowly supplied.
  The blood undergoes many changes in disease.   It becomes
buffy or sizy.   This is usually explained on the supposition that
its coagulation  being slow,  the red  globules fall to the bottom,
leaving the  yellow lymph  on  the surface; this explanation is
easily shewn to be unsatisfactory.   It becomes incoagulable from
great fatigue  and extremely violent inflammation;  in death also
from lightning, and from a blow on the pit of the stomach ; but
remains florid or black, and does not assume a buffy crust.  Blood
is black in typhus ; attenuated and dissolved, as the phrase is, in
scurvy ; loses its  salts and serum in cholera.
  Hemorrhage—a symptom more alarming  than  dangerous in
itself; occurs  in opposite states of the  system ; when active, is
less serious than if passive—in the former case,  may have some
good effect, as a mode of local depletion.
  III.  Of the  Respiratory  System.—Dyspnoea  and orthopncea
defined,  and  accounted for.  The chest should be carefully ex-
plored.— Vide Chapter containing Examination or Exploration
of  the Thorax.
   Cough, the most common symptom  of pulmonary inflamma-
tion, is yet not always present as a token of  that condition.
   Expectoration of mucus, or of thin, bloody, offensive, ichorous
serum, may take  place in various  states and stages  of bronchial
disease, without giving occasion for  very definite inferences;  so
also of purulent matter, this may either be from an abscess, from
the circumference of a tubercle, or from the unbroken mucous
surface ;  it does not prove abscess or  ulcer to exist.
   IV.  Of the  Sensorial System.—Pain is the most general symp-
tom of disease, the expressions indeed being almost  synonymous;
yet, owing to the complexity of  morbid sympathies, it  by no
means denotes of course the principal locality of disorder.   The
degree of pain depends upon the general sensibility of the patient,
and upon the local sensibility of the part affected; it is also modi-
fied, both in kind and degree, by the nature of the case, so that it
bears no regular proportion to the danger of the attack.  The loss
of  sensibility, whether  local or general, must augur unfavorably. 
24
   Permanent dilatation of the pupil is untoward, as being proba-
bly occasioned by compression of the brain ; permanent contrac-
tion, by meningeal inflammation.   Insensibility to light, as evin-
ced by a fixed state of the pupil, is also unfavorable.  Hallucina-
tions of various kinds, amounting to delirium and insanity, are more
to be dreaded when low and gloomy, than if cheerful or violent.
   V. Motory System.—Great muscular  prostration is always to
be  dreaded.  Relaxation  of  the  various sphincters,  indicates a
high degree  of  danger.   Paralysis is still  more unfortunate,
whether of one half the  body, transversely divided, paraplegia,
usually affecting  the  lower limbs, or hemiplegia, which is  con-
fined to the right or left side,  and both extremities.   Trembling
of the  head, a common circumstance in the debility of  old age;
of the  hands and tongue, often from  intemperance.   Cramps, or
tonic contractions of particular muscles, result from many various
irritations—are often connected with digestive disorder and uterine
irritation.  Convulsions and spasms more common  in childhood,
derived from numerous causes; in general, more alarming than
imminently dangerous.
  VI. Excretory  System.—Very difficult to assign any  rationale
of the  coldness and corrugation of the skin in ague,  or the gen-
eration of so much cutaneous  heat in  certain fevers—most obser-
vable  in yellow fever.  Rush makes the remark, which is con-
firmed  by my own experience, that a cool moist state  of the skin
in the disease just mentioned is indicative of great danger.  Inor-
dinate sweating the principal circumstance noted in the ancient
fatal epidemic  called  Sudor Anglicanus, as supposed to  affect al-
most exclusively the people of England.   The perspiration under-
goes changes of quality as well as of quantity, assuming  a yellow
or brownish  hue, becoming acid, and offensive  in  smell.  The
skin itself, suffers changes of  color, being yellow as in jaundice ;
pale, white, and semi-transparent, as in dropsy; orange, in yellow
and bilious fevers, and hepatic disorders, and from intemperance ■
and livid, mottled and spotted in petechial fevers.
  The urine was of old regarded with special attention, and the
most precise indications of the state of the  patient supposed to
be drawn from the appearances presented by it.  It becomes abun-
dant and limpid in nervous diseases, as in hysteria and  some head- 
25
aches, scanty and high colored in fevers, loses its urea in diabetes,
in one form of which it contains much sugar;  deposits sediments
of varying color, under circumstances not exactly defined.
   Much affected in dropsies—containing varying proportions of
albumen and becoming readily coagulable, in many cases.
   Strangury—unfavorable  in the  commencement of fevers, fa-
vorable  in their advanced stages.
   Total suppression, declared by most to be a fatal symptom.   I
have, however, seen recoveries after it.
   The  alvine excretions offer important observations, in  warm
climates especially.  Much influenced  by the  state of the liver,
as well as of  the intestinal  canal.  Long continued  impediment
to the process of  fecification, or  the remarkable  stercoraceous
change  undergone by the ingesta, always denotes danger.  Clay
colored  stools show torpor of the liver—vitiated  secretions of
bile  color them dark  green, and make them offensive and acri-
monious.   They are black under some particular states of enteric
inflammation, as in yellow  fever, containing flocculi or granule
of black color.  In dysenteric  irritation they are  mucous, and
bloody,  and sanious.  A peculiar pink colored, highly offensive
ichor, shews instant danger,  being occasioned, I believe, by ac-
tual  gangrene of some portion of the mucous membrane.  This
may come away,  also, in small  flakes in the stools—or portions
of fibrine or  coagulable  lymph.   In dysentery, we  meet also
with scybala; these are sometimes described as lumps of har-
dened feces,  at others as consisting of caseous, or of fatty matter.
   In children the stools are often acid and green; at times  serous
and colorless.   Purulent matter  may come away from the intes-
tines, either when  ulcerated or highly inflamed.
   The countenance of the patient should be remarked, as expres-
sive of his condition.  Any obvious change is unfavorable.   The
countenance of malignant fever is always notable.
   " Risus Sardonicus," described as a grim, sarcastic smile, pro-
duced by involuntary contraction of the muscles of the lips and
cheeks.   The  "Hippocratic  countenance," consists in  hollow,
sunken  eye, pinched up nose, fallen temples, tense pale forehead,
lividness of face ; universally, as far as I have observed, the fore-
runner of death.
                               4 
26
  The decubitus or posture  in  bed.—Inability  to  lie down  is
unfavorable—so is confinement on either side—lying on the back
with the knees drawn up, and sliding to the most depending part
of the bed, shew great debility.   Restlessness and jactitation are
bad symptoms ; it is worst of all when the patient  expresses an
anxious desire to move  from  bed to bed, and from  one room  to
another.
  Periodicity.—The tendency to periodical revolution is one  of
the most remarkable phenomena of  disease.
  Diurnal revolutions observable both in health and disease,  as
may be noted in the pulse, and in general  in all our  habits and
customs.   They are likewise  obvious  in all  fevers—continued,
remittent, and intermittent.  Continued fevers show some abate-
ment  in the morning, and augmentation in the evening.   Remit-
tents refer to  the types of intermittent with which they are most
closely connected.  Intermittents have their special  hours of ac-
cess;  the quotidian in the morning, the tertian a  little  before
noon, the quartan in the afternoon.
  Septenary revolutions are not less clearly distinguishable.  The
menstruation of the human female occurs regularly on the  twenty
eighth day—its anticipations  and postponements are  usually  of
seven or fourteen days.  The  relapses of fevers  occur at the
same  periods  usually.
  The first I attribute to insolation,  the  influence of the sun.
The second in like manner to lunation, the influence of the moon.
  The combined influence of the two, liable  perhaps  to other
complications  more  obscure in their nature, will account for all
the types of fever, as well as of crisis, or the agency of critical days.
  Certain diseases seem to possess  an  inherent  or  independent
periodicity, arising from some characteristic peculiarity in their
own nature.   These are  called  self-limiting; they can  neither
be arrested in their course, nor prolonged by any means  known
in our art.  The exanthemata present the best examples of this
order.  Small pox, vaccine, measles, and scarlatina, run through
a definite  course  and terminate  after a certain  duration.  The
consequences or sequele of these  diseases,  however, depending
on lesions of the organs affected in their progress, may be indefi-
nitely protracted. 
27
   The true test  of a self-limiting disease, is its  spontaneous
 subsidence at a determinate and calculable  period.  Some have
 confounded illimitable or uncontrollable maladies with the  self-
 limiting.   The distinction is easy.   We may protract an attack
 of typhus or of pertussis  by mismanagement; we cannot add
 an hour to the duration of  measles or small pox, though we may
 render them more violent and even fatal.
   The condition  of convalescence may be briefly described  as
 one of extreme mobility and susceptibility, modified, however,
 by the contingencies of the preceding disease in a great diversity
 of modes, and as requiring  the special notice and attention of the
 practitioner.

          MODUS OPERANDI  OF MEDICINES.

   Medicines have been enumerated among the causes of disease ;
 they all produce it in the sound or healthy system,  how do they
 then effect in the sick the restoration of health ?   There is no
 such power existing in any known agent, as shall be  displayed
 in the mere, production or increase of vitality, or healthy action
 in  an animal body; nor is  there any thing in nature, properly
 deserving the title of antidote, except in reference to its chemical
 affinities.   Medicaments must therefore  be useful by an indirect
 agency; their effect  being always  modified by, and dependent
 upon the condition of the recipient.
   Therapeutical agents may be arranged under several  heads in
 relation to the mode in which they affect or impress the subject,
 as follows:—
   1st. Abstraction.—Darkness, silence, fasting, recumbent posture,
 cold, the lancet, leeches and cups, cathartics, diuretics, &c. &c.
   2d. Stimulation.—Wine,  alcohol, bark,  opium, electricity,
 heat, &c.  &c.
   3d. Revulsion.—The most important perhaps of therapeutical
principles.   The use of cathartics  in fever, of these and emetics
in inflammation, of the lancet, leeches and cups, (as properly un-
der this head, as the first,) of sinapisms, blisters,  acupuncture, &c.
  4th. The homoeopathic action, as exemplified in the applica-
tion of belladonna  in scarlatina; of vaccine to prevent or modify 
28
small pox; of emetics to  remove  nausea, and of cathartics to
cure diarrhoea.   Yet homceopathists reject altogether, and protest
against the doses ordinarily employed by the  other  schools, and
exult in the discovery, that the most beneficent effects can be pro-
cured from atoms, or indefinitely minute portions of medicine;
exhibiting the  thousandth part of a grain,  or of a drop of our
common drugs.
   5th. The contra-stimulant influence—exhibited best,  perhaps,
in the use of very large doses of opium in tetanus, and  of anti-
monials in intestinal spasm.  The Italians of the contra-stimulant
school, are found in the opposite extreme to the German practice
of Hahnemann.   They administer boldly,  the most enormous
quantities of the remedies indicated, with the  purpose of combat-
ing directly the force of morbid impressions made upon, or mor-
bid action going on in the  system.
   6th- The alterative effect, such as  we attribute to mercury,
and the metallic preparations generally, to the mineral acids also,
and  indeed  such  as  may be obtained  from  a great number of
medicines, as guaiac, iodine, camphor, cathartics.  By the word
alterative, I would mean the substitution of the  effect  of the
medicine, for the  effect of the originally acting cause.   To be
regarded as an alterative, a medicine  must be capable of produ-
cing then a forcible impression, which may be kept up at will, by
its continued exhibition, and which shall readily subside on with-
holding it.  By the combination of these powers, its value is  given.
  It  is doubtful whether the three last modes  of action, may not
with propriety be all resolved into the form of revulsion.
  The modes of administration by which we  apply our ordinary
remedies, are four, viz.  1st.  By the prime vie or surface of the
alimentary  canal.   2d. By the  cutaneous surface.   3d. By the
pulmonary surface.   4th. By introduction into a vein, or  inser-
tion  into a wound.
  There are besides these, some mechanical, and in a certain
sense, chemical remedies, not directly referrible to either of the
above heads,  as friction, percussion, acupuncture, electricity and
galvanism.
  Medicaments  may act when  applied in  either of the  above
modes.—1st.  Upon the extremities  of the  nerves  immediately, 
29
and through the sensorial system upon the whole body.—2d.  By
introduction into the circulation and actual mixture with the mass
of fluids.
  Instances of  the first kind may be found in the instantaneous
death which follows  the swallowing a large quantity of alcohol
—the same result is produced by touching the  eye or  tongue of
an animal with strong prussic acid—and in  the  effects of stimu-
lating volatiles upon the body through the olfactory nerves.
  The latter, I believe, is common in the agency of our ordinary
medicines.   The effects of medicine, introduced into the stomach,
are  exactly similar or identical with  those which they produce
when injected into a vein.  Opium, dissolved and thrown into a
vein, produces sleep and stupor; ipecacuanha vomiting;  jalap and
castor oil purging; and  arsenic more readily brings on  gastric
inflammation  when  inserted into  a wound, than  when swal-
lowed.
  It is only on these tissues or systems, the vascular and senso-
rial, that medicines can act primarily.   They affect the first by
actual  admixture with  the circulatory fluids.   They affect  the
sensorial system by a direct impulse or impression upon  the ex-
tremities of the nerves, which we do not understand, and cannot
describe.   They  are separable then fairly into two classes,  as
they affect one or the other of these systems.
  Friction, percussion, acupuncture, act upon the nerves directly
subjected to their influence.  These they irritate, vascular deter-
mination ensues, (ubi irritatio ibi fluxus,) and thus prove reme-
dial on  the  principle of revulsion.  Acupuncture is maintained
by  many theorists  to owe its efficacy to  electric  impressions.
Electricity and galvanism seem to exert as pervasive an influence
over living as upon inanimate  matter, and |rct with  wonderful
force upon all the solids and fluids of the  living body.  They
are stimulants of  high value and general adaptation.
  The  operation of each and  every medicament, is specifically
directed upon some particular organ of the body.   Besides this
specific operation, which it has a tendency to  produce  under all
circumstances,  there are other influences which may be  derived
from it, depending either upon the quantity employed, or upon
the condition of the recipient. 
30
   1st.  The direct or specific operation of medicines, we  see  in
 the emesis from tartrate of antimony and ipecac; in the sleep and
 stupor from opium, in the dilatation of the pupil from belladon-
 na, &c.   We may even point out  more minutely, distinctions as
 to the modes of effect, when their action  is upon the same  organ;
 thus ergot causes the uterus to contract, affecting its fibrous struc-
 ture ; guaiac  acts upon the secretory vessels, causing them to
 pour out their due fluids.  Cathartics act  variously on the bowels.
   2d.  The indirect or consecutive.—These  may,  or  may  not,
 include
   3d.  The poisonous.
   Among the indirect effects of medicines, those namely  which
 depend on dose and condition of subject, we may mention the
 emetic effect of castor oil,  of calomel—catharsis from the latter,
 the diaphoresis from antimonials.
   There are some medicines  of which we know no poisonous
 effect, properly speaking, as of bark, oleum ricini, calomel, &c.;
 while others exhibit such an influence, as opium, alcohol, iodine,
 prussic  acid:  it is one of the  triumphs of our art, to be  able  to
 regulate the indirect influences even of these, so as to  educe
 beneficial results.
   In regard to the effects of medicines, one important observation
 should be kept in mind by every practitioner : that certain of the
 most powerful  and valuable articles of the materia medica are
 accumulative  in their operation, and thus become dangerous.
 Thus mercurials shall sometimes, when administered in repeated
 doses, seem inactive,  exhibiting no obvious effects until at once
 we have  ptyalism, ulceration of the lining  membrane of the
 mouth, and caries of the teeth; the system having become, as it
 were, slowly saturated  with it.  Thus  it is  with  arsenic  and
 thus also  among others with digitalis.   The  first shall be given
in vain, as it might appear, for some days,  when on a sudden
there will be pain and disorder of stomach, with great prostra-
tion, and swelling of the face and eyelids.
  Digitalis will, at times,  act neither  as  diuretic,  nor in any
other way, until, its administration  being persevered in, vertigo
comes on, dim vision, intermittent pulse, palpitation, and perhaps
coma and convulsions. 
31
PRACTICE  OF  PHYSIC

                   OR

     THERAPEUTICS.
   Some classification and  arrangement are  essentially necessary
to assist the progress of learners in all sciences.
   It has been found difficult to agree upon the principles on which
diseases shall be arranged.
   I prefer to all others the  Physiological Nosology, which distin-
guishes the tribes of disease,  according to the seats which they
occupy; the orders of parts (or systems) which they affect; the
functions which they disturb or impede.
   I shall treat of them as they affect—
    I.  The Circulatory organs and their functions.
   II.  The Digestive.
   III. The Respiratory.
   IV. The  Sensorial.   This  class nearly coincides with  the
"Neuroses" of Cullen, Parr, &c.
   V.  The Motory, comprising the diseases of bones, joints, mus-
cles, tendons, ligaments.
   VI. The Generative.
   VII. The Excretory, comprehending the cutaneous affections,
those of the urinary organs, and the local  diseases of the large
intestines.
  Before attempting the cure of a disease, it is necessary that we
should carefully distinguish it from every other; the  diagnosis,
then, of every case, must be considered separately in this relation.
   DISEASES  OF  THE  CIRCULATORY  SYSTEM.

  The diseases of the circulatory system are of paramount impor-
tance, and  require our earliest attention.   Among these, my pur- 
32
 pose being chiefly practical,  I shall  select for consideration such
 maladies as are in our own country and climate of most frequent
 occurrence-^—for example, fevers, hemorrhages,  dropsies, scrofula.
 Yet none of these topics are  susceptible of satisfactory discus-
 sion, without a previous inquiry into the  very extensive  and  im-
 portant subject of inflammation, which either as cause or effect,
 as coincident or consequence, is so generally combined with  the
 principal forms of circulatory or vascular disease.

                     INFLAMMATION.

   Its seat I  suppose to be in the capillary system—the nutrient
 and secretory arteries, the vasa vasorum.  Some however have re-
 garded the fluids, the blood especially, as  liable to it;  but of this
 there is no clear proof.  Its nature is unknown.   There has been
 much useless argument to establish the uniform and essential con-
 tingency of the increase or diminution of  excitement and action,
 in inflammation.  It does not depend upon, nor consist  in, degree
 of action; yet, it would seem, that there is always, at least in  the
 first instance, increased action.   The smaller vessels, like  the
 heart,  are endowed with  the power of expansibility—the  capa-
 city of active dilatation.   We cannot otherwise account for  the
 phenomena;  for it  is absurd to suppose the heart or larger ves-
 sels capable  of elective propulsion or determination of blood to
 any particular part of the body.  The minute vessels then expand
 in the production of inflammation, as they do in blushing, red-
 ness from friction and  stimulants;  but there is some superadded
 essential condition, or blushing would be inflammation.
   There are  two conditions or states of a  part, which precede or
 give rise to  inflammation.  The  most common is irritation__a
 term which implies organic excitement of  the nerves of the part
 and has been used by some pathologists as synonymous with  in-
 flammation.   The second is congestion—where there  has been
 from whatever  cause,  an  undue proportion  of the sanguineous
 fluid forced into the  structure  of any organ thus engorged  or
unnaturally distended—as in inflammation of the liver,  spleen
 and other internal viscera, from the concussions of intermittent
 fever, or the  shock of cold applied to the  surface.  It is  almost 
33
superfluous to remark, however, that neither of these is of neces-
sity followed by inflammation.   The internal organ may disgorge
itself and return to a natural condition ; the irritated part may be
soothed into tranquillity without any exhibition of vascular excite-
ment ; or this may be so temporary and transient, as not to de-
serve the name of inflammation.  The redness from slight fric-
tion on the surface, or from acupuncture, is not inflammatory, any
more than the vascular  excitement of the whole  system from
wine or exercise, is properly fever.
   All inflammation is in nature morbid, as we know both from the
symptoms and the results.   Surgeons recognize a healthy inflam-
mation,  but the  phrase is  rude and  unscientific.   Union  of
opposite  surfaces, by the organization of effused lymph or fibrin,
is made incidentally useful in surgical operations, as for the cure
of hydrocele,  artificial anus, &c; but can no more  be called
healthy inflammation, than  that which unites the pleura costalis
with the pleura pulmonalis, indeed they are absolutely  identical.
Uuion by the first intention, has been attributed to inflammation,
but  incorrectly.   The vessels of divided surfaces are placed  in
apposition,  so  that  circulation  goes on, and among  the  other
functions,  restoration  is effected  by the  deposit of nutritious
matter from the  vessels.  A finger or  piece of flesh, cut off and
replaced,  sometimes adheres.   But in this  case, union must pre-
cede inflammation, or  only one surface   can inflame.  Indeed
inflammation impedes the occurrence of union by first intention.
It occurs  always  to a certain extent  no doubt,  but merely as a
coincident effect of the violence applied to a living body.   Inflam-
mation was formerly attributed to spasm of the vessels, error loci
of part of the blood, lentor, or inspissation of that fluid.  It is
probable  that spasm of the excited vessels does take place;  that
is, that they act more or less irregularly or convulsively, when thus
irritated.    Error loci we know to exist, for the red globules are
seen in vessels which did not previously admit them; but this is
an effect  or consequence of  inflammation, rather than a cause.
There is  no proof of lentor or inspissation of the blood.  The
circulation in the part,  so far as we  know,  is not obstructed,
notably,  that is, not essentially, or of course.  There may be
                              5 
34
 obstruction from swelling, or effusion, or morbid depositions in
 certain cases, but this does not uniformly happen.-
   The general symptoms of inflammation are the same, whether
 its seat  be internal or external—pain, redness,  swelling, heat,
 throbbing.  The pain  differs in kind and  degree, according to
 the  structure of the part affected, its sensibility, and the general
 sensibility of the patient.  It is in proportion to  the suddenness
 and extent of  the  changes which  take  place, being  of course
 greater in acute than chronic cases.   It results probably, from the
 excitement of the minute vessels, which by their dilatation, pro-
 duce tension and pressure on the nerves.
   The redness and swelling are easily accounted for by reference
 to the vascular fullness and determination which exist.   The heat
 of the  part is somewhat heightened, as depending on the vascu-
 larity of  the part, and the force and fullness of local circulation.
 It never  can be higher than the heat of the  interior of the body,
 and is  most notably increased at the farthest point from  the heart.
 Throbbing results  from the admission of a forcible current, im-
 pelled  by  the  heart into vessels which were before too small to
 admit  of such impulse, or which have spontaneously  dilated to
 receive it.
   The local effects of inflammation  are modified by the structure
 of the part in which it occurs, and by the nature of the cause
 which has produced it.   In illustration of the first, we  may refer
 to what  are called the  terminations  of inflammation of the
 serious tissue;  these  are  most commonly adhesion and dropsy,
 sometimes purulent effusion—rarely ulceration.  In inflammation
 of the mucous tissue, we have very commonly purulent  secretions
 and  ulceration—rarely  adhesion, &c.  In  the  skin,  erysipelas
 and phlegmon; in parenchymatous masses, abscess and  schirrhus.
 The modifications from cause, are still more marked and precise.
In certain predispositions we have arthritis,  cancer &c.__each
 peculiar.   From certain morbid agents, we have specific modes
 of inflammation, as upon the application of arsenic, tartrate of
 antimony,  lytta, &c.   Sphacelation seems  to be determined, for
 the  most part, by the intensity of the morbid excitement, rather
 than the nature of the cause.  It may be defined as a  species of
 disorganization, of which death is a  necessary consequence.  Dis- 
35
organizations  are  effected  (as   in  scrofulous and schirrhous
degeneration) without depriving the part of its vitality, and death
may occur without disorganization.  Sphacelus implies a union
of the  two circumstances.
   Inflammation may or may not be attended with the excitement
of general febrile disorder.   After wounds and injuries, especiallyju^ ^fsCffMji§^l
in  vitiated constitutions, and  at  an interval mtdoiunwwngt and
varying, fever is apt to come on with shivering or without it, the
skin becoming hot and dry, the pulse hard, frequent and quick,
the face flushed, and the  eyes red, with headache  and perhaps
delirium.  This is one of the types of symptomatic fever, assum-
ing a  continued form,  that is, without  intermission or regular
and definite remission ;  it is closely analagous to, if not  identical                 t
with,  the  febrile derangement, connected with the long list of
internal inflammatory diseases,  hence called Pyrectic, as  pleurisy,                 ij
gastritis, &c.   In these latter, the  fever supervenes usually with                 1'
great promptness soon after  the invasion of the disease.   Hectic,                 f
the second of the types of symptomatic fever,  is intermittent, and
attends protracted inflammation, both  internal and external.   It
shall receive special notice hereafter.
   In the general treatment of inflammation, we refer  to three
modes of remedial management.
   1. By abstraction of excitement, venesection, leeches, cold,                 '■',
low diet, purgatives, emetics, nauseants &c.                                     '
   It is under this head chiefly, that I would  include the agency
of opium as a remedy for inflammation.  The first  step in the
lighting  up of inflammatory disease  is, often a mere irritation,
which  is capable of being entirely subdued by the anodyne and
soothing influences of  this most  valuable drug.  In its farther                 )
progress  too,  inflammation is  liable to be aggravated  by pain,
which  is the result of morbid excitement of the nerves of a part;                 *
and this can often  be allayed  promptly and  entirely by opiates.                 if
The stale of sleep which they so admirably induce, is singularly
adapted to  promote  the subsidence of all undue actions of any of                 J
the organs,  and especially of the  brain, whose agitation readily                 fl
disorders every fibre of the system, and whose restored tranquillity                 :i|
is so often the harbinger of general repose.                                      | 
36

               From opium also, we may obtain, by proper management of its
             indirect operations, very great benefit as a diaphoretic, and as a
             most impressive stimulant, but these effects are referred to under
             the following heads:
               2. Revulsion, as by venesection; purgatives, diaphoretics, stim-
**.e\Vv$.sii,%lHants> sinapisms, epispastics, &c.
               3.#Byalf.era*i«e influence, as in the mercurial treatment, and
             in the substitution of a new and transient form of inflammation,
             as when we apply a blister  to erysipelatous surfaces, arsenic to
             a cancerous ulcer,  and stimulants  generally  to indolent ulcers
             and  chronic  inflammations.  In strict propriety, perhaps these
             are but modes of revulsive affection.

                                       FEVER.

                The  phenomena of fever, prove the co-existence of two prom-
             inent conditions in  both  the  vascular and  sensorial systems.
             There is evident concurrence in each of
                1. Diminished energy—defective power, with
                2. Undue action—morbid excitement.
                This latter expression implies that with the diminution of the
             amount of power, there is irregular distribution of the remaining
             power.
                The  combination of these elements,  perhaps in varying pro-
             portion in different cases, forms  the proximate cause of fever.
                It  is probable  that the  earliest disturbance occurs   in  the
             extreme vessels, the  nutrient,  and secretory,  and excretory,
             denominated  the  capillary system,  but this is little better than
             conjecture.
                There  are doubtless cases of fever—nay, perhaps classes of
             cases—which seem to impugn  the correctness of this statement;
             where the vascular actions are enfeebled, and the sensorial organs
             excited, or  both prostrated  at once and intensely.  With regard
             to  such instances  it may be observed that  however numerous,
             they constitute, after all, mere exceptions to the  general rule ; no
             disease being so liable as fever, to be modified both by the con-
             dition of the individual whom  it affects, and the circumstances
             which may attend its production and spread. 
37
  Farther, I cannot regard the  true pathology of any disease, as
a mere question of less or more, plus or minus, power or excite-
ment.   There is  always something beyond  this.   There is
disorder  in  the  mode of  performance  of  function—delirium,
depraved sensation, undue dejection, or exhilaration in the senso-
rial system.   In  the  vascular,  early vitiation of secretions,  and
as Stevens maintains, a morbid change in the blood itself.
  Fevers are properly divided into Idiopathic and Symptomatic.
The  distinction  intended,  is generally  recognized  in  marked
cases,  as  when we refer on the one hand to fever from local
injury,  succeeded  by inflammation, and on the other, to the
regular recurrence of an  habitual quartan.   Certain intermediate
instances  are often dwelt on, in which the  peculiarities of these
classes are much softened  down, as in pleurisy, dysentery &c.
The best definition therefore, which can be  offered, is that which
connects  symptomatic  fever  essentially,   with  some  obvious,
regular  and  early local inflammation,  idiopathic  fevers being
such  as do not shew distinctly any such  connection.  The latter
head will then  comprise  inffrmittents, with  the  exception  of
hectic; remittents generally, and among the continued  fevers,
typhus, catarrhal fever and pneumonia typhoides.  Examples of
the  true symptomatic  fever,  are given in  pleuritis, hepatitis,
phrenitis, gastritis, enteritis, the exanthemata &c, with the in-
flammatory fever which  occurs immediately after a severe injury,
and the irritative or  hectic, which comes on later.   Most of the
above are,  however, arranged  in  preference according  to the
 locality of their  characteristic  phenomena,  as phrenitis, &c, and
 the exanthemata.
   It  has been much disputed, whether the first step in the for-
 mation of fever  is the  production of  debility,  or of irritation.
 The true nature of incipient febrile action, is unknown.   Many
 of the remote causes of fever, it is true, are of a stimulant, or irri-
 tating, or exciting quality,  but not all.  Typhus, the " famine
 fever" of Ireland, is the  result of agents  of opposite tendency,
 and large losses of blood are very apt to be  followed by fever.
   Cullen's definition of  fever  examined.   Fevers do not always
 begin with a cold stage.  When they have  so commenced, the
 animal heat of the surface is not always augmented.  The fre-
 quency of the pulse is sometimes diminished. 
38
   Nothing is more strongly characteristic of fever, than the gen-
eral diminution and depravation of the secretions of all the sur-
faces and glands; hence the thirst, the clammy mouth, the furred
tongue, nauseated stomach,  constipated bowels,  harsh dry skin,
paucity of  urine,  which is high colored, &c.
   The ancient notion of the tendency of fever to  run a certain
course and subside spontaneously, is fallacious and  must  not  be
depended on.   The congestions and inflammatory determinations
which belong to the history of fever, tend on the  contrary to the
production  of organic changes in the tissues, which, reacting, keep
up fever, and prostrate the constitution.   Hence,  as these irri-
tations,  congestions and inflammations are at least in a certain
measure controllable by proper  remedies, we must class fever
among curable diseases.  Not only in this way, indeed, is it re-
moved, but we occasionally see  it cut short by impressive meas-
ures,  which  relieve  the system of it suddenly  and at once,  as
venesection,  the  cold  bath, emetics,  cathartics, mercurials, &c.
The perturbing methods of treatment are  therefore  preferable in
their general  results to  the expectant management of fever.
   The doctrine of critical days requires notice.  Crisis  is defined
as a sudden and  notable change, occurring spontaneously in the
course of fever, and  exhibiting a remarkable influence  on  its
character and termination.   The change may be either favorable
or otherwise.   The question is, whether these changes are to  be
expected on certain calculable days.   These days,  if we collate
the writings of the principal and most zealous supporters of the
doctrine, are  the 3d, 4th,  5th,  6th,  7th, 9th, 11th, 13th, 14th,
15th, 17th,  20th, and 21st—thirteen days in twenty-one; the non-
critical days are the 8th, 10th, 12th, 16th,  18th, and 19th—six  in
number.   We cannot  wonder then, if, as is asserted, a majority
of crises do occur on the so-called critical days.   The  regular
observance of the types of fevers, all which refer originally to the
intermittent form, however obscurely,  I think,  has been the cause
of the belief  in critical days.
   The diurnal and  septenary revolutions have been spoken of;
to the combined influence of these, I attribute  the types of fever.
Continued  fevers  usually have reference to  the  quotidian inter-
mittent ; remittents to the tertian, with its modifications, double 
39
and triple, and perhaps sometimes to the quartan.  Remittents
when they become obscurely remittent by protraction,  running,
as the phrase is, into a continued type, exhibit in a still indistinct
way, this reference to intermittent type,  and  these imperfectly
marked references have been called crises.
  The  remote causes of fever shall  be enumerated under each
specific head.
  The effects of fever, the local derangements developed  during
its progress,  and  displayed  in  post-mortem  examinations, vary
both with predisposition and exciting causes.
  The brain, in  its  substance  and upon the membranes which
envelope it,  shows vascular engorgement,  and sometimes the re-
sults of inflammation.
  The mucous membrane of the stomach and intestines, suffers
various lesions  from similar  inflammatory  determination, and
other modes of derangement.
  The  pleura and peritoneum are also attacked—the lungs and
the mucous lining of the trachea.   The liver, especially in warm
climates, is often notably altered  in appearance, being  increased
in size,  in weight, &c. &c.
  These local affections are not necessarily inflammatory; they
are  congestive, perhaps, as often.
  In Crampton's account  of a  Dublin epidemic,  the  following
estimate is given, of the  relative  proportion in which the organs
were altered in condition, or had undergone notable  lesion.  Out
of 755 cases, 76 were of the abdominal viscera, 129  of the chest,
550 of the head.  Similar  tables are  presented us  by Tweedie
and other British physicians.  Among us, owing to  influences of
climate and determinations thereby given, the proportions would
be reversed.  Here the abdominal viscera are chiefly affected, (the
stomach, intestines and liver,) next the head, lastly the chest.   I
believe the former never escape derangement in the warm months.
  Fevers divided into  Intermittent, Remittent, and Continued.
These  types are  fairly distinguishable, although there are cases
in which the distinctive marks are very slight.
  An  Intermittent presents repeated paroxysms  of fever, with
intervals between of absence or apyrexia. 
40
   A Remittent is characterized by notable and regular exacerba-
tions, and diminutions of febrile excitement; there being no com-
plete apyrexia, but an observable approach to that state.
   A Continued fever is so denominated when there is no notable
or prominent difference at regular periods in the degree of febrile
intensity.  The influence of diurnal revolution, is however, gen-
erally observable,  there  being slight morning remissions,  and
evening exacerbations.

                 OF INTERMITTENTS.

   Intermittents assume  various types, according  to  the periods
they occupy.  They are divided into three stages—the cold, the
hot,  and  the sweating.   The whole  time from the  commence-
ment of the cold stage of one  paroxysm, to the commencement
of another, including the apyrexia, is technically styled the period
of an intermittent.
   1. The Quotidian occupies 24 hours in this way, returning
daily.
   2. The Tertian 48, returning every second day.
   3. The Quartan 72, returning every third day.
   Each of these has  its usual hour of access, and  its relative
duration and violence of stages.  The quotidian comes on in the
morning, has the shortest cold stage, but the longest exacerbation
or febrile excitement, continuing about eighteen hours; its apy-
rectic interval about six.
   The tertian  comes on about or a little before noon, duration
about twelve hours; its  interval is long.
   The quartan attacks in the  afternoon, with the longest cold
stage has the shortest duration; continues seldom more than nine
hours.
   These  are the original  types, which are variously complicated;
we have the double tertian, the attacks on alternate  days corres-
ponding in  time  of access, violence, duration, &c.; the  triple
tertian, two paroxysms  on one day,  and one on  the alternate •
the double quartan and the triple quartan are also mentioned.
   The paroxysm of an intermittent  described.  The cold stage
marked by the following symptoms—languor, muscular feeble- 
41
ness,  yawning, stretching, sighing,  paleness of the face, with
lividity of the lips  and ends of the fingers, shrunken counte-
nace with cutis anserina,  a sense of chilliness increasing to vio-
lent trembling and shiverings of the whole  body,  uneasiness at
stomach, amounting to nausea sometimes, and vomiting.  Pain
in the head, and over the back and limbs, pulse small, and feeble,
and quick.
   Hot stage.—The chills alternate with flushes of heat, gradu-
ally pervading the  whole surface,  which is glowing  and dry,
pains in the head and limbs increase, with turgidness of the face
and eyes,  vomiting goes  on, and  bilious matter is thrown up
mixed with mucus  and other contents of the  stomach ; there is
thirst, and the pulse has become frequent, full, and hard.
   Sweating stage.—After some  time a moisture is felt  upon the
forehead, breast, and arms, which progressively extends over the
whole body, and the sweat flowing freely, the symptoms above
enumerated go off, leaving the patient more  or less exhausted.
   Masked or disguised intermittents present, instead of the above
regular succession of phenomena, some single symptom of great
intensity,  occasioned by morbid determination to, or affection of
some  part, as of the eye,  the stomach, the brain, &c.   We dis-
tinguish these by their periodical recurrence and regular abate-
ment,  and the previous exposure of the  subject to the causes of
intermittents.  As to the nature of these " masked cases," (so
called,) I entertain some  doubt,  however.   Periodicity is so fre-
quent  an attribute of disease,  that  we need not refer it to any
supposed connection with intermittent fever  or it,s causes.
   Causes  of intermittents.—Malaria the  principal.  Said also to
arise  from  alternations of temperature, moist clothing, fatigue,
&c.;  but such instances must be very rare.     *
   General prognosis.—Favorable, allowance being made for their
obstinate tendency to recur, the season of the year—vernal being
more easily curable than autumnal attacks—and climate.  In hot
and moist countries, as on the coast of Africa,  intermittents put
on often a malignant and fatal character, and in very damp dis-
tricts  of more northern latitudes, as in Holland  and  England,
(Lincolnshire,) though less immediately destructive, they are te-
nacious and sometimes fatal.
                           6 
42
  Special prognosis.—Favorable, mildness of symptoms, post-
ponement of time of access,  completeness of apyrexia.   Unfa-
vorable, extraordinary violence, anticipation of period of access,
unpleasant feelings and uneasiness during apyrexia, coma in cold
stage, with difficult breathing, delirium in hot stage,  great pros-
tration of strength during  the  sweating stage, or at the subsi-
dence of the paroxysm.
  Effects of intermittents.   Patients sometimes die in the  cold
stage, from  congestive determination to vital organs,  the brain
and lungs; they may sink exhausted (though this is rare) at the
close of the sweating stage,  or when the vomiting  has been
severe.  Enlargements of the liver and spleen are the most com-
mon consequences of the  protraction of intermittents; these may
be either indolent or inflammatory; dropsies, jaundice, hepatitis,
dysentery, may also be mentioned here.    <
  Treatment of intermittents.  During  the cold stage,  external
heat to the extremities and general surface, and sinapisms should be
assiduously applied.  If the stomach be oppressed, a quick emetic
may be given.  The tourniquet has been applied to the limbs by
Kellie.  The lancet has been  used  of late  freely by Mcintosh
and others.  Its effect doubtful, if not dangerous.   Opium is of
all our remedies most generally useful,  and  is capable both of
preventing and cutting short a paroxysm, when given in full dose
with sufficient promptness.  If the chill be severe and prolonged,
in a debilitated  subject, we  may combine it with camphor, pipe-
rine, capsicum,  and other stimulants.
  During the hot stage,  if  special determination to the head be
present in robust subjects, the lancet may be used ; cold affusion
to the head, and the cold bath employed with advantage; a ca-
thartic may  be^iven ; diaphoretics, assisted with cooling drinks.
  In intermittents of malignant character, the symptoms of over-
whelming congestion and of typhoid prostration, must be met by
a resort to stimulants of the highest power—sinapisms and other
modes of  external irritation, brandy,  ether,  and laudanum inter-
nally, in no timid doses.   The stimulating diaphoretics, camphor,
and the volatile alkali, with hot wine whey, and stimulating ene-
mata, are  also of use here. 
43
   During the intermission.—Cinchona is our most important
remedy.   The only objection to its employment  consists in the
inflammatory determination kept up sometimes to some organ, as
the liver, spleen, stomach, lungs, brain.   This being subdued, it
should be freely resorted to.   It is given in substance, in infusion,
tincture,  and  extract.  The sulphate of quinine,  prepared from
it, is a medicine of inestimable value, on account of the concen-
tration of valuable tonic powers; dose, one to three grains, every
two or three hours.  Larger  quantities  excite the stomach and
determine to the  head, and are in ordinary cases unnecessary;
but we meet  with instances  of obstinate protraction,  in which
xfe may administer  with  the  best effect very free doses, as from
three  to twenty grains.
   Piperine shows its best influence in combination with quinine.
It is too  much a stimulant to be used throughout  the  apyrexia,
but may be added with much advantage to the dose of quinine,
just before the paroxysm  is expected.  It forms thus a very use-
ful combination.
   Narcotine, or rather the muriate of narcotine, is highly eulogi-
zed by O'Shaughnessy and other East Indian physicians.  I have
found it, like quinine, very useful in a long list of maladies recur-
rent periodically.
   Serpentaria—not  valuable  alone,  but useful in combination
with cinchona.
   Sulphur—second only to bark in the cure of intermittents, and
particularly serviceable, as it may be given when bark ought not,
in cases of imperfect apyrexia.  Is well applied  in  all masked
intermittents—when mingled with cinchona, forms an impressive
combination.
   The carbonate  and prussiate of iron, and the sjulphate of zinc,
are highly recommended.
   Arsenic—a very powerful remedy; it should be cautiously ad-
ministered ;  best  adapted to the more obstinate chronic habitual
forms of intermittent.
   The above means failing, the patient should be subjected to a
mild mercurial treatment, or sent to take a long journey, or a sea
voyage. 
44
                     REMITTENTS.

             BILIOUS  REMITTENT  FEVER.

  Belongs  especially to warm climates;  produced almost exclu-
sively by malaria, aided by the occasional or exciting causes for-
merly enumerated, heat and alternations of temperature, moisture,
&c.   Strangers from cold countries, or from upland districts, are
predisposed to its more violent, forms, and should carefully avoid
the adjuvant  agencies which bring it on or aggravate it—should
live temperately, but not abstemiously—shun extremes of tempe-
rature, dampness, dews, night air, &c.   Blood-letting, purgatives,
and mercurials,  objected to as prophylactics.   They predispose
by reducing the  system  and rendering it susceptible.
  Symptoms.—Commences sometimes with,  and often withou|,
a rigor or chill;  then follow languor and weariness—gastric un-
easiness—pains in the head, back, and limbs—skin becomes hot
and dry—pulse full and bounding, and abrupt and frequent—rest-
lessness—vomiting—thirst—tongue at first  white and  lightly
coated ;  soon covered with a thick yellow  or brown fur; its edges
red and  indented,  as if swollen and pressed against  the teeth.
Bowels  constipated—stools, when obtained, greenish and acrid.
The exacerbation continues about twelve to eighteen hours.
  Remission or  abatement of symptoms, then takes place in a
greater or less degree.   The return of exacerbation refers to the
tertian period of access, at or a little before  noon—observing
the double  tertian  type in the correspondence of alternate days.
Cases not unfrequently occur bearing analogy to the triple  tertian,
when we  have-on one day two exacerbations,  and on the next
one.   In the exacerbation, if the disease is not checked, the vom-
iting becomes more  frequent—there is heat at the epigastrium,
and pain on pressure—the headache is intolerable—the eyes can-
not bear the light.  The tongue is dark  brown, black along its
central line—dries, is chapped or cracked.  The bowels are cos-
tive, or the stools thin and watery.  Respiration  is more and more
embarrassed with sighing—restlessness—the pulse  sinks, becom-
ing small and feeble.   There is great prostration, with muscular 
45
twitchings;  the fatal termination occurs in from seven to thirteen
days—average about nine.
   Typhoid  state or stage.—After many repeated exacerbations,
the patient sinks sometimes into a condition thus  designated, in
which the symptoms resemble those of typhus.   This more fre-
quently happens among old  residents,  the  termination  taking
place more promptly (whether  favorably or otherwise) in youth
and strangers.   The disease may be, in this  modified form, pro-
longed to thirty and thirty five  days; average fifteen or twenty.
   Malignant  remittent.—The skin cold and clammy ; counte-
nance pale, and livid, and shrunk;  pulse frequent and fluttering;
low delirium or stupor ; syncope ; sometimes painful local affec-
tions of the head,  stomach, or bowels.   Fatal rapidity in many
cases, one or two exacerbations destroying the patient.
   General prognosis in bilious remittent, favorable.  Proportion
of deaths throughout the south and west, as small as in any part
of the world.   In  our  own city, not more than  one in thirty or
forty, perhaps  even less.
   Individual prognosis.—Favorable when the remissions  are dis-
tinct and prolonged,  with tranquil sleep and sweating ; if the
bowels  are  moved easily and the evacuations assume  fecal ap-
pearance and  quality;  if the stomach  become  quieter and the
tongue cleaner and less red.
   Unfavorable when the remission is imperfect and short, when
the stomach is specially irritable, when there is much wandering
of  mind or delirium;  inordinate  frequency of pulse  is a bad
symptom—recoveries are rare when it transcends 130 or 140; _so
are great tenderness of  epigastrium or tympanitic swelling, with
or without vomiting, obstinacy of intestines, laborious breathing,
coma, subsultus, fatuity.
   There is  considerable liability to relapse.   This is to be dread-
ed when digestion is weak, tongue furred or red, bowels irregu-
lar ; occurs  more frequently on the 7th or 14th day.
   Effects of remittents.—If  the patient continues to reside in a
malaria district, remittents often run into intermittents of great
tenacity.   Both in this way  and more  immediately, they are apt
to give rise  to jaundice, dyspepsia—pulmonary complaints, when
there is predisposition—enlargements of liver and spleen, hepati-
tis, splenitis, dropsies. 
46
    Necrotomy.—The vessels of the brain and its membranes are
 found engorged;  those of the gastro-enteric mucous membrane,
 in similar condition.   The spleen and  liver enlarged, discolored,
 full of dark blood, heavy, indurated sometimes, at others softened
 and brittle.   The bile discolored and vitiated, tenacious, floccu-
 lent, granulated.
    Treatment.—The first indication, both in point of importance
 and time, is the reduction of the force of morbid  excitement, as
 directed upon particular organs or parts.  This may be effected
 by the following means :
    Venesection.—Not a general remedy.   Adapted to cases of ro-
 bust, plethoric strangers; to cases also, in which  at the invasion,
 or during the early stages of the attack, the  local determinations
 are specially violent  and  painful, as when  there  is delirium or
 mania, or coma, or great epigastric tenderness, &c.   When re-
 sorted to, should be employed freely, the blood being permitted
 to flow until the pulse yields.  And in precisely the same cases,
 local  blood-letting by cups and leeches, will be found useful after
 venesection.
   Cold bath.—May be considered a general remedy.  Contra-
 indicated by feebleness from age, or other circumstances,  by a
 moist  skin,  by chilliness.  Forbidden also  by determination to
 the lungs, and by the presence  of diarrhoea.  Should not be re-
 peated if it  produces a continued sense  of  coolness.   Affusion
 preferable—next immersion.  Its remedial value cannot be exag-
 gerated.
   Emetics.—Not often called for.   If the stomach be oppressed,
 with imperfect vomiting, may be useful both by cleansing it, and
 by determining  to the  skin and bowels.  Should  be  abstained
 from if there is pain at the  epigastrium,  increased on  pressure.
 The antimonials are in general  preferred.
   Cathartics.—Absolutely necessary in the  treatment  of fever.
 Great care must be taken to choose the least irritating and most
 efficient.   I would avoid  the combination so generally used in
 the southern country in domestic practice, and on plantations, of
drastic purgatives with harsh emetics.  I would select  such arti-
cles as cause  least nausea or griping.   Calomel,  pulv. rhei, and
the Epsom salt, may be given so combined and alternated, as to 
47
produce all the good effects which we can hope for,  from the
evacuation of the bowels, and the disgorgement of the liver, and
other abdominal viscera; and may be prescribed in  such doses,
and at such intervals, as to keep up a permanent and highly salu-
tary determination to the intestinal canal.  But it is not necessary
to persevere in what is termed active purging; and if the bowels
yield readily, we should discontinue the exhibition of cathartics.
Much harm may be done by urging their  use too far, especially
if there be much nausea and vomiting,  with great epigastric ten-
derness, and the stools are frequent and small and mucous, and
attended with pain, or  griping, or faintness, or vomiting.  Yet,
on the other hand,  it is an  error more mischievous, to neglect
entirely this very valuable class of medicines, and  to leave  the
patient to suffer all the unmitigated evils of abdominal congestion
and engorgement, and the irritation of accumulated morbid secre-
tions in the alvine canal.
   The mucous intestinal surface, is one to which revulsive deter-
mination  may be excited  very  safely, and  to the great relief of
more important  and  delicate organs.   Its secretions may be in-
creased to such an amount too,  without any injurious consequen-
ces, as to form a very impressive means of depletion.
   Diaphoretics may be administered in union or alternately with
cathartics.   The saline and sedative are at first to be chosen, as
the nitrate  of potassa with infus. rad.  serp., acetate or citrate of
potassa, acetate of ammonia, and nitrous ether.  The use of these
means should be continued  through the remission and so timed
as to produce  their fullest effect just at the period of exacerbation
—the room being kept dark, cool, silent, and well ventilated, and
cool drinks and ice allowed.  The vapor bath is a good adjuvant
to diaphoretics, internally administered.
   If  the  exacerbation  be  often  repeated,  and your  patient's
strength  seem about to yield, resort to the stimulating diapho-
retics—camphor, the volatile alkali, tinct. opii camph., with infus.
rad. serp. et cinchone.  His  drinks may be stimulating and nu-
tritious, as arrow root, with wine whey, &c.
   Epispastics should  be used as well for their stimulant, as their
revulsive influences. 
48
   When stimulants become necessary, such must be chosen as
shall  least irritate the stomach.   Of these  capsicum and spts.
terebinth, are ascertained to be the  most generally admissible.
Under such  circumstances the  tinct.  cantharid. may be occa-
sionally used with advantage.  By giving rise  to  inflammatory
irritation of the urinary organs, it acts both as revulsive and gen-
erally excitant.
   The irritability of stomach  in bilious remittent, is one of the
most embarrassing symptoms.  It may at first arise from the pres-
ence of crude or improper ingesta,  and afterwards be kept up by
the undue accumulation of vitiated  secretions;  under these cir-
cumstances an emetic or a repetition of emetics will be called for;
but this is very rarely necessary.  If connected with inflamma-
tory affection of the stomach, as shown by  heat there, and pain
increased  on pressure and motion, resort must be had at once to
the mercurial treatment,  our best  hopes  of relief—in the mean
time applying an epispastic without delay.  If of ordinary vio-
lence and duration, it does  injury chiefly perhaps by preventing
the exhibition of such medicines as the condition of the  patient
may seem to call for.   It is improper here,  as  is often done, to
urge the organ  by a great diversity of prescriptions.   It will  be
best to desist awhile from all such efforts, while we employ exter-
nal means only, such as leeches  or cups,  fomentations and sina-
pisms.   Laxative enemata may be administered to determine to
the bowels.   Among the remedies most  in use  for the relief of
this gastric irritation,  are soda water,  the effervescing draught,
lime water, with or without milk, the capsicum pill, small doses of
anodynes, both by the mouth and rectum, and endermic applica-
tions of opium and morphine.
   Constipation is another troublesome attendant.  If  it presents
itself while the pulse is full and hard, and the strength good—bleed
freely and to relaxation.  Dash cold water on the legs and abdo-
men, give purgative glysters, administer large quantities of fluid
in this way, by De Haen's or other proper apparatus.   Do not
hope to  overcome it by increasing  the dose of  cathartics—you
may thus destroy the stomach.  Vary them, using the mildest
and least offensive. 
                             49

  Hiccup in the latter stages is very harassing.  I have seen it con-
tinue three, five, and nine days, and yet the patient recover;  com-
bat it by musk, opium, and the volatile oils.
  The mercurial treatment must be resorted to,  if the attack be
malignant or specially violent; if the patient be feeble or cachectic,
or in bad  health previously to his seizure ; if the disorders of the
place or season be unfavorable—in Sydenham's language, if the
epidemic constitution of the air be bad;  if the case be unusually
protracted, or run into the typhoid state.  The dose should be
proportioned in frequency  and amount to the exigency of circum-
stances, from two to ten  grains  every two or  three hours,  until
the symptoms of incipient ptyalism shew themselves.   Calomel
thus employed does not interfere with any of the other remedies
indicated.  The  objections to this mode of treatment discussed
and answered.  Its occasional inefficacy acknowledged ; its evils
of use as  well as of abuse described.  That it implies some suf-
fering, and perhaps some risk, will not be denied, but these should
be compared or contrasted with the probability of the fatal termi-
nation which it so often averts.   Confessed to  be attended with
much uncertainty in the case of young children; advised there-
fore that  in such subjects, dependence be placed  on the other
remedial measures already suggested.
   Country Fever.—In this city we meet often with a very insidi-
ous and dangerous modification of bilious remittent, originating
in transient exposure to the intensely concentrated malaria of our
low country,  as  by sleeping  a night or more upon a plantation
after the frosts of spring have ceased.  Observation shows that
such an attack is attended with  peculiar hazard,  and the return
to our city atmosphere is  universally believed  to endow it with
special malignity.  The progress of the case is irregular, the re-
missions uncertain both in degree, time of occurrence, and dura-
tion.   The type exceedingly complicated, obscure and confused.
A like aggravation of the  endemic  remittents of the far west,  is
said to result  from similar removal to the healthy uplands,  from
low miasmatic spots, during the  latent period,  and before the
febrile influences of  malaria  have  developed themselves in the
system.
                            7 
                             50

  The prognosis, unfavorable—proportional mortality very great.
Safest to treat such cases,  however mildly they may commence,
as of the worst kind.  My usual resort is to the mercurial treat-
ment, eagerly employing the first well marked remission to give
the bark, either in  infusion, or, the sulphate of quinine.
  It has been mentioned that our remittent runs occasionally into
a typhoid state.  It is sometimes from the very beginning of a ty-
phoid character; these are called congestive cases, and have been
described as " malignant."   In the first stage of such attacks, the
hot bath, (110° to 120° Fahrenheit,) should be employed, and sina-
pisms applied extensively,  the bowels moved and excited by stim-
ulating enemata; and the stimulating  diaphoretics, either com-
bined or alternated with calomel in full doses.   In some instan-
ces of this nature the most energetic and persevering use of stim-
ulants is demanded; among  these a fair and free trial seems to
be due to the spts. terebinth.
  During the convalescence, attention is necessary to prevent re-
lapse or recurrence of fever.  The bowels must  be kept soluble,
though  active purging is not admissible.  Of tonics, the  sulphate
of quinine, the chalybeate preparations, and the elixir vitriol are
preferable.
  The exercises of gestation,  at first in a carriage or boat, after-
wards on horseback, are  however, the best tonics.   The diet must
be carefully regulated as to quantity ; its quality may be deter-
mined by reference to the patient's habits of living.
  A slow or chronic irritative fever continuing  to harass the pa-
tient, evinces the existence of some visceral  obstruction or inflam-
mation of obscure character.   The blue pill, in small dose nightly,
combined with Dover's  powder or some other preparation of opi-
um, in such quantity as to produce a gentle anodyne  effect, will
probably give relief.   In the mean time the diet should  be very
light, and prudent avoidance of every excess or exposure enjoined.
  The mercurial sore mouth may be washed with some astringent
gargle,  as  the sulph. zinci, accet. plumbi,  or alum, the mineral
acids, infus.  cinchone.   After all the  means proposed however,
there is much need of patience on the part of the sufferer, as it is
slow of subsidence under any mode of management. 
51
              remittent  of  children.

  Infantile Remittent—olim, Worm Fever.—Attacks between
the third and twelfth year.  Begins with irregularity of appetite,
furred tongue, offensive breath ; the nights are restless and wake-
ful,  the skin being then  hot and dry,  with much thirst and
headache,  the  pulse frequent and  jerking;  the  child  starts
frequently  in  its sleep,  and  grinds  the teeth;  the bowels are
costive, or irregular,  with loose acrid stools.  As  the disease pro-
gresses, the abdominal disorder becomes more and more prominent,
the  belly is hard  and tumid, the face and feet are puffed and
edematous—there is loss of strength—a light delirium is present,
with screaming at  intervals,  or there are stupor and coma;  con-
vulsions supervene and death soon follows.
   The  disease is ranked  among the remittents on account of the
distinctness of abatement of febrile symptoms, alternating  with
obvious exacerbations.   The period of remission is not regular.
The exacerbation  conies on   sometimes  about noon, but most
usually at  night;  its general  duration  is  from  nine  to twelve
hours.
   Causes.—Infantile remittent may arise from any derangement
of the  digestive system, at the age above  specified, costiveness
allowed  to become  habitual,  the use of unripe or decayed fruit,
unwholesome  diet generally,  want of cleanliness of person, or of
ventilation, especially in the sleeping room.   It is sometimes pro-
duced by the irritation of  worms—lumbrici—present in undue
number in the intestines.
  Prognosis,  generally  favorable.   Signs  of  danger are  such
symptoms as betoken special  derangement of the sensorial func-
tion,  great  restlessness,  delirium, coma,  subsultus tendinum,
convulsions, strabismus, dyspnoea.
   Treatment.—Our principal  remedy is the  purgative, which
must be administered freely.   Calomel is necessary, combined
best with castor oil or rhubarb.   The neutral salts may not be
trusted  to alone.
  The  tepid bath is highly useful in general,  sinapisms if there
is much local determination, cold affusion, if the  head is affected. 
52
 upon that part;  anodyne, mucilaginous enemata, if the bowels
 be loose and irritable.
  If worms are ascertained to be present, combine some anthel-
 mintic with the cathartic means—spigelia (the efficacy of which
 is not however confined to its vermifuge property) melia azedarach,
 turpentine or camphor.  The infusion rad. serp. et cinchon., with
 some alkali, should be given as soon as  an intermission of fever
 occurs, or even in good and distinct remissions.


                 CONTINUED  FEVERS.

                     YELLOW FEVER.

  Its nature,  history,  and type much disputed.  It is a distinct
form of continued fever—not to be  confounded with typhus on
 the one hand,  nor with bilious remittent on the other.   It is an
 endemic of the region we inhabit.   It consists specifically of a
 single paroxysm, which whether long or short is never repeated.
  The  cause of yellow fever is peculiar, and exceedingly obscure.
 No  successful effort has yet been made to designate it, nor even,
 as it seems to me, any plausible conjecture offered on the subject.
  For its production the following conditions are demanded:
  1. Heat.—Some have asserted with precision, that it will not
 prevail when the temperature is below eighty degrees Fahrenheit;
 but this is not made out.
  2. Moisture.—It certainly is most apt to arise in wet summers,
 though to this  rule also there are exceptions.  When it com-
 menced among us in 1828, the season had been unprecedentedly
 dry.
  3. Malaria.—It  is met  with chiefly in malarious situations.
 But  malaria alone, or  merely aided by heat and moisture, is not
 capable of generating  it, or it  would reign annually over our
 lower and middle country, where bilious remittents abound.
  4. A fourth condition is then essential to its generation;  this
 consists in the peculiar circumstances of a city atmosphere—the
 state depending upon a crowding together of human habitations.
 Yellow fever is the disease of cities and towns, not of villages
 and country places.   In the apparent exceptions of its prevalence 
53
in ships at  sea, and in marine and other hospitals, as at Onrust
and Edam, we still have all the conditions above specified.
  The  nature of this last essential cause is unknown.   Its mode
of action is probably twofold—both upon the  bodies subjected
to its influence, in which it creates predisposition, and also may
give development  to the attack; and upon the air with which it
may be mixed,  contaminating  it,  and assimilating it  to its own
impure  poisonous state.  Yellow fever almost always commences
at some foul  wharf or ship,  or in some ill-ventilated lane or
alley—whence, as a centre, it spreads in all directions.
  Yet these influences, however much they may conduce to the
generation and spread of yellow fever, are by no means capable
in themselves of  creating it.  Its existence is confined to well
known  localities, beyond which, it makes excursions  or extends
itself occasionally.  It is unknown in many regions  where all
the foregoing conditions of heat, moisture, malaria and density
of population  are  found, as in Canton, Calcutta, Cairo and  Con-
stantinople.   The  essential generating cause of yellow fever then,
which exists in Havana and Vera Cruz,  and does not exist in
other cities where the temperature is as high and the air appa-
rently quite as impure, is hitherto undetected.   That it is com-
municable both by the transportation of  infected atmosphere in
a foul ship, by ordinary fomites,  and by actual contagious dis-
semination  from the  bodies of  the  sick, is to say the  least
probable, and the evidence in support of this opinion, is every day
accumulating and gaining strength.
  In  the  hot  climates in which  it occurs,  the natives of cities
subject  to its  invasion enjoy the privilege of exemption from its
attack.   In  the West Indies and New Orleans, this immunity is
perfect; in Charleston nearly so.   In colder climates and northern
cities, the case is far otherwise; all are alike and  equally liable
to it.  The following suggestion is offered  to explain  this cir-
cumstance.   The influences  of climate, heat,  and cold, are
opposed or contrasted in their effect on the human constitution.
The  southerner retains from summer to  summer  the habitudes
generated by  the  agencies of heat, as his winters are  neither
intense  or permanent  enough  to  alter these habitudes.  The
northern man, on  the other hand,  is continually undergoing the 
54
alternate affections of two climates—his summers, though shorter,
being as hot as they are in low latitudes, and his winters colder,
and much longer.
  No attack of any other endemic form of fever, as bilious remit-
tent,  tends  to destroy the  predisposition of a stranger to yellow
fever.   This predisposition is, however,  gradually lost by long
residence and complete acclimation.
  Negroes  are rather less  liable to  it than  whites;  they may,
however, be attacked, if born in the interior and  removed to town.
No African is known to have been seized with  it here.
  The  prophylaxis  consists  in  the  careful  avoidance  of all
ordinary exciting' causes.  Temperance, but not abstemiousness
recommended.   Low diet,  venesection, cathartics and  mercurials,
so far from being serviceable, are dangerous and injurious means.
The  heat of the sun by day, and the damp dews of evening and
night must be shunned.
  History and Symptoms.—Yellow fever  presents itself  under
two  modifications,  which depend probably in  a great measure
upon the state  of  system of  the subject attacked,  but  partly
perhaps, also, upon the  intensity of  the  causes applied.   The
modifications  are familiarly referred to in the phrases Inflamma-
tory and Congestive, which are fairly enough characteristic of the
distinctions between the two in appearance, symptoms, progress,
and  necessary treatment.
   Of the inflammatory form.   The paroxysm may  or may not
commence  with chilliness;  to  which soon  succeed heat and
dryness of skin, v/ith gastric uneasiness and pains of head, back
and  limbs,  rapidly becoming intense; anxiety—restlessness—
flushed, turgid  face—red  and watery eye, its motions being
painful.
   Head often attacked severely; patient being maniacal or de-
lirious, and screaming with  sharp pangs—confusion of thought
no uncommon symptom from  the very first.
   Stomach irritable,  with frequent vomiting, which occasions
pain—there is heat and burning there, with a feeling of weight
and hardness, and pressure on the epigastrium cannot be  borne.
   Respiration usually hurried and embarrassed, sometimes slow
and labored—sighing and oppression at precordia. 
55
   Skin pungently hot and harsh, soon becomes yellow or of an
orange or bronze hue.
   Pidse not to be trusted.  In the worst cases little altered;  in
milder attacks, full, hard, jerking and frequent.
   Tongue at first soft and swollen and indented by the teeth—
edges fiery red, centre furred and brown.
   Thirst—water is urgently  desired, as much for the coolness
it imparts to the burning stomach, as for the relief it affords to
thirst.
   Bowels usually torpid and moved with difficulty.   I have seen
a case begin with diarrhoea.
   Countenance marked, and expressive of anxiety, distress, gloom,
impatience, sadness, wildness, terror.
   Such is a description of the first stage, following the descrip-
 tion given by writers, who recognize a division into three obvious
, stadia.
   The  stadium comprises the whole of the febrile paroxysm or
 excitement—its duration from four to sixty or seventy hours; the
 average is probably  thirty-six to forty.
   Second stage—by many considered, but improperly, as a state
 of remission.   "It  is a stadium without any fever."   (Lining.)
 It commences with a gradual abatement of the preceding symp-
 toms.   Head is somewhat  relieved—pains in back and limbs
 disappear perhaps.   Skin becomes cooler, perhaps moist and soft.
 Pulse  nearly natural, but increases in frequency  and  grows
 weaker.   Respiration  easier.  Pain and burning of stomach les-
 sened—vomiting  attended  with less  effort.  Countenance less
 turgid.   Eye less red, and assuming a yellow tinge.
    The patient is less anxious and distressed, and begins to indulge
 hopes of recovery.  This stadium lasts  but a few hours,  never
 more than from twenty four to thirty six.
    The  third stage is distinguished from the second by no mark-
 ed line.  The symptoms of prostration are gradually shaded more
 and  more deeply; the pulse sinks, is quick, unequal and depress-
 ed.  The skin takes  on a  mahogany hue, which  disappears on
 pressure, and returns slowly.   The tongue sometimes soft, swol-
 len,  moist, indented, brown on the top, with a dark streak along
 the central line, often  clean,  and of a deep fiery red,  as also the 
56
 whole mouth  and lips—perhaps dry and cracked.   Stomach ex-
 cessively irritable, its contents ejected, without the effort to vomit,
 either by sudden contraction or hiccup.   The black vomit comes
 on.   The  bowels yield,  with black  acrid and offensive dischar-
 ges ;  the surface  is cold and  clammy;  there is low muttering.
 Hemorrhage often bursts from every outlet, and death comes to
 the relief of the sufferer.
   In  the congestive form, the tokens of open, inflammatory ex-
 citement seem wanting,  the system  being prostrated before the
 excessive force of the morbid cause.
   If the head be the centre of determination, there is lethargy,
 stupor, coma, convulsions.
   If the stomach,  the symptoms resemble those of poisoning with
 arsenic or other corrosive  poison; there is no regularity of pro-
 gress.
   The lungs occasionally bear the onus of the attack,  with livid
 face, difficult breathing, suffocation.
   These cases are all marked, in a peculiar degree, by the ma-
 hogany or bronze  hue of the skin, occasioned, I believe, by slug-
 gish or suspended action of the capillaries, perhaps by actual pa-
 ralysis of this system of vessels.  It  is a most gloomy symptom.
   Under these circumstances,  the patient usually utters little or
 no complaint—there may be no vomiting—the epigastrium bears
 pressure—the  bowels are costive—the tongue dark, red, smooth
 and dry—the countenance stolid and fatuous—the skin insensible
 to irritation, or if inflamed, becoming gangrenous and sphacelated.
   Anomalous cases, forming pathological curiosities, occur in this
 terrible disease.  I have seen a patient walking about to the very
 moment of his death, carrying with  him a vessel to receive the
 black vomit which he threw up frequently and copiously.   Oth-
 ers die complaining of a single symptom, as headache and the like.
   The duration of yellow fever varies much.  It may terminate
in a few hours.  It may run on into a typhous condition, and last
 from twenty to twenty five days.  The majority of deaths occur
here on the fifth and sixth days.
  Convalescence tedious, and apt to be harassed by abscesses on
 the surface. Relapses  never occur.   Second attacks are  rare,
and do not  happen  to subjects  remaining in the same locality. 
57
When the residence is changed,  by advancing from a northern
to a southern climate,  the protection thus  gained is not however
absolutely to be depended on.
   Prognosis.—Yellow fever,  the most dreadful  form of fever,
taking precedence even of the plague in proportional mortality.
The  deaths at different times of  its occurrence and in different
localities, stated at one in three, (Gibraltar, 1804)—two in three,
(Philadelphia, 1820)—seventy per cent. (Xeres de la Frontena,
1820.)   In our  city,  will not average one year  with another,
more than one in eight—different epidemic  seasons differ much,
however, in proportional mortality.   It is greater of course in the
congestive forms.
   The  newly arrived stranger—the much exposed,  as sailors—
the intemperate, are in the greatest  danger.  With  reference to
this latter circumstance, national habits are of importance—the
Irish, Germans, English,  and Scotch, suffer most;  French and
Italians least.  Young children when attacked are in great danger.
   Unfavorable symptoms.—Much pain, heat, and tenderness at
the epigastrium.  Weak pulse.  Skin relaxed and moist, unless
this be  attended with  notable general  relief and the strength
holds out.   Shortness of  first stage of febrile paroxysm ; I saw
a patient recover, however, in whom it had lasted but four hours.
Suppression of urine, or rather want of the secretion, considered
by Rush  a  fatal sign; I have met with it in several instances,
two of which recovered.   We must not confound it with stran-
gury, which is almost always favorable, yet I have lost a patient
after its occurrence.  Spots on the skin, petechie, vibices.  Hem-
orrhage is among the  very worst  tokens of danger.  Blood may
be seen oozing  from the tongue, gums,  lips, and cheeks;  it is
ejected from the stomach;  it colors the urine, and flows profusely
from the bowels.  It is often highly offensive in smell, and occa-
sionally is so thin that it  refuses to coagulate.   It  may exude
from  every opening of the body,  draining away the strength of
the patient—from the nose and ears, and from the surfaces of
blisters.  Finally, black vomit.  This symptom deserves a sepa-
rate consideration.
  Black vomit consists of black specks or  flakes, swimming in a
brownish fluid  resembling  soot and water,  coffee grounds,  &c.
                             8 
58
It is not, as was once supposed, composed of portions of the vil-
lous coat of the stomach, eroded and sphacelated, and mingled
with the fluids of that cavity, for recoveries occur after its having
taken place, and I have collected it from stomachs entirely une-
roded.
   It is not bile in any manner vitiated or altered, for it has been
found in the stomach when the  pylorus  was closely contracted,
and has been traced into the gastric vessels.  It is found often in
the stomach and intestines when the gall bladder  and ducts are
filled with ordinary bile.  It differs besides in all its qualities from
bile, however changed.  It is not  blood effused into the stomach
and there acted on, for in distinct hematemesis the blood under-
goes no similar change, retaining its purple hue, however long it
may remain in the organ—to suppose a peculiar fluid thrown out
in the diseased stomach which shall  be capable of so  changing
the blood,  is merely offering two conjectures to explain one phe-
nomenon.  It is more simple to suppose the black fluid, as I believe
it, to be the result of a specific action of the  gastric vessels upon
the blood which they contain.  It is so characterized before leav-
ing the vessels, being traced into their very calibre.  It has been
maintained to constitute in its secretion the termination of a spe-
cific form of inflammation, and though this may be the  fact in
the gastritis and enteritis of yellow fever, yet it does not apply
to its occurrence in other circumstances, as in pregnancy, rupture
of uterus, dropsy, &c.
   I have not  seen black vomit occur in yellow fever earlier than
the 16th hour, the 20th and 30th.  It makes its appearance for
the first time most frequently during the second stadium, improp-
erly considered as a remission, towards its termination—or at the
commencement of the third stadium.   I  have seen many  recov-
eries from it; many more  have occurred in the practice of my
friends.
   Autopsy.—Brain  usually with its membranes engorged and
inflamed—water has been found in the ventricles, and rupture of
blood-vessels with  evtravasation.
   The lungs and pleura sometimes found to have undergone in-
flammation. 
59
  The stomach invariably more or less inflamed on its inner sur-
face, sometimes on its outer also;  so with the duodenum.   I have
never seen gangrene or sphacelus.
  The liver often healthy—so the gall bladder.
  The urinary bladder, not unfrequently inflamed and contracted.
   Treatment.—In the inflammatory form, venesection is usually
considered an essential  remedy.   It may be indicated as in bil-
ious remittent, but I do not regard it as generally necessary or
useful.  Local  blood-letting  is  unobjectionable;  and cups or
leeches may be applied to the head and abdomen.
  The cold bath has proved in my hands equally effectual with
the lancet, and safer. Affusion at first or immersion, afterwards
aspersion or sponging should be employed as the case progresses.
  Cathartics form an indispensable part of the treatment.   The
articles best retained by the irritable stomach,  and in part there-
fore, for that reason preferred by me, are calomel and the sulphate
of magnesia.   These prescribed in alternate doses will act prompt-
ly, freely and effectually.
  Emetics are injurious, unless when the patient has eaten a full
meal just before the attack, and the vomiting has not been suffi-
cient to empty the stomach.
  Diaphoretics are useful.  The pulv. antimon., infus. rad. serp.
and ether nitros. may be employed.
  But our reliance cannot be  placed on any other mode of man-
agement of this terrible disease than that commonly referred to as
the mercurial treatment; to this, therefore, I resort early.
  Calomel should be given in large and free doses, repeated with
a frequency proportioned to  the violence of the case, until the
disease is subdued.  It is a dangerous error to cease from its ex-
hibition when ptyalism  has merely commenced.
  It is objected to this mode of management, that it is too slow.
I have produced the alterative influence of the remedy, as shewn
by ptyalism, in 15 hours—20, 24, and 30 hours.  This is early
enough in the majority of the cases. Armstrong, with much less
urgent employment  of it, talks of succeeding  " within the  first
and second days."  The best adjuvants  are the  cold bath and
the saline purgative. 
60
  Those who complain of the danger and ill effects of mercurial
remedies, are chiefly such as have never used them or seen them
properly used, and with the requisite boldness and promptness.
They find calomel, they tell us, too powerful in doses of one,  two
and five grains;  we find  it, alas!  deficient in power, though ad-
ministered in half drachm and drachm doses.
  If it be alleged that some die in spite of its  use, we have but
to acknowledge that man is mortal,  and will die of curable dis-
eases occasionally, and in spite of  our best skill and  most ener-
getic medicaments.
  It is farther true that if the case has progressed too far for res-
toration, the effects of the remedy will add not  a little to the  suf-
ferings of the patient;  nay, he may die with a sloughing cheek,
and gums, and tongue ; but this no more detracts from the value
or propriety of the plan of  treatment, than the sphacelation  of a
blistered spot from the value and  propriety of epispastic applica-
tions, and is to be explained on the same principle, namely,  that
the vascular action has fallen so low  under the circumstances, as
to be incapable of supporting the local inflammation superinduced.
  The permanent ill effects of mercury are rare and much exag-
gerated ; they have never occurred in my own practice.   I have
never met with them in an  adult.  I have  seen in  consultation
two  such deaths (in a young child  and a youth of fifteen)  as I
have above alluded to.
  In children, I should not resort of choice to the mercurial.   Its
alterative influence is seldom well developed in these cases.  The
milder purgatives used freely in the  first stage, and  afterwards
the combination of an  alkali with an anodyne diaphoretic, such
as a weak solution of carb.  potass,  with a small portion of tinct.
opii camph., form my usual  treatment of this  class  of patients.
If the intensity of local determination requires  it, the lancet may
be used or leeches may be applied to relieve the head and stom-
ach.  While the  skin continues pungently hot, the cold bath will
be exceedingly beneficial, and even after the earlier excitement
has subsided, we shall  find much advantage in occasional spong-
ing with ardent spirit.  The restlessness of the latter stages  too,
is often subdued, and  comparative tranquillity procured, by im-
mersing the little sufferer in the tepid bath. 
61
  The acetate of lead is much extolled by Irvine and  others ; I
have not succeeded with it.   I suppose it best  adapted in  cases
of the hemorrhagic character, perhaps the most intractable of all
the modifications of this terrible pestilence.  In such cases I em-
ploy also the nitrate of silver, in  free doses internally,  and  as an
application to the bleeding surfaces.
  The tinct. cantharides may be  employed in  the latter stages,
both as a stimulant and to procure revulsive determination to the
urinary organs.
  The spts. terebinth,  is highly  useful with similar views, and
under similar circumstances.
  Certain measures in the mean  while may be instituted for the
relief of particular symptoms or local affections.  To relieve the
violent headache,  shave the head, pour cold water on it, apply
pounded ice, leeches to the temples, a blister on the  back of the
neck.  For the irritability and pain at stomach, apply  leeches to
the epigastrium, and sinapisms.   The alkaline solutions, the alka-
line draught, opiates occasionally, and  in the latter stages capsi-
cum in pill and  infusion, and turpentine, may be used with ad-
vantage.
  Muscular pains, sometimes intolerable—relieved by sinapisms
and opiates.
  In the congestive form of  yellow fever, the hot bath is invalu-
able. .  Sinapisms, stimulants by the mouth and in enemata, and
mercurials.   An active emetic has succeeded in rousing the in-
susceptible system—mustard and salt being preferable for this
purpose.
  The apartment  must be kept in all cases well ventilated and
perfectly clean; so also the  bed and  body of the  patient.   Re-
coveries from yellow fever have occurred under such  extraordi-
nary circumstances, that the condition of the sick man  can  never
be known to be absolutely desperate.  He must never, therefore,
be abandoned.

                  CATARRHAL FEVER.

  The most frequent of epidemic fevers—most common in  win-
ter and spring,  and in cold  climates.  I have, however, seen it 
62
 epidemic here  in  every month  of the  year in different years.
 When generally prevalent is called influenza.
   Causes.—May be produced by exposure to damp and cold, and
 alternations of  temperature; but  is not, in the majority of in-
 stances, dependent  in  any degree upon the sensible qualities of
 the atmosphere.
   History and Symptoms.—Catarrhal fever commences usually
 with chilliness, headache, sneezing, coryza, red and watery eyes,
 light soreness  of throat  and  larynx, with cough and rattling of
 mucus in the chest—at first no expectoration ;  afterwards of mu-
 cus and muco-purulent matter—tongue red on the edges, and cov-
 ered with white fur—pulse frequent, hard—skin  hot and dry,
 pains in the back and limbs—unaccountable depression of spirits—
 exacerbation at night, with restlessness and  cough, and  some
 gastric uneasiness—with tension and stricture across the chest.
   It sometimes happens that the whole  force  of the attack is
 determined to  the  head, assuming a peculiar form.  There is
 extremely violent pain in the forehead, usually on  one side; the
 eye of that side, and  the skin  surrounding it, looking  red and
 inflamed.   The pain is  depressing and  insupportable, and  takes
 on an intermittent or distinctly remittent character,  the exacerba-
 tions recurring for the most part in the morning or  forenoon, and
 exhibiting  an  obstinate tenacity.  It is obviously seated in the
 frontal sinus, and occasionally affects the antrum.   The voice is
 altered in a characteristic manner.
   General prognosis  favorable—fever  subsides,  expectoration
 becomes  easier and thicker,  skin moist,  respiration free,  sleep
 refreshing,  appetite returns.  In adults rarely fatal,  unless by ex-
 citing more serious disease.  In the predisposed, apt to  produce
 phthisis in  its several forms, especially chronic bronchitis.  Asth-
 ma has followed.   In pregnant women may bring on  uterine
hemorrhage and abortion, whether by its specific irritation,  or by
the mere mechanical  agitation of repeated  coughing, is not de-
cided.  In old people and very young children, may suffocate by
engorgement of the air  cavities—olim, Peripneumonia notha.
In infants, the symptoms of croup  often  mingle themselves  with
 the other circumstances denoting the invasion of catarrhal fever,
The determination to the head is  sometimes so great, as to give
rise to coma and convulsions. 
63
   Treatment.—Catarrhal fever may often be arrested in its form-
ing stage by the  free exhibition of opium,  and indeed of other
stimulants, but the opportunity for the use of these is transient.
In the  more common inflammatory form, venesection is often
advisable—if the  tongue  be much furred, or the breathing dif-
ficult, an emetic—next purgatives—these maybe combined with
diaphoretics—the latter persisted in, and combined with anodynes
and ^demulcents when the  excitement is, in a certain degree,
subdued.  Dover's powder is here an  invaluable medicine.  If
the local irritation run high,  a blister may be applied to the chest
or the back of the neck, according as the  thorax or head is most
affected.
   The  peculiar  catarrhal  affection of the frontal sinus,  above
described, is of very difficult management.   The lancet will pro-
cure a certain degree of relief.  Cups or  leeches applied to the
temples are of some service.   It will  be necessary to determine
to the bowels by an active cathartic.  These depletory measures
being premised, I give at bed-time a full dose of Dover's powder,
employing pediluvium, and  keeping warm cataplasms with mus-   #g
tard applied  to the  lower extremities.  The sulph. quinine and
arsenic have been recommended in these cases.
   The chamber should be kept at a regulated temperature during
the treatment, say sixty degrees of Fahrenheit, but wesliventilafed.
Bed curtains  objected to.   Convalescence  carefulr^iprotected
from exposure.
   Catarrhal fever sometimes puts on a typhous or low character,
more  frequently in Europe and in large cities—here rarely, unless
among  exposed negroes.  In such cases, the hot bath, sinapisms,
stimulants and  stimulant  diaphoretics, with opiates, must  be
promptly and perseveringly  employed.
   In children, catarrhal fever takes on a modified character—there
is much gastric and intestinal disorder—the tongue is much furred
and becomes ulcerated, so also the lips and mouth—the stomach
irritable—the breath  fetid—the stools dark green, and offensive,
or thin and  acrid—the pulse incalculably rapid—the  thirst  in-
tense—the breathing hurried and difficult, with great restlessness.
In these  cases the emetic is necessary, and will probably require
repetition.   The  warm bath  also, is exceedingly useful.  The 
64
 mild purgative must be perseveringly administered, alternated at
 night with  an anodyne diaphoretic.  If convulsions supervene,
 cold water must be poured on the head from a height.

                 '  TYPHOUS FEVER.

   A favorite arrangement of fevers among writers, from Cullen
 down to Good, contemplated three forms—the Synocha, as pwrely
 inflammatory—Typhus, or  purely  nervous—and Synochus, a
 compound of the characteristics of the two.  According to the
 views  formerly advocated, I regard all fevers as of this mixed or
 Synochus form.
   Typhus may arise  from any of the causes  which  produce
 debility direct, or from abstraction of accustomed stimuli—bad
 innutritious scanty food—cold or fatigue long  continued—depri-
 vation of fresh pure air.   These  circumstances  depress  the
 energies of the sensorial system, and the symptoms of such de-
 pression are prominent.   It is the Famine Fever of the Irish—pre-
 vails among the free blacks in the northern cities to a great extent,
 and  in  camps, jails, foul  ships and hospitals.  It occurs among
 our plantations sometimes, from the filth of the negro houses;
 and a removal to new huts  is found both remedial and prophy-
 lac^c.    ^
   TWi<#fs  fever is contagious—it is also of epidemic dissemi-
 nation.
   It has been variously divided and subdivided.   The old English
 writers distinguish Typhus Mitioror Nervous Fever, from Typhus
 Gravior or  Putrid Fever—the more recent speak of Simple, In-
flammatory, and Congestive Typhus, as mere grades, characterized
 by difference of intensity, and affecting in their progress differ-
ent parts of the body in different modes.  The French recognize
many  varieties,  the Simple, Adynamic,  Ataxic,  Putrid,  &c.
There is still better foundation for the division into Cerebral and
Abdominal forms.   An  essential distinction is, by some  writers
maintained, to exist between "Typhus proper" or "true Typhus"
and  " Typhoid fevers"—phrases which have now come to be
universally employed  among medical writers, yet without suffi-
cient definiteness.   There is no  agreement or uniformity in the 
65
views of those who argue  most strongly for this essential differ-
ence of type.   The characteristic distinction^nost dwelt on, are
a  peculiar mode  of  intestinal  lesion,  and an exanthematous
eruption ; but it is not clearly settled to which  of the varieties of
this class of fevers, these symptoms are confined.  Dr. Gerhard,
for example, represents true typhus as free from intestinal lesion,
which  he affirms  to be regularly present in typhoid fever, the
DothQn entente of Bretonneau.  Yet he admits that this "folli-
cular  ulceration" may occur " incidentally" in  true typhus.  On
the other hand, the majority of European writers, describe this
epidemic  and  contagious  typhus, as  very frequently, nay, in
some  localities, " uniformly complicated" with the condition of  '
the bowels.   I cannot, therefore, venture to rely on any of the
diagnostics proposed,  or look upon any of the  suggested distinc-
tions  as well defined  or specific, and shall continue to regard all
the varieties of typhus and typhoid fevers as mere modifications
of a single type.
   There is no class of cognizable cases in which the exanthema-
tous  eruption  is of  regular occurrence.  Chomel, writing of
" typhoid affections," says it is wanting in about one fourth the
whole number of  cases.   I have  not seen it in more than that
proportion, perhaps because a majority of our  patients here are
blacks.   The  intestinal lesions are not constant, any more than
the exanthema, in any season, or in any special type; seeming to
be referrible to locality rather than to any other condition or cir-
cumstance.  Armstrong and Lawrence  have  seen  fatal  cases
without  it.  Andral recognizes a whole  class  of ataxo-dynamic
fevers, " in which no  lesion of the  digestive tube exists."   Lom-
bard  states  the following facts.  In Paris and  Geneva,  he found
this lesion uniform—an essential element of typhus;  in Glasgow
it occurred not oftener than once in three cases—in Liverpool and
Dublin  in a still smaller proportion.  In Birmingham he found it
again uniform.   In London, Dr. Tweedie says, it affects not more
than  one  in four, varying with the seasons, and met with most
frequently in autumn.  Here it occurs often, but is by no means
uniform, and  seems to me  to  depend on the  protraction of the
cases, rather than on any other contingency.
                             9 
66
   Typhus Mitior—vu\go, Nervous Fever,  usually occurs spo-
radically,  comes  oji slowly and very gradually;  anorexia, with
furred tongue, and unpleasant taste in the mouth precedes—there
is  chilliness, weakness,  and languor—depression of spirits—op-
pression at  precordia—sighing.   The pulse is frequent,  small,
and weak—the skin becomes hot and dry—there is headache, or
vertigo, or light  delirium.  The duration of these mild cases is
uncertain, and may be measured by septenary periods.  Hf>r the
first  and  second weeks the bowels will probably  be  torpid and
inactive;  in  the third, they begin to be  disturbed and irrita-
ble, with  diarrhea, colic,  and meteorism.   The stools are small,
dark,  and offensive.   The eruption, which has been regarded as
characteristic,  comes out  in the second week, about the ninth
day.   It consists of minute  rosered spots,  circular,  very little
elevated,  disappearing on  pressure.   Their  duration is very un-
certain.  A very different  cutaneous affection is often met with.
Minute hemispherical  vesicles, called Sudamina, are found on the
sides of the neck and in the groins and arm-pits.  They are filled
with a transparent fluid,  and are more  easily felt  than  seen.  I
have  not  often  noticed them.   Still later,  and in the more un-
promising cases, petechie appear.  These are easily distinguished
by the central red spot, caused by extravasation, which cannot be
obliterated by pressure.   When  the  patient  is to recover, the
symptoms above enumerated subside gradually; the skin is soft,
the tongue pale and moist, and he sleeps calmly and refreshingly.
Or, about the tenth or eleventh day, the muscular debility be-
comes great, with tremors  or subsultus tendinum, the pulse rapid,
the tongue dries, is of a deep red hue, and chapped or cracked—
the teeth  and lips covered with a dark, tenacious sordes—gloom
and anxiety, with muttering delirium supervene, with picking
the bed-clothes, and  catching  at  imaginary objects  in the air;
coma, or brief convulsion,  precedes death.
   Prognosis generally favorable in this form of typhus.
   Typhus Gravior—vulgo, Putrid Fever—scarcely ever sporadic
—spreads rapidly by contagion or  epidemic influence.  Com-
mences with  alternations of heat and cold, succeeded  by a
pungently hot,  harsh  dry skin.  The countenance expressive of
anxiety and distress;  the face turgid, with dark red flush; eyes 
67
heavy and red,  headache severe, mind disturbed and dejected ;
pulse small, hard, tense, frequent, irregular; tongue coated with
thick brownish or yellow fur;  gastric  oppression  great, with
nausea and retching; bowels torpid.
  In a short time, three or four days, tongue becomes dark, red,
clean, smooth, dry, cracked—mouth and teeth  encrusted with
sordes—pulse sinks, and is feeble and undulatory and very rapid.
Syncope  on  moving—subsultus tendinum—hurried  respiration,
with sighing and sobbing,  or coma with  slow and laborious
breathing ; breath fetid; petechie  and  vibices,  hemorrhages of
black blood—death from the fifth to the thirtieth day.
   Prognosis in Typhus gravior, doubtful.  All symptoms which
betoken increased sensorial and vascular prostration are unfavor-
able, as  stupor  and insensibility to  external impressions and
irritations.  Meteorism  is not  only a gloomy symptom, but  a
dangerous condition.   It is of twofold  character.   1.  A mere
flatulent  distention of the intestines with air: this may give rise
to  perforation of the bowels  when ulceration of its tissues or
softening is  present.  If painful it may destroy the patient by
the irritation it produces; if painless, it shows a loss of sensibility
in  the parts,  perhaps an impairment of their natural contractility.
2.  Effusion of air within the  peritoneal  cavity.   This has been
denied,  but  may I think be reasonably inferred when the alvine
movements  go  on, with discharges both of flatus and feces, the
distention continuing  undiminished.   This  I have  repeatedly
seen.   On the other hand reviving attention to these impressions,
eruptions about the mouth,  boils on every par**»f the body, a    •%
fuller and larger pulse, are favorable.               *4#>          ^j
    Autopsy.—In  different cases different organs  are found  most   ^
affected.  In some there is arachnitis;   in others, effusion into
the ventricles and upon the surface of the brain; in all there is
vascular  turgescence;  a softening  of some part of the brain is
occasionally  met with.  The  lungs are often found engorged,
and  sometimes hepatized.   The abdominal viscera rarely escape
injury, especially in protracted attacks;  the mucous  membrane
of  the  stomach  and intestines showing various conditions of
disease, from mere vascular injection, with or without thickening
and  softening,  to ulceration and even partial sloughing.   This 
68
         ulceration most frequently attacks the glands of Peyer, less so the
         isolated follicles;  hence most commonly found in the ileum.   I
         have seen them in the colon also, perforating in one instance the
         coats  of a  large vein, and  occasioning death from hemorrhage,
         when the patient was apparently convalescent.   Their presence
         is to be feared whenever we have an irritating obstinate diarrhea.
         They perforate sometimes  through all the  coats of an intestine.
         I once saw such an ulcer in the ileum.  The patient after eating
         an orange,  was suddenly seized with violent  abdominal pains,
         and died in a few hours.   On examination I found several pieces
         of the  orange  in the peritoneal cavity, which had evidently
         escaped  through  an ulcer of about  one  third  of  an inch  in
         diameter, of ragged edges, situated near the  lower end of the
         ileum.
            Treatment.—In the milder cases, it will suffice to empty the
         stomach with an emetic, followed by a purgative.   The best is
         the combination  of mere, dulcis and pulv. rhei, persisted  in to
         a moderate extent for a  few  days.   Diaphoretics may be given
         in the mean time, assisted by the tepid or vapor bath.   We may
         unite  both these purposes by the exhibition of an infus. cinchon.
         et serp. with sulph.  magnes. in small quantity.   If the disease is
         obstinate, and the strength of the patient threatens to yield, re-
         sort to calomel in  proper doses as an alterative, while you employ
         stimulants  freely  internally.  Wine is the best of them ; should
         be given unmixed—white preferable, as Madeira and Sherry;
         Port may be chosen if the bowels  are loose.   Sinapisms and
/fontJ-  vesicatories  may  be applied, and in such  succession,  that the
 jfrstlAf  patient  muet be continually under their influence.
     &     The  mercurials do not seem to be well borne when there is
         much abdominal irritation, unless combined with opium.  If this
         be contra-indicated we may prescribe  with advantage the  acet.
         plumbi in  small  doses.  Here too,  the nitrate  of silver is used
         with good effect.  It disposes the mucous ulcers to heal, and
         seems to relieve tympanitis.
            In  the management of cases  of typhus gravior, our task is a
         delicate and difficult one.   Our urgent indications are to  relieve
         morbid excitement  and  undue  determinations  to vital organs,
         with the least delay, and the  least subtraction  from  the vis  vitce. 
69
   Venesection seems so obviously forbidden by the great apparent
debility,  that it requires courage  to  resort to  it.   A moderate
bleeding will sometimes be well  borne and do service in young
subjects  of good constitution, with  tense  pulse and vehement
local determination.  The  topical  detraction  of  blood  is, how-
ever,  generally to be preferred.  Leeches  or  cups  should be so
applied as to relieve the organ suffering most prominently.
   The cold bath will be useful if the  skin  is hot  and dry.  If
cool and constricted, the  hot bath  should be substituted.  An
emetic is next  serviceable; if it do  not move the bowels suffi-
ciently,  it may be aided  by simulating  enemata;  or,  if the
strength allow it, a cathartic—the combination  of calomel  and
rhubarb, above  mentioned, is preferable.   The mercurial treat-
ment should  not be omitted—it affords our best hope of safety.
In the mean time, stimulant diaphoretics should  be freely  em-
ployed, as camphor, the volatile  alkali, aided  by wine whey and
infus.  serpentaria.   The vapor bath is often advantageous under
these circumstances.
   Opium is considered  m  a doubtful remedy.   I often employ,
however, the camphorated tincture with good effect.  Indeed I
see no reason for the avoidance of opium, if indicated, as it often
is, by intestinal pain and  spasm,  and diarrhea.  In very many
cases I use it without hesitation, and so far as I am aware with-
out injury and with decided benefit.   Coma vigil, which perhaps
bears to somnolent  coma the same relation  that somnambulism
has to sleep—a very annoying symptom, and one which not only
distresses but exhausts the patient—may thus be relieved.   It is
often  of great  importance  to procure a few hours of refreshing
rest and repose, and there is nothing but opium available for this
purpose.
   Sinapisms may  be  applied extensively and  frequently; but
vesicatories,  although they are often beneficial, yet embarrass us
occasionally  by sloughing, especially in the latter stages of pro-
tracted cases.   Wine is infinitely our best and safest stimulant,
and should be given unmixed;  it is important  that the patient
should take it with pleasure and in abundance.
   When wine  seems to fail of its  stimulating influence, and the
patient still sinks, we must resort to the various modes of admin- 
70
istering ardent spirit.  Of these,  milk punch seems  least irrita-
ting, and deserves a preference for its nutritious quality.  In cases
which still seem tending to a hopeless stage  of prostration, we
may resort to the tincture of cantharides, phosphorus, and turpen-
tine, which, though not the  safest, are among the most active
stimulants.
  The mineral  acids constitute  agreeable  drinks,  quench  the
patient's  thirst well, cleanse his mouth,  and correct  the fetor of
his discharges.
  In tedious cases, the parts pressed on as the patient lies in bed,
must be relieved by all  the arrangements employed  in cases of
fracture—the points of pressure  must be  changed and  often
gently rubbed.   The body  and clothes and apartment of the sick,
must be kept scrupulously clean, and the latter well ventilated.


                PNEUMONIA TYPHOIDES.  ,

  The form of fever which I treat of ujader  this appellation, was
noticed first in Massachusetts in 1806, whence it  spread  north-
ward into Canada, and  southward  until  it  reached the state of
Georgia.   It appeared in Philadelphia in 1813—in Charleston in
1815, and underwent in this course numerous modifications, from
varying  circumstances  of  locality  and predisposition.   Among
common  people, it was known  as " the cold plague,"  " spotted
fever."   I have arranged it as a new and  distinct disease ; some
contend,  however, that it is a revival of the ancient " febris pete-
chialis"—others  that it is a mere typhoid form of influenza.
  Causes.—It was justly,  and indeed of necessity, in its first
appearance and  early progress, above alluded to,  ascribed to a
peculiar epidemic constitution of  air; the modes of excitement
being precisely those which give  rise to attacks of, and predispo-
sition to typhus, as low  bad diet,  fatigue, long  exposure  to cold
and damp, bad air, &c.  Negroes  seem to be specially predisposed
to it, perhaps from their constitutional  inability  to endure severe
cold.  The number of cases which we meet with, indeed, seems
to be  very  directly proportioned to  the severity of any given
winter. 
71
  History and Symptoms.—The most common form throughout
the southern  section of our country is that in which the tokens
of pulmonary irritation are prominent.  It is ushered  in  by a
chill, succeeded by pains in the head and chest of great severity.
The skin becomes hot and dry—the pulse frequent, small, irreg-
ular in force—the respiration  catching, or hurried and  embar-
rassed, with teasing cough—there is  great muscular  prostration,
with shifting pains in the back and limbs—the tongue clean and
fiery red.  A degree of delirium exists often from the first, sinking
soon into a low muttering condition.   On the third or fourth day
the tongue becomes  coated with a  dark  crust, and dries—the
teeth  and  lips are covered with sordes—the  pulse grows weak
and undulatory—from a sleepless state the patient falls into heavy
slumbers, or is comatose—the breathing is more  and more diffi-
cult, and death follows.  Or about the 8th, 9th, or 10th day, his
expectoration becomes freer—the  anxiety less—delirium sub-
sides—the  pulse rises,  becoming fuller and slower—a soft, warm
moisture bedews  the surface, and he recovers.
   The general prognosis  in this form of pneumonia typhoides
is favorable.  In  individual cases  the  unfavorable  signs are ex-
treme anxiety and dejection, restlessness, debility, insusceptibility
to external impressions, dyspnea and orthopnea, with livid coun-
tenance, petechie and vibices, inattention to light,  the pupil being
fixedly dilated or contracted.  On the other hand, cheerful hope,
uniform warmth of surface, easy breathing with  free expectora-
tion, intelligent attention to surrounding objects, and pulse fuller
and slower, are favorable omens.  Duration usually from six  to
twelve days.
   This form of pneumonia typhoides, is also frequently modified
in our southern country, by combination with circumstances  of
gastric and hepatic disorder.  The  first  stage is characterized
more distinctly by the tokens of open inflammatory excitement.
The pulse is full  and  frequent—the tongue furred,  with nausea
and retching—pain in the  chest and  dyspnea.  This state does
not last long, prostration soon following, with the symptoms re-
counted above.
   The anginose  cases, or those in which the throat was affected,
were  not unfrequent  in the middle Atlantic states.  There was 
72
  in these,  at first, slight soreness of the throat, with ordinary ca-
  tarrhal symptoms.  On a sudden, respiration became much impe-
  ded, and  great prostration took place.   The fauces and  tonsils
  were of a dark mahogany hue.   The proportional mortality was
  very great—the patient sunk in a1 short time irrecoverably.
    The lethargic cases, described by the Massachusetts physicians,
  as occurring among females, deserve  notice :—" There was uni-
  versal, deadly coldness—the skin as white as polished marble and
  smooth—countenance perfectly placid—pulse  imperceptible at
  the wrist—action of the heart scarcely to be felt—respiration only
  by gasping, and that not frequent."—Report Med.  Soc. Mass.
   Sudden deaths, under anomalous and inexplicable circumstan-
 ces, occasionally took place during the epidemic prevalence of the
 disease.   Men  died in the fields, being seized when at work, and
 sinking before they could be carried home.  Others again seemed
 to be taken off by the most inadequate ailments, "dying,"  as the
 phrase was,  "of a pain in the foot, or in the ankle, or knee, or
 wrist."  Children seem to be exempt from its attack.
   Autopsy.—The thoracic viscera bore the chief marks of inflam-
 mation.  Flakes of lymph were sometimes found attached  to the
 surface of the  heart.  The lungs were sometimes hepatized.
 The brain and its membranes showed similar determination and
 engorgement.  Effusions ofserum, of lymph, and of a sero-puru-
 lent fluid, were found on the surface and in the ventricles.
   The abdominal viscera presented no regular appearances.  The
 blood was black.   The odor of the dead body was sometimes less
 offensive than during life.
   Treatment should  vary with the form and  circumstances of
 the case ; these being much influenced by locality, the reports of
 remedial management, accordingly differ much.   Venesection
 much trusted to, usually in our southern country  in the first stage.
 I did not see it often required.
   An emetic is often used in the first stage with advantage,  or an
 emetico-cathartic.
   The stimulating diaphoretics were, however,  the remedies
most generally confided in—Dover's powder, carb. ammon.,  cam-
phor, &c.   Stimulants, both external and internal,  should be as-
siduously employed. 
73
  In the anomalous cases described above, opium constituted the
almost exclusive dependence of physicians,, and was exhibited in
very large doses;  it deserves the highest confidence and the most
unlimited eulogy.  The mercurial treatment is recommended by
the New England  physicians.  I have not  found this resort ne-
cessary, however, in any case.
  The convalescence is  slow, and for a long  time  imperfect.
Various tonics have been  recommended, of which many prac-
titioners  have chosen the preparations  of arsenic.   I  prefer,
however,  the cinchona—placing even before the sulph. quinine,
the compound infus. cinchon. and serpentaria, with some alkali.

                 SYMPTOMATIC FEVER.  --

  May be defined as obviously  connected with loeal  injury, de-
rangement or  irritation—and subsequent to or consecutive upon
the local disorder.
  May be distinguished  into the  Continued and Intermittent.
I know of no  remittent form of symptomatic  fever, properly
speaking.  Symptomatic fever in both these types may be con-
nected with the  same local  excitement—the former  (in such
case) always preceding  the  latter, being connected with recent
injuries and acute inflammations;  the latter taking its origin in
chronic and subacute inflammations, and supervening upon uncured
injuries of long standing.
  Continued symptomatic  is hence styled inflammatory;  inter-
mittent symptomatic has received  the appellation of hectic, the
fever emphatically of irritation.
  Inflammatory symptomatic is  the continued fever with which
every surgeon is familiar,  as following within a  short period,
wounds of soft parts, injuries of the head, fractures and compound
dislocations.  Here we have  all the  ordinary tokens which de-
note the  presence of fever—hot dry skin, flushed and turgid face,
red suffused eye, anxious countenance, tongue red and foul, thirst,
nausea, and gastric oppression, headache, languor, muscular pain,
occasional delirium, a pulse bounding, abrupt and frequent.   The
history of this form of fever is the greatest  difficulty in the way
of exclusive  humoralism.  It is not  even  pretended, so far as I
                            10 
74
 know,  that  the incipient phenomena here imply any cognizable
 vitiation of the  blood or the fluids.   It arises also in connection
 with internal  local  inflammations, as  pleurisy, hepatitis,  sore
 throat.   Indeed  it usually becomes of paramount importance in
 all these pyrectic disorders, of which it forms an essential part.
   It  is subject to be modified by the seat of local affection, and
 the state of constitution of the patient.   In gastritis and enteritis,
 the fever is of low character or adynamic, with small pulse, great
 muscular weakness and prominent tokens of sensorial depression;
 in  phrenitis  and rheumatism the strength is less impaired,  the
 pulse full  and  bounding,  and the tokens of general vascular ex-
 citement  are  prominent.   In erysipelas we  may have either of
 those  states,  of high  excitement, or  of typhous  prostration,
 according as the  patient is  of  robust or feeble constitution, and is
 situated in a crowded, ill-ventilated hospital, or in the fresh pure
 air of the country.
   Of the treatment of this  form  of symptomatic fever, we cannot
 speak  in this place without  impropriety; we shall discuss it as
 we proceed, in reference to each special case.
   Hectic—intermittent symptomatic fever—is on the other hand,
 remarkable for this trait in  its character, that it preserves its reg-
 ularity  of  history, and  progress, without any modification of
 consequence from any circumstance whatever.
   An  idiopathic hectic has been spoken of by J. Hunter, Good,
 and Percival, but (as I believe  may be shown) altogether inac-
curately, and on  no good grounds.
   Hectic is connected with a vast number of external sources of
 irritation.   The local disorder from which it arises, may be seated
 in any viscus * or part  of the body—is usually of the inflamma-
 tory kind,  and  must have been of some considerable previous
 duration.
   Nor is it modified by the peculiarity of function of the part
 thus  affected, as other  fevers are,  being identically the same
 whether based upon bronchial irritation, lumbar abscess, phthisis
  * There is a single exception.  I have not, either in reading or observation
with any one instance of the supervention of hectic upon any form of dis
affecting the brain or its membranes. 
75
tuberculosus, or  cancer uteri.  The formation and absorption of
pus is not, as was formerly thought, necessary to its production;
it  accompanies  induration and  obstruction of the  mesenteric
glands,  and of the pancreas, and gouty and rheumatic and scrof-
ulous swellings of joints without suppuration.
   The predisposition to hectic is specially developed in connection
with  the scrofulous diathesis, and perhaps extends throughout
the phlegmatic temperament.
   When fully developed, hectic  presents two paroxysms in the
twenty four hours,  one  coming on two or three hours before
noon,  the  second eight to twelve hours later.  There is some-
times,  though perhaps not generally, a formed chill, succeeded
by hot, dry skin, with burning heat at the soles of the feet and
palms  of the hands;  pulse  small, hard, tense, abrupt, and very
frequent; there  is great  paleness  of face, with a small circum-
scribed spot of florid red on each cheek; sparkling eyes, thirst,
tongue  smooth  and red, as also the lips and mouth, with some-
times light aphthous ulceration ; the stomach retains its tone, and
the  appetite and digestion are good, yet there is great muscular
debility, and  great emaciation;  the nails are adunque, the teeth
and sclerotica are of pearly whiteness.
   The patient  is usually cheerful and full of hope.  I think  I
have observed,  however,  that  this is  only the fact  while the
digestive system retains its tone, and would regard it as diagnostic;
always inferring disorder of the chylopoietic viscera,  or  some
one of them, when the spirits are depressed.
   The emaciation of the patient,  even when he eats heartily,
may be accounted for in two ways.  Either the digestive function
is directly impaired,  which  happens  sometimes, with diarrhea,
&c, or the respiratory function is imperfectly performed—animal-
ization and assimilation of chyle, which can be perfected only in
the lungs, remain incomplete.
   The stages of the symptomatic intermittent are less regularly
exhibited  than  in  the  idiopathic  intermittent.  The  day par-
oxysm  rarely or never shows a sweating stage.   The night sweats
of consumptives, &c. are,  I think, the termination of the night
paroxysm. 
76
   Hectic usually supervenes with the access of the day paroxysm;
to which is some time after added, the evening or night parox-
ysm—the first,  then, being absent for a while ; it again appears
towards  the conclusion of the case, and both harass the patient.
I  have,  however, seen hectic  develope  itself with the  double
diurnal paroxysm from the first.
   Treatment.—In general terms,  if the local affection whence
hectic is  derived be curable, our attention  should be directed to
its management.  If it cannot be cured, but can be taken away,
let it  be removed surgically.  If  it can  neither be cured  nor
taken  away, we must aim our efforts at the reduction of the
excitability and  irritability of the patient, and at the diminution
of the influence of the local irritation upon the system.  Narcotics
and tonics must, with these views, be resorted to.   Of the first,
opium, or some of its preparations, morphine, mur. and acet. mor-
phine, narcotine, and denarcotized laudanum, will be the chief—
prussic acid,  spider's web and conium, have  been recommended.
   Of the tonics, cinchona is the best.  The sulph. quinine may
be used,  or the infus. cinchone etrad. serpen,  cum. carb. potass.
vel sode.
   I  have succeeded in preventing the day paroxysm, not unfre-
quently,  with the combination of quinine and  piperine, formerly
mentioned.   It  does  not,  however, seem  to exert  a  similar
influence over the night paroxysm.
   The metallic salts are much used,  arsenic especially.  The
tinct. acet. eth. ferri, is a useful and agreeable  tonic.
   The mineral acids do something in restraining the debilitating
night  sweats and diarrhea.   The  mur. tinct. ferri, I prefer, as
combining the advantages of the last two classes of remedies.
   Sulphur has been also employed, upon the analogy of its utility
in idiopathic intermittents, but to little purpose.
   Fresh  air, exercise, change  of place by travelling—these when
they can bo* borne, are incomparably the best tonics. .   -
'"■'''      :' • ■>      '
                        SYNCOPE.

   Leipothymia.—Defined by Cullen—" Motus cordis imminutus
vel  aliquamdiu quiescens."   This  languor or  suspension of  the 
77
circulatory function, is the  prominent point  in its description or
history.
  Causes.—Among the predisposing, we  may rank  general
debility from previous disease or suffering—constitutional mobility
of fibre, both accidental and hereditarily transmitted.  The exci-
ting or occasional, may be arranged under three separate heads.
  The 1st,  comprises certain  structural disorders of the heart, or
of the large vessels or parts  in  the  immediate neighborhood,
which may mechanically interrupt and disturb the regularity of
the circulation, as passive hypertrophy or aneurism, ossifications,
effusions, &c.
  2d.  Such circumstances  as depress the circulatory  power,
whether directly or indirectly—hemorrhage,  inanition from want
or from protracted disease, inordinate discharges, whether natural
or morbid, the removal of the abdominal distention  in dropsy, by
allowing  the blood to rush into the vessels from  which it had
been  for some  time  previously  expelled by pressure of  fluid.
Pregnancy presents occasional  attacks of  syncope,  as giving rise
to undue determination of blood to the uterus, leaving the heart
insufficiently excited.
  3d.  Under this head I include those agents which make their
primary impression upon  the  sensorial  system—pain,  sudden
relief  from  great pain; disagreeable  impressions not absolutely
painful,  as  the effect of heat and bad air in crowded places, of
unpleasant  odors—or  from  idiosyncrasies, odors not unpleasant;
the sight of disgusting objects;  most of all, of the passions and
emotions, as joy, grief, terror, horror, and  impatience.
  How these latter act is  difficult to point out with precision;
none of them are positively sedative in their operation.   Cullen,
ingeniously attributes the result to a rapid and sudden exhaustion
of the nervous energy.  Perhaps something ought  to be ascribed
to the very inordinate cerebral determination, which undoubtedly
follows  the  application of the above causes ; this may be so ex-
quisite and  exclusive, as to leave the heart so  far unsupplied, as
to render its action languid or interrupt it.  That such cerebral
determination  is  an occasional coincident in syncope, is evident
from the occurrence not rarely of convulsions from venesection,
and  in recovery from the fainting  state. 
78
  Fainting  comes on with an oppressive sense of weakness and
languor,  with paleness or lividity of the visage.  The  pulse is
weak or ceases,  the  skin  is  cold,  the eyes are turned upwards
and  half closed.   The respiration is scarcely to be perceived, or
there is gasping and moaning—the patient falls insensible.  After
an  uncertain  duration,  the  surface  being in  the mean  while
clammy, cold, and  pale or  livid,  the circulation is gradually
restored,  the  breathing  more distinct, sensibility and strength
return.  Recovery is  attended with vertigo generally, and more
or less nausea ; there is sometimes vomiting.  I. have twice seen
violent convulsions—quasi epileptic—in  patients not subject to
attacks of epilepsy, either previously or afterward.
  Diagnosis.—From  apoplexy, distinguished  by  the paleness
and  coldness of the face and skin, the feebleness and quickness
of the pulse, and  the languor of respiration.   From asphyxia,
generally, by the history of preceding circumstances.
  Prognosis,  almost  universally favorable.  A few fatal  cases
are, however, recorded.
  I  am inclined to  suspect  that we  should place here, some at
least of the  deaths  ascribed  to what has been called " simple
apoplexy," i.  e.  apoplexy without  any traces of cerebral lesion.
It has been affirmed,  that coup de soleil is often " a pulmonary,
not a cerebral apoplexy."  If so, may not  the  condition of the
lungs  thus alluded to, be owing to intense syncope ?—the blood
being congested in the thoracic vessels, because denied a passage
through the inactive heart.
   Treatment.—'Modified by cause and condition of the patient.
If syncope be  produced by the first  class of causes, above recited,
a cure is not to be  hoped for.  As palliatives, physical repose
must be enjoined, and  mental  tranquillity; diet unstimulating,
but  moderately nutritious.   Perpetual blisters  or setons in the
chest or arms are used ;  venesection and digitalis.
  In cases  of the second order—those namely connected with
inanition—the patient must  be placed in a recumbent position,
so as to allow of a freer and more forcible passage of blood  to the
brain,  now insufficiently stimulated—dash cold water  in his
face, apply  ammonia and  other  pungent volatiles to his nostrils
and eyes, warmth to  the  extremities, sinapisms, and other irri- 
79
tants—electricity and galvanism, if at hand.   When recovering,
give him some warm nutritious fluid, with wine.
  The  management of cases arising from  the third series of
causes,  will be more nice and delicate.   If the patient have been
excited by the more violent passions, his pathological condition
presents some of the contingencies noticeable in apoplexy, and it
will be  perhaps advisable, to take blood  from the jugular vein or
temporal artery, or at any rate, to apply cups and leeches to the
temples and neck.   If by the less vehement emotions, as pity or
disgust, external irritants will probably rouse him, and stimulants
and antispasmodics complete his restoration.
   To prevent recurrences of syncope, the general health must be
properly regulated  by observance of a proper regimen and diet—
nutritious but unstimulating  aliment being preferable—and  the
use of tonics, the metallic salts apd mineral  acids being preferred
—and above all,  exercise in the open air. \
   Women are much more liable than men to attacks of syncope ;
children are seldom seized with it; I have, however, seen sev-
eral attacks  of  great violence and long duration in a child  not
more than seven  weeks old.

                   ANGINA  PECTORIS.

   Syncope  anginosa—Sternalgia—Asthma dolorificum.—An
obscure disease,  probably an  affection of the heart.  Its nature
not well ascertained.  Spasm  perhaps of the cardiac fibres or of
some of them—attended with great pain in the chest, and sense
of suffocation and impending death—paroxysmal, recurrent.
   Causes various.   It is connected often,  but not always, with
the plethoric condition—sometimes with  gout—rarely  appears
before  middle age.  Autopsies have exhibited diversified struc-
tural  derangement  of the  heart  and  large  vessels; thus  the
coronary arteries of the  heart  have been found ossified, so have
the cardiac valves—hypertrophy concentric and eccentric—but
none of these appearances are constant.
   The earlier paroxysms brought on by violent muscular exertion,
as  in  walking against the wind, or ascending a height;  after a
time, the  slightest effort occasions a return of the habitual par- 
so
 oxysm, as in coughing,  &c,  until at last it invades, without
 obvious cause.
   History.—The first attacks,  produced by severe exercise,
 cease as soon as  the  patient stands still; when it has become
 habitual, they may last an hour or even more.   The pain in the
 chest is  exceedingly intense,  shooting  across the sternum, and
 extending  down one or both arms (most commonly the left) to
 the  elbow or wrist.  There is dyspnea, the countenance being
 pale or livid; the pulse varies much.
   Prognosis unfavorable.   Death not  unfrequently occasioned
 by the violence of a  paroxysm.   The tendency to recur is ob-
 stinate, and  the system  sinks under a repetition of attacks.  I
 have seen apoplexy occur at the termination of a paroxysm.
   Treatment.—During the paroxysm, if the patient be plethoric
 and of robust  habit,  and the  case  recent, bleed promptly and
 freely, with revulsionjlof the most rapid and impressive character.
 Cold affusion is often useful.  If he'be, on the other hand, feeble,
 or the disease chronic and habitual, the most vehement stimulants
 are  demanded,  as ether,  laudanum,  brandy,  sinapisms  to the
 chest.
   In the intervals we  proceed with  reference to the cause and
 the condition of the patient.   If there be organic affection of the
 thoracic viscera—regulated diet,  rest, small  bleedings, digitalis.
 If the patient be arthritic, the treatment of gout is required.  If
 plethoric, endeavor to restore the balance of functional power and
 action—if  debilitated,  stimulate and revive  him.  Tonics are
 much employed.  Exercises of  gestation are well borne and
 highly useful; the metallic salts, the mineral acids and sulph. qui-
 nine are also serviceable.   Much stress is laid upon  the effect of
 revulsives and counter-irritants, as epispastics applied to the wrists
 and  ankles, and setons  and issues in the arms  and the  thorax.
 The pustular inflammation of  tartrate of antimony, excited and
kept up for a long time, is said to have been  of great advantage.

                      HEMORRHAGE.  * fly-

   May be here defined, a flow of blood from  some part of the
 body, without wound or external  injury;  apt to be  considered a 
81
 sign of rupture of some blood-vessel;  this is, however, not very
 often the fact.   Ulcers may corrode the coats of a vein or an ar-
 tery, or they may otherwise  lose  their  power  of cohesion, but
 usually the blood is poured out from an  unbroken  surface, by a
 sort of diapedesis or transudation, not well understood.
   Divided into Active and Passive.  Cullen  has placed hemor-
 rhage among the Pyrexie, regarding fever as an essential part of
 the definition of active hemorrhage.  This  is an error.  Active
 hemorrhage frequently takes place unpreceded  and unattended
 by fever.  Yet  it is most  generally soon followed  by a febrile
 exacerbation—a statement which is also  true of  what are called
 passive hemorrhages.   Good has substituted  the preferable phra-
 ses, Entonic and Atonic hemorrhage.   The first occurs when the
 system of the  patient  is at or above  the ordinary condition  of
 strength or tone.  Atonic or passive hemorrhage, when he is no-
 tably below this point,  and in a weak and enfeebled state of gen-
 eral health.
   Causes of hemorrhage.—Among the principal of these, plethora
 is much dwelt on by authors, and  deserves a moment's consid-
 eration.
   Plethora was looked on by the older writers as of several vari-
 eties ; they recognized  P. ad molem—ad spatium—ad volumen
 —ad vires.
   Plethora ad molem contemplated the absolute  superabundance
 of the vital fluid—hyperemia.  This I do not believe to exist in
 any case; though  it  is a favorite opinion of Andral and other
 justly celebrated moderns.  Plethora ad spatium expressed the
 quantity in reference  to the  contracted state of the vessels.  It
 may be questioned whether something of this nature  does not
 form a part of the early history of congestive and malignant fevers,
 as shown by the oppressed pulse.   Plethora ad volumen regards
 the supposed expansion of the blood itself.  By some such effect
 on the actual mass, which is subject to the universal law of in-
 crease of  volume with  elevation  of temperature,  we account for
 the headaches of spring and early summer, apoplexy and insola-
 tion, as well as the frequent hemorrhages of  that season.   Ple-
 thora ad vires is a condition of the system in which  the mass of
fluids and the force of circulation are disproportioned to the tone
                            11 
82
of the vessels containing them or to their power of resisting the
impulse incessantly acting upon them.  If in any part the integ-
rity of the tissues of which the vessels are composed is impaired,
they must then give way;  hence the hemorrhages in diseased
lungs, and from inflamed surfaces.   Such degeneration of tissue,
is among the most important predispositions to hemorrhage.
  Its occasional causes are, in  general, such  circumstances as
either excite or increase the force of the circulation, and  such as
give rise to strong local determinations—running, leaping,  violent
passions ; all stimulants under the first head ; under  the  second,
cold, heat, their alternations, diminution of atmospheric pressure,
as at great heights,  external violence, improper  postures  of the
body, ligatures, undue employment of certain organs,  as  among
goldsmiths and musicians.
  Hemorrhage may occur from either arteries or veins; in early
life, the blood is usually inferred from its florid color  to be  arte-
rial—in old age, venous.   Each of the individual hemorrhages
seems  to be  more  specially incident to a  given stage of  life;
Epistaxis  in  childhood, Hemoptysis at puberty, Menorrhagia,
H. proctica and H. cerebri  in old age; scrofulous constitutions
most liable to them all.
  The premonitory symptoms of hemorrhage,  the phenomena
which immediately precede  its  appearance,  are  analogous  with
those which  denote the presence of inflammation.   The  part
from which the blood is to burst  forth, is  affected often  with a
sense of heat, throbs and suffers pain of some kind, usually sharp
and  pungent; there is also a feeling  as if it were swollen and
heavy.
  The hereditary transmission of hemorrhagic tendencies is not
denied; and  numerous examples are on record,  in which whole
families are thus affected in successive generations.
  Hemorrhage is remarkably liable to recur, and in many cases
observes a regular  periodicity of  repetition.   This is,  by many,
attributed to lunar  influence, and with much plausibility.  He-
morrhage was anciently regarded as a salutary effort of  the vis
medicatrix natural, to save the system from worse evils; and this
notion is even now prevalent concerning two of  its forms—epis-
taxis and  hemorrhoidal  discharges of blood.  The utmost that 
83.
can be made out in favor of this notion is, that one disease is thus
substituted for another;  hemorrhage  is no less a disease, and re-
quires proper management to avert serious and even fatal conse-
quences.
  All hemorrhages may thus be vicarious or revulsive, as is often
noticed in cases of obstinate amenorrhea.  They may burst forth
from any part of the  surface of the body, as from the  mamma,
the finger, or as I have  myself seen,  from the skin of the cheek
just below the eye,  at that  part which  is so often discolored  in
sexual diseases of females.
  Particular Hemorrhages.—Epistaxis or  bleeding  from the
nose, often preceded  by headache, vertigo, flushing of  the face.
Cold should be applied to the surface, either generally or partially,
and determination to the head relieved by the lancet if necessary,
and saline purgatives.   If it is apt to return, a blister should be
applied occasionally to the back of the neck,  or a seton introdu-
ced there.
  Bleedings from the gums and fauces are sometimes very troub-
lesome, and afford  us an opportunity of remarking—1st.  That
hemorrhage is often a simple transudation; the blood has been seen
issuing from the whole surface of the mouth, gums, tongue, &c,
without ulcer, or erosion, or wound of  any kind.   2d.  That the
unmanageableness of hemorrhage, when it is of embarrassing ob-
stinacy, or recurs frequently, is owing sometimes to a loss or im-
pairment of the coagulating quality in the blood.   I do not affirm
this to be always true, but I know it to be occasionally so.  Cold
and astringent washes will, generally, check the discharge.
  Hemoptysis, or spitting of blood.   Rarely occurs as a primary
disease; but for  the  most part, attends upon  inflammatory and
scrofulous affections of  the  respiratory organs and their tissues.
It may happen, however, in individuals whose lungs are not im-
paired in structure—Hemoptysis plethorica.  Hemoptysis gener-
ally follows puberty, and takes place  between the  15th  and 30th
years of life.
  Diagnosis.—The  blood  is thrown out from the mouth after
coughing or deep hawking or expectoration, frothy, and of a bright
florid  hue—there is usually pain or heat and weight in some part
of the thorax. 
84
                Prognosis.—Not usually attended with  great imminent risk.
              Few bleedings from the lungs are so profuse as to kill at once,
              but it may happen.   In general the danger  arises from the previ-
              ous condition of the patient, whose prospect is gloomy, if he have
              labored under any chronic pulmonary disease, whether bronchitis
              or pneumonia proper.   There is much less to fear—indeed, there
              is no great reason for dread, if he be free from previous disease
              of the thoracic viscera.
                 Treatment.—If hemoptysis  be entonic,  the pulse  firm  and
              strong, and especially if febrile symptoms attend, venesection
              must  precede other remedies.  The lancet must,  however,  be
              employed with caution.  Much harm has been done by  its rash
              and indiscriminate use.  A good domestic prescription  is the ad-
   z          ministration of common salt, which may be taken largely, and is
 U.L: -. •«•■/,    often promptly efficient in checking  the flow of blood, which it
iftc ,t,i"C^j '   does probably by stimulating  the  extensive surfaces of  the pha-
i.'•■■'    or^    rynx, esophagus, and stomach, and thus deriving from the neigh-
              boring thoracic vessels.  It is also  serviceable by  nauseating,
              when  taken abundantly.   Other nauseants are exhibited with
              benefit—ipecac, especially, which I prefer—tart,  antimon. and
              the sulphate of zinc. <
                As sedatives, the nitrate of potassa and digitalis are often resort-
              ed to.  Some have ventured  on cold applications,  but this is at-
              tended with much doubt and risk.
 i  ^" ty *yyJ /f   ^ne acetate °f leQd is prescribed here as  an astringent, and is
-! ou >~*p *}i*+ undoubtedly useful in cases of a chronic character.   When com-
 i   "         bined with opium, to diminish irritation, and with ipecac, so as
              to produce slight nausea, it is among our very best  formule.
          V ■'   Revulsion must be attempted vigorously.   Sinapisms and blis-
              ters should be applied to the chest and limbs, and the former may
              be kept under the perpetual irritation of vesicatories, or of the tar-
              tar emetic ointment.
,,'    /           Cough may be  allayed by demulcents and opiates.   Strict
     / /       silence enjoined—the diet kept very low—and the patient, for a
     !         time, remain perfectly at rest.         \
                In atonic  hemoptysis, we  must modify our treatment, by ab-
              staining from venesection, and allowing a freer and  more nourish-
              ing diet.   Here opium may be given pretty largely ; and the mu-
( 
85
riated tincture of iron will be found serviceable as a tonic and
astringent.  Absolute silence must be advised. -                {•
  Hematemesis,  or vomiting of blood.   Blood thrown up from
the stomach is  grumous, dark, clotted, and mixed with mucus,
and other contents of that viscus.   The discharge is often pre-
ceded  by gastric uneasiness  and oppression,  with faintness and
nausea, and sometimes heat or a pricking pain.  These symptoms,
with the absence of cough and other respiratory disorder, readily
distinguish the disease from Hemoptoe.
   Causes obscure.   Intemperance predisposes to it;  brought on
by  external violence, by straining to vomit, by  obstructions to
abdominal circulation, as in pregnancy and  in disorders of  the
liver and  spleen, and by the suppression of some accustomed
evacuation, as of the catamenia in women, and the hemorrhoids
in men.
   Prognosis.—Not generally attended with great danger.
   Treatment.—If entonic, with  pain  and heat of epigastrium
and hard  pulse, venesection and  the  Epsom salt should be re-
sorted  to, and the  bowels freely operated on.  Cups or leeches
may be applied  to the epigastrium, which  should afterwards be
irritated  by sinapisms.   It is more frequently atonic  however;
the pulse is feeble, and the whole frame debilitated, and requiring
a very opposite  management.  Stimulants  and astringents  are
required.   Small draughts of brandy and water may be given—
acet. plumbi  in  moderate doses administered with opium;  the
tinct.  mur. ferri is  also useful; a vesicatory should be applied
over the  stomach without delay, to prevent a return.  The infus.
cinchone, with  any  of the mineral acids, may be taken,  and a
generous diet allowed.
  Hematuria, or discharge  of blood from  the  urinary organs,
though not of frequent  occurrence, will  sometimes fall  under
your care.  It is generally brought on by accident  or violent
muscular exertion.   The most obstinate case which I have seen,
was regularly  produced by coition.
  This hemorrhage  generally requires, and is readily managed
by venesection,  mild cathartics, cold applications to the pubes,
and perseverance in a recumbent position.   If tenacious, we may
use the acet. plumbi  and  the  tinct. mur. ferri as astringents. 
86
  Hemorrhagia proctica.—Discharge of blood from the anus, is
of very rare occurrence, idiopathically, being for  the most part,
an attendant upon  hemorrhoids, dysentery,  &c.   I have met
with three or four cases of spontaneous flow of blood  from the
anus, however, when there v/as no hemorrhoidal tumor, and the
bowels were otherwise apparently in a healthy state.
  Besides the remedies enumerated under the former heads, you
will find much advantage here in the employment of cold and
astringent enemata.

                        HYDROPS.
                        i,
  Dropsy is generally assigned to consist in a preternatural col-
lection of serous fluid in one or more of  the cavities of the body
or in the cellular membrane.   The definition is thus taken from
a single symptom, but the pathology of the disease is exceedingly
obscure.
  Dropsies  may be  local or general.  By the first we mean a
collection of fluid in some part, without disorder of the general
system  or farther extension of the effusion  of fluid.   General
dropsy is a phrase  which implies the existence  of hydropic
diathesis—that  is,  the tendency  to effusion of fluid every where
—with  the actual  presence of some collection.  Hydrocele is
exclusively a local collection of fluid—so is ovarian dropsy—so,
for the most part, hydrocephalus.  Anasarca may be an insulated
or exclusive affection.  On the  other hand, ascites and hydro-
thorax are almost  invariably connected with, dependent upon,
and symptomatic of general hydropic diathesis.
  It is  usual to account for  the  accumulation of fluid  in these
cases,  by the supposition that the natural and healthy corres-
pondence between  exhalation and absorption is interrupted—
impaired either locally or generally.  Some  maintain an undue
excitement—some a relaxation of the exhalent vessels-^-others
suppose an imperfect action or condition of debility in the absorb-
ents;  but there is an almost universal accordance in the  doctrine
that the fluid accumulated, is the same which is thrown out in
health by the exhalents to lubricate the surfaces, as the phrase is,
of the  cavities.   The correctness of this view of the matter is
f 
87
rendered doubtful by the fact  among others, that the cellular
tissue is the frequent seat of hydropic effusion;  while it is not
alleged  that in a  state of health its  cells contain any fluid
whatever.
   The  causes  of hydrops are  very various.  Among them are
enumerated both  hypercemia  and anazmia,  general  plethora,
debility  from whatever source, whether low innutritious diet,
bad air, or previous disease,  great losses of blood or other evac-
uations,  and intemperance chiefly.   Many diseases give special
predisposition to dropsy.   This is remarkably the fact in reference
to scarlatina—it  is  true also df  peritonitis, tympanitis, hepatic
and splenic affections, and perhaps of small  pox and influenza—it
follows  sometimes the  abuse of powerful  remedies, as drastic
purgatives, mercury, iron, and the vegetable acids.
   Hydrops is connected both with the entonic and atonic states
of constitution, which,  therefore, it would be well to substitute
for the old terms Acute  and Chronic.
   Prognosis in general dropsy unfavorable, as would be readily
inferred  from the perusal of bills of  mortality every where.   It
depends upon  the previous  state of  the patient, and his  habits,
upon the form which it  assumes,  and upon the locality  of the
effusion.
   Dropsies which are  among  the  ultimate manifestations of a
cachectic condition of the body, are  almost of course incurable ;
such is  the state of the  sot.  On the  other  hand,  we have much
hope of removing such as occUr from whatever cause in a system
but lately healthy and vigorous;  as when dropsy  comes on from
any one of the exanthemata or other recent malady, or  from a
transient exposure to some morbid influences.  Entonic dropsy
is for the  most part more easily managed than  its reverse^ for
obvious reasons.
   The  locality of the  effusion  seems to  be of  importance in
reference to the  organ, with the performance of whose  function
it may interfere.   If such function be important to be performed
vigorously and without interruption, the  danger  is of  course
great, as in hydrocephalus.   Hydrothorax  also presents  a similar
character. 
88
   The worst prognosis is, however, to be drawn from the man-
 ifestation of a general or universal diathesis,  by the concurrence
 of several effusions in different localities.   In such cases, although
 you may relieve the patient of the accumulation, and in various
 modes  procure  the discharge of  the  fluid, yet this is far from a
 cure  of the disease, which remains obstinate, and  will  show
 itself by the  renewed  accumulation of the same effusions, until
 the patient can sustain it no longer.
   The morbid  anatomy  of dropsy deserves attention.   If the
 hydropic affection have been  general,  the cavities of the body
 contain a watery serous fluid, which is indeed diffused  through
 all the tissues.   The very fibres of the muscles seem sodden  in
 it, and water will continue to drip from them for a long time, if
 taken  out  and  hung up.   The cellular structure is abundantly
 injected with it.  I  have seen the heart  itself flabby, pale, soft
 as if soaked or macerated.
   In hydrocephalus the effusion may accumulate in the ventricles,
 or spread upon the surface of the brain externally.  In  the former
 case it will  be spread out, and in the latter condensed  and small.
 Dr. Wistar saw it distended  like a bag, against  the cranium, not
 more than one  eighth of an inch thick;  and it has been found
 not larger than an egg, lying on the base of the skull.
   The  fluid collects in the  pericardium,  in  the pleure, and in
 the substance of the lung.   By its pressure, absorption  or perhaps
 rather  condensation of the lung may occur;  I have met with  it
 smaller than a man's fist.
   In ascites  the effusion is always connected  with obvious signs
 of hepatic disease, enlargement  and obstruction.   The spleen
 may be  in  the  same condition.   The kidneys are  occasionally
 diseased.  I  have seen them full of hydatids, or bodies closely
 resembling hydatids.
   Treatment.—This  must  depend upon  the condition of the
patient, and  the obvious or probable cause of the access of the
disease.  In the  entonic forms of dropsy,  the lancet must often
be used freely—drastic purgatives are much employed—the saline
and vegetable diuretics—the antimonials and mercury, as diapho-
retics and alteratives;  and when  the undue vascular excitement
is reduced, various tonics, bark, iron, wine, &c. are resorted to. 
89
   On the other hand, in atonic cases, tonics and stimulants are at
 once prescribed, and every effort made to reanimate the enfeebled
 functions.

                        ANASARCA.

   Hydrops cellularis.—One of  the  most  frequent  forms of
 dropsy, consists in a collection of serous fluid in the cellular tissue.
 This  infiltration often occurs  in a local or partial form, when it
 is termed Edema, as in old age, in the last stages of phtisis, and
 in  many other diseases, and not uncommonly in the debility of
 early convalescence from severe maladies.
   A pale swelling of the  lower extremities, easily pitting upon
 the  application of pressure, unattended at first with any heat or
 soreness of  skin, is the first symptom of anasarca; the intumes-
 cence becomes more general, until the cellular structure  every
 where is filled with fluid, giving to the countenance a heavy and
 flabby expression, and impeding all the movements of  the  body.
 If not relieved,  the  distention of the skin  increases so  as to
 produce  inflammation,  ulcer, and  gangrene—large quantities of
 serum being thus discharged.
   These symptoms are attended with languor and general feeble-
 ness  and inactivity—the  surface  is harsh and  dry,  the  thirst
 considerable, the  tongue often foul, and the appetite and digestion
 impaired.
  Anasarca may be either entonic or atonic.   In the former case
 the  pulse will, be quick and hard,  and the skin above the  usual
 temperature.  In the  latter, which is by far most general, we
 have an opposite condition of the circulation, and the skin is cool
 or even cold.   The urine is usually small in quantity, and high
 colored.  The bowels are costive.
   Causes.— Anasarca is connected with a great variety of circum-
stances, which are thought to have given rise  to it;  mere debility
of circulation,  as  in cases alluded to above—inflammatory affec-
tion  of the subcutaneous  cellular  tissue,  as when it  follows
the exanthemata,  scarlet fever especially—visceral obstructions.
Some writers  describe  an  acute  or sudden anasarca, connected
 with pulmonary disease—diseased state of the kidneys.
                            12 
90
   Prognosis.—If occurring alone, and in constitutions previously
healthy, anasarca is readily curable; under other circumstances,
the prospects of the patient are unfavorable.
   Treatment.—This must vary obviously with the causes of the
pttack, and the  condition  of the  patient.   In the entonic or ex-
cited state of the system, the lancet is used freely and with much
advantage.  Drastic  purgatives are  also employed—jalap with
supertartrate of  potassa, and  such generally as procure thin and
watery evacuations, hence  called Hydragogues.   Of these elate-
num, scammony, colocynth,  and gamboge,  are  recommended.
The three first I never employ, the fourth rarely—they are vio-
lent and irritating, and may, I think, be dispensed with from the
materia medica.  The  Epsom salt is  serviceable,  and may be
combined with the other formule prescribed.
   Emetics are often  used in anasarca; and when we have, as is
very frequently the fact in our black patients, a very foul tongue,
and a stomach  much disordered by their bad and irregular habits,
we shall find advantage in vomiting, occasionally excited.   Ipe-
cac, and tartrate of antimony may be used separately or combined.
The emetic is required  to  be frequently repeated in the case of
those who eat clay or dirt—a habit met with now and then, and
apt to be productive of marasmus and anasarca.
   Diaphoretics  are also employed.   The Polygala seneka and
the Serpentaria Virginiana, are much used among  us, and consti-
tute, in infusion, good bases for serviceable formule.   They com-
bine well with the nitrate, tartrate  and supertartrate of potassa,
and  other  salts,  both  cathartic and diuretic, while they act as
very efficient  diaphoretics.   The antimonials have also  been
highly eulogized.  Dover's powder,.when no contra-indication is
presented, is among the best of this class of remedies; and in-
deed I would lay much stress upon the  free use of opium in most
cases of dropsy.  Whenever attended with much  general dis-
tress, irritation, restlessness, and sleeplessness, this divine remedy
is of infinite value.
   Diuretics have been promiscuously employed in  all dropsies,
and most unduly extolled.  The original notion of a direct de-
pendence of the  accumulation of fluid upon a diminished urinary
secretion, led to  this practice, which has seemed to  be supported 
91
by the alleged observations of Blackall upon the changes in urine,
connected with the presence of dropsy, and the remarks of Bright
and Christison upon the frequent co-existence of disorganization
of the kidney.   The received opinions  on this subject seem to
me erroneous.  I do not conceive any medicine to be useful, di-
rectly in dropsy as a diuretic,  that  is,  merely by promoting uri-
nary discharges.   And further, all remedies which are successful
in their application to  the various cases,  produce, as in the treat-
ment of fever, an increase of this  as of the  other  excretions.
Thus  the  lancet,  mercury, opium,  the antimonials, all give rise
to large discharges of  urine, when  used with judgment.  Digi-'
talis is the object of  almost  unanimous preference  among the
diuretics, specifically so called.   Yet there is no satisfactory proof
of its direct diuretic influence.   I use it extensively in pulmonary
and  other  diseases, without observing any such operation.  Of
the squill the same may be said,  as also of tobacco.
   A  great number of articles are  prescribed  under this  head.
The nitrate,  acetate,  and  supertartrate of potassa, the vegetable
acids, horse-radish, and parsley, are among the  best.
  The Eryngium Yuccifolium,  or  button snake-root,  and the
Colchicum autumnale, deserve also to be exhibited.
  The tonics are entitled to much confidence in a large class of
cases.
  Among  our  negro population, anasarca usually occurs of low
and  depressed  character, and connected with a very cachectic
state  of the  body.  Here cinchona is  our  best remedy, and is
very often  sufficient in itself for a perfect cure.  Iron is also ex-
tensively used aud much confided in.  So also  the vegetable bit-
ters.   The cold bath is serviceable  when it  can be borne.   To
evacuate the fluid,  distending  and irritating  the  integuments,
scarifications should be made from  time  to time, in the most de-
pending part, with the point of a clean and sharp lancet.   If these
little wounds ulcerate,  or indeed of choice, acupuncture may be
substituted, and will often answer very well, the needle giving
discharge to considerable quantities of serum, and thus bringing
great relief to the  patient. 
92
                           ASCITES.

     A collection of serous fluid within the cavity of the abdomen.
   Its presence is marked by a gradually increasing equable swelling
   of  the  belly, attended by a sense of weight, and usually with
   perceptible fluctuation.   The general health is much disordered.
   There is in almost every case more or less  febrile  excitement,
   thirst, diminished perspiration, with harsh dry skin,  diminished
   urine, drowsiness and  languor;  the tongue  is foul, the appetite
   and digestion disturbed, the  bowels costive, the respiration im-
   peded from the upward pressure of the  diaphragm ;  after a short
   time, anasarca ensues, and sometimes hydrothorax.
     The diagnosis is important, but not always easy.   It is to be
   distinguished from pregnancy in women,  from tympanitis, from
,-  physconia or visceral enlargements,  and  from ovarian and en-
   crysted dropsy.   We must consider,  in relation to the first, the
   signs, as they are called, of pregnancy.  Where  these are alto-
   gether wanting, and  the other tokens of hydropic diathesis present
   themselves,  the inference is clear; unfortunately these two states
   sometimes occur together,  and are confused.
     Tympanitis is distention without weight—it is  tense and re-
   sounding.
     Physconia is  slower than  ascites, for the  most part, in its in-
   crease,  and  is irregular in form,  and not equable  in the swelling
   it occasions.   So also of encysted dropsies,  which are,  besides,
   unconnected with notable disturbance of general health.
     Causes.—Ascites  is rarely idiopathic, in the primary or inde-
   pendent sense; it is generally connected  with visceral  disease,
   hepatic, splenic, nephritic.   It may be developed suddenly, as in
   a case related by Darwall; two of a similar nature occurred to
   Chapman; and I have seen an instance following in a few hours
   upon dysentery, and preceded by very transient tympanitis.
     Prognosis generally unfavorable ; but we should refer, in  par-
   ticular instances,  to  the cause, and to the  previous state of the
   patient.   If entonic,  and unaccompanied  by anasarca or hydro-
   thorax,  recoveries from ascites are not unfrequent. 
93
   Treatment.—Besides the remedial management generally insti-
tuted in anasarca, and equally well adapted here, we must lay no
little stress upon the exhibition o£ mercurials, on account of the
ordinary dependence of ascites on visceral obstruction.  They
should  be administered slowly and  in small quantities, and in
combination with the other remedies indicated.   Ptyalism should
be avoided, as irritating and injurious.   ,%   "■   i
   The propriety of paracentesis has been a matter of much dis-
pute.  I should not hesitate to resort tojthe trocar, to relieve the
patient  from the distress produced by distention.  Pressure appli-
ed carefully after the belly is thus emptied, has been found useful.
The bandage  should be  applied uniformly and with assiduous
attention.  Tonics and exercise are  indispensably necessary to
a cure.     \        •       ;     '} /            V         '

                     HYDROTHORAX.

   Collection of serous  fluid within  the  cavity  of  the thorax;
sometimes called Hydropleura, as the serous collection is usually
within the sac  of the pleura.
   Some vague dispute has been held, whether dropsy of the chest
is ever an idiopathic affection,  and a few writers have  unhesita-
tingly considered  it as the mere result of pleuritic inflammation.
This I  regard  as an error.  Accumulations of fluid within the
thoracic cavities, indeed  occur from inflammation of the mem-
brane, but are readily to be distinguished by previous symptoms.
Besides this, they  rarely affect more than one side,  and  are not
attended with anasarca or  ascites.   Hydrothorax, which is con-
nected with general hydropic diathesis, and which exhibits, with-
out previous tokens of pneumonia or pleurisy,  proofs of effusion,
I treat of as one of the forms of idiopathic dropsy.
   It is the disease of advanced life and of broken constitutions,
for the most part.   There is notable paleness of the face, dyspnea,
inability to go  through any muscular exertion, orthopnea.   The
general health  is impaired,  as  in the other varieties of dropsy—
there is a short dry cough—great restlessness at night, with occa-
sional paroxysms of threatened  suffocation.  Anasarca, if not early
present, almost always attends in the course of the malady; and
ascites is also often added. 
94
   The diagnosis is  difficult.  We dwell  on the dyspnea and
orthopnea, so apt to come on with extreme severity in nocturnal
paroxysms.   There is often palpitation of the heart, with irregu-
lar and intermitting pulse—great anxiety and despondency.   Ex-
ploration of the chest displays increase of fullness on one  side
sometimes, with loss or diminution of capacity for making a full
and deep inspiration. * There is  loss of respiratory murmur over
the most of the chest.   In exploring we should carefully note the
relation of this dullness oi|percussion, and the impairment of respi-
ratory murmur, to the position of the patient.  If owing to the
presence of fluid  in the cavity of the pleura only, they will be
more  notable at the lowest parts of the thorax, and change places
when he rises and reclines.  Fluctuation is said to be, but rarely,
perceptible.!* On percussion a dull sound is returned^ Bichat pro-
poses,  as a test,  pressure on the abdomen, which increases very
much the sense of suffocation.
   Causes.—Those of dropsy in general, already enumerated.
   Treatment.—Must  be guided  by the principles already laid
down, as applicable to the other varieties of the disease.  In the
entonic form,  the lancet should be used freely to subdue morbid
excitement;  but it should be recollected, that we must not make
the pj-ilse our exclusive guide in the resort to venesection,  as it
often  remains unaccountably hard and full  to the very last mo-
ment  of life in hydrothoracic patients.
   The employment of purgatives has been vehemently objected
to. I would administer them in just such cases as require vene-
section, but with some caution.   Nor must we  expect the same
obvious good effects from them as in ascites.
   The diaphoretics—antimonials, seneka, &c. must be exhibited,
as has been already advised in the analogous cases.
   Diuretics are regarded as here  specially  applicable,  and to
digitalis is assigned the  first place.  Squill is useful, both in this
way,  and as an  expectorant.  The solution of supertart. potass.
or an infusion of common parsley, may be used as ordinary drink.
   Mercurials have seemed to me almost indispensable to the
cure of hydrothorax.   They  should be administered in  such
small  quantities,  and at such long intervals,  as to procure, if
possible,  their alterative influences,  without the occurrence of
salivation. 
95
  Opium, if it exerts no marked effect in the removal of the
disease, lends a most admirable aid in relieving or palliating the
sufferings of the patient.  I prescribe anodynes freely, to dimin-
ish  the  intolerable distress of the sick man in his nocturnal
paroxysms of dyspnea.                                     "
  External irritants to the thorax are of some value here.  A suc-
cession of blisters will do service.  The ungt. tart, antimon. has
been recommended.
  Paracentesis thoracis is occasionally performed—oftener by the
physicians of  the  continent of Europe,  than  by American and
English  practitioners.   I  can see no  reasonable objection to it,
when  the  presence of fluid within the cavities of the pleure is
clearly made out.

                   HYDROCEPHALUS.

  Collection of  serous  fluid within the cavity of the cranium.
The effusion may occupy various localities;  it  is most frequently
found  within the ventricles—occasionally, as we are informed by *
Cheyne  and  Golis, deposited in the very parenchymatous tissue
of the brain itself—sometimes poured out upon the surface of the
arachnoid—and in more  than one  instance on record, between
the dura mater and the bony skull.
   The nature of the disease is obscure, and has been the subject
of much dispute.   By many it is denied to exhibit any analogy
with other hydropic affections, and considered as a mere phrenitis,
an  inflammation of the brain and its membranes, of which the
effusion  is an  ultimate and uncertain or accidental result.
   It must be acknowledged that such collections in the cranium
are often preceded by symptoms which would seem to denote
inflammation, but  this is not always the fact.  Congenital hydro-
cephalus is not rare, in which there is no proof of the precedence
of inflammation; and most of the cases which develope themselves
in  early infancy,   are free  from  any such indications as are
supposed to be inseparably connected with inflammation.  Besides
this, instances are not wanting in which  the  symptoms which
are believed to denote hydrocephalus, are mingled, or combined,
or alternate with those of ascites and anasarca.   Two such have 
§6
occurred to me in black children of nine and ten years of age, and
a  third in an  adult, a  physician, a friend  and  former pupil.
Blackall offers us some facts.   He has witnessed,  as in the cases
just alluded  to, the metastasis of disposition to serous effusion
from other parts to the head, and also the extension to that part
of general hydropic disease.
   On  these grounds I regard hydrocephalus, and treat of it here,
as one of the  forms of dropsy.
   It is customary with  authors to follow the  division of hydro-
cephalus into acute and chronic.
   The former,  it  must be acknowledged, would seem  by the
very description to  be a mere  phrenitis; but it is  after  all not
very definitely depicted,  nor distinguished accurately from affec-
tions of the head, which do not issue  in  the same  result—an
effusion, namely, of serum within the cranium.
   The precursory symptoms are various, some of them referring
to derangement of the sensorial,  others to disturbance  of the
digestive  system.   The appetite is  capricious or impaired, the
tongue foul,  the breath fetid,  the belly tumid and costive, or
irregular, with occasional diarrhea—the urine is scanty and high
colored, and  there is some febrile  excitement.  The face of the
child is flushed and turgid—he is restless; sleepless, moans,  puts
his hand to his head, shrinks from light, or seems to suffer from
pain in the ear.   These tokens of acute disease having continued
for a longer or shorter time, a more  characteristic series of phe-
nomena supervene, which are assumed to be produced by pressure
of effused fluid upon  the  brain, as the former are  attributed to
inflammatory excitement of greater or less violence.   The pulse
becomes slow  and unequal—there  is  stupor, alternating  with
screaming and jactitation—the vision is  now obviously  im-
paired—there is strabismus, with dilatation and immobility of the
pupil—the child lies heavily, with the eyes half open.   It can
sometimes be roused for a moment so as to take food and drink,
but soon falls again into a  lethargic state—the hands are tremu-
lous and  raised frequently to  the head—the  lower limbs are
paralyzed, or contracted and  crossed—the  bladder and  rectum
pass their contents without the  consciousness of the patient—
great emaciation ensues, and death is often immediately preceded 
97
by violent convulsions.  The duration of this stage also varies,
but may be rated at from twelve to fifteen or sixteen days.
   The diagnosis of this form of hydrocephalus is not possible
before it  has run into the second stage.  The symptoms of the
first are therefore deemed  "precursory,"  as depending on con-
ditions of disease, which may, or may not result in effusion.
   Chronic hydrocephalus,  it  has  been said, is often congenital.
In such instances the causes are of course unknown; but as it
occurs frequently in several children of the same  parents,  and
has happened very often when a scrofulous taint is  known or
suspected to be present, many physicians consider scrofula as
its most probable cause.  When it occurs in early childhood, it
may be either  the result of the acute form, developed with less
than  fatal intensity; or it may happen at once and unpreceded
by the symptoms  of inflammatory excitement,  described as
belonging to the first stage.   The  parietes of the cranium yield,
and an immense distention takes place, occasioned by the accu-
mulation of fluid;  the  head  becomes  thus misshapen and too
heavy for the muscles of the patient to support, requiring to be
borne  upon the shoulder of a nurse or laid always on a pillow.
Fluctuation  is distinctly perceptible.   Pressure on the head  is
said to produce in  some a complete stupor.  The senses seem
to be all lost or much impaired,  the powers of voluntary motion
are enfeebled, and convulsions of great violence sometimes shew
themselves.  When the hands are moved at all, there is picking
of  the nose—the  teeth  are ground together.  As the case  pro-
gresses, the respiration is affected, the legs are crossed and drawn
up to  the  belly,  the pulse becomes weak and intermitting, and
at last ceases, or the patient dies worn out with tedious irritative
fever  and  ulceration of parts, which  bear the pressure of his
weight.  It happens, though rarely, that the brain accommodates
itself to  this morbid condition, and the patient drags out a long
and wearisome existence, attaining mature age.
   To the few such instances recorded in the books, I add a case
on  the authority of my friend,  Dr. W. M. Lee,  who saw the
subject in Abbeville District, S. C.   His head was twenty-eight
and a half inches  horizontal circumference—nineteen  and a half
inches from one meatus auditorius to the other—could not walk,
                             13 
98
but  trundled  himself on a chair on rollers—conversed intelli-
gently—general health good.
   The  prognosis of hydrocephalus is decidedly unfavorable.
Few cases are recorded of recovery after the unequivocal devel-
opment  of the  disease,  by enlargement of the head and other
signs of effusion, had  taken  place.   Previous to this stage,
however, and during the progress of the precursory symptoms
or first stage, as it has been called, we are not without hope.
   Morbid anatomy.—Water is found, as has been mentioned, in
the ventricles,  in the substance of  the brain, between the mem-
branes in which it is enveloped, and external to the dura mater.
An instance of this last kind occurred to myself.
   The  brain is  often found presenting all the marks of inflam-
mation—engorgement of its vessels, softening of its substance,
adhesions of opposite surfaces of its membranes.   Occasionally,
C.  Smyth says frequently,  nothing of all this  is to be observed.
It has been found pressed out,  and in thickness not more than
one eighth of an inch;  it has been seen condensed and smaller
than an egg.
   Treatment.—By those who, with  Rush, regard this effusion
as a mere termination of  phrenitis,  venesection is placed  at  the
head  of our  list of  remedies.  The jugular vein is selected and
opened repeatedly.   Others prefer the application of leeches.
   Purgatives are employed freely by almost every practitioner;
and in their continued effect, we place,  I think, our best hopes
of a cure.  I  prefer  the  combination of  a resinous  drastic, jalap
or rhubarb, with an alkali—the  carb. potass, or soda.   To
obtain the full influence of these remedies, a judicious perseverance
is required.
  Mercury is a  fashionable remedy.   It  may be  occasionally
added, with advantage, to the cathartics prescribed.
  I have no confidence in the class  of diuretics, as applied here;
but digitalis is recommended by Smyth, Withering, and others.
  Antimonials have  been used largely by Laennec.
  Cold  applications to  the head are of great value, and should
be persisted in.  I prefer  the frequent pouring of a stream of cold
water upon the scalp, to any other mode. 
99
  Blistering  the  head is often  resorted to.   Caustic issues and
setons are also employed, and in the last resort, paracentesis capitis
has  been  repeatedly ventured  on;  and  we  have instances  of
restoration after thus relieving the little patient, related by Drs.
Vose and Conquest.

                        SCROFULA.

  The various  morbid  affections which are included under the
above  title,  afford perhaps the best exemplification of the  de-
pendence of local disease upon morbid peculiarity of constitution
or predisposition.   This predisposition or  diathesis is said to be
so well  marked  by characteristic appearances of conformation
and  physiognomy, as to be recognizable before the actual occur-
rence of open disease.   The  skin is fair and  soft, the hair light
and  silky, the eye blue and mild, and of gentle expression, the
upper  lip  tumid  and deeply fissured in the centre.   A child of
this  constitution  often exhibits precocity of mind, united to irri-
tability and obvious debility of body.   The cheeks flush readily
upon muscular exertion or mental emotion, and fatigue is prompt-
ly induced.
  Scrofulous affections are not, however, exclusively confined to
individuals whose aspect has been above described, but are met
with, and not unfrequently, in persons of dark hair, coarse skin,
and  brown complexion.
  It prevails more in certain climates than others.  Great Britain
is particularly subject to  scrofulous  disease.   Dry and warm re-
gions are, comparatively, exempt from its presence.
  Scrofulous inflammation, when  it affects any other  than  the
cutaneous surface, is apt to result in the secretion of  a peculiar
matter, which  is,  in some situations, mingled with much serum
and  pus, and in others, tends to condense or concrete itself into a
solid body, known as a tubercle.  These  are developed in  im-
mense numbers in the lungs in scrofulous phthisis,  and shall re-
ceive a particular description under that head.   The children of
parents who have labored1 under  any of the known forms of scrof-
ula, are very  liable to  be attacked by similar disease, and thus
heriditary  transmission  is universally recognized as  the  direct
cause of scrofula. 
100
   The predisposition is gradually built up, in the first instance,
under the influence of a number of circumstances, which dimin-
ish the vigor of the system.  The cold and damp air of any par-
ticular district of country? living in close ill-ventilated apartments;
being fed upon unwholesome, scanty,  and innutritious diet,* de-
fective clothing* sedentary or depressing occupations,- want of per-
sonal cleanliness—all these, when acting upon large masses, are
known  to give rise in a notable  proportion  among them, and a
still larger proportion of their children, to various maladies, which
long continued observation has led us to consider as connected
by a common character, and as depending upon a similar morbid
state of general constitution.
   Every tissue of the body is likely to be attacked by scrofula—
the skin, the eyes, the  glands, the joints,  and the bones.   Age
modifies the disposition of particular  structures to be  affected.
In early childhood, papular and  squamous eruptions about  the
head and ears, ulceration and discoloration of the tunica adnata
of the eye, and induration of the  mesenteric glands, with tuber-
culous enlargement,  are among its  first tokens.   Next, we have -
Morbus eoxarius and white swelling of the knee, and at or before
the time of puberty, glandular enlargements  and tumors about
the neck, and pulmonary tubercles.  The  lungs and bones con-
tinue to sustain a  like liability through after life.   It is worthy of
remark, that not only is the predisposition  transmitted heredita-
rily as above stated,  but children have actually been born, labor-
ing under scrofulous inflammation and pulmonary tubercles.
   The nature of  the original  defect of constitution is not known.
By some it is supposed to be seated in the digestive system.   I
rather ascribe it to improper action of the minute order of vessels,
whose function it is  to separate the materials of growth and  nour-
ishment, and the  several secretions.
   Scrofula also  implies a contamination  or deterioration of  the
fluids of  the body.   Sauvages considers the horse liable to scrof-
ula.  The disease which, in this animal, he entitles Scrofula far-
cimen, has  been propagated by transfusion of blood from a dis-
eased to a healthy subject,  and even  from a horse to an ass, by
Professor Coleman, 
  /     '''         >-    101    -      ,
 ' The most common development of scrofula, or as  it was for-
merly called King's Evil, consists in the appearance and growth/
of small hard tumors in the course of the  lymphatics, and espe-
cially on the neck.  They increase slowly, often becoming indo-
lent and remaining long stationary, giving no pain, and attracting
little attention.   After  an indefinite time they enlarge, and are
evidently inflamed.   Matter at last forms  in one or more; not
true pus,  but a thinner fluid,  containing flaky, curdy coagula.
The tumors often coalesce,  and their contents are discharged by
ulceration,  which leaves irregular and deforming scars.
   The treatment is properly divided into fthe curative and pro-    r,
phylactic4—the  former suited  to the management of cases,  in
which local inflammation, tumor and tubercle have  been devel-
oped ;  the  latter required where we have  reason to anticipate or
dread the occurrence of such local affections, either from known
descent from scrofulous parents,  or from  the presence of those
physiognomical peculiarities which point out the predisposition.
   Mercurials have  been much employed in the cure of scrofula.
They  require  to be  administered in very  minute  doses, and
watched with great care.   If ptyalism be allowed  to supervene,
injury is always done  to the  patient; but with the  precautions
suggested, mercury will be found among our  best remedies.  I
prefer to exhibit the corrosive sublimate, in quantities indefinitely
small.
   Cathartics, used in mild formule, with patient perseverance,
are of much benefit.  I combine them with some alkali, as there
is,  generally, notable  tendency to fermentation and acidity of
stomach.
   Tonics are greatly confided in.   The chalybeates  are selected
by some physicians, cinehona by others.
   The baths are valuable auxiliaries—the cold should be chosen,
if it is pleasant to the patient; otherwise the tepid bath.             <
   The most precise cleanliness is necessary—of the person, the  ^ .-;
clothes,  and the chamber.   Where local excitement runs high,  /
and still  more,  when there  is  general sympathetic  irritation,
articles of  stimulating quality must be avoided;  nay, even ab-
stinence may be, for a  short  time, necessary.  Except at such
periods, a nourishing diet should  be allowed. 
102
   Burnt sponge has been  long in use for the cure of scrofula.
 It contains some of the alkalies already spoken of, and the peculiar
 agent  iodine, which is now regarded  as the chief remedy for all
 scrofulous disorders.   Some caution is, however, necessary in its
 employment.   I prescribe  the  aqueous solution,  exceedingly
 dilute, (LugoPs,) and  in  this form have seen it productive of
 extensive benefit.   The new preparation known  as the deut-
 iodide of mercury and potassium, promises to be highly useful in
 all modes of scrofulous affection.
   The combination of an indefinitely small proportion of iodine
 with  some  purgative salts minutely diffused in  large quantities
 of water, as in many mineral springs both in Europe and America,
 deserves  to be valued as our best remedy  for all the incipient
 developments of scrofulous disease, and perhaps for all its stages,
 except in the instance of pulmonary tubercle, where the effect
 is thought  questionable.  The muriates or chlorides have been
 generally extolled—common salt, the muriates of lime, barytes
 and  magnesia.   It  is to the mixture of some of these in  sea
 water, that  its acknowledged utility is to be ascribed.   It is one
 of the best purgatives when recent and pure.
   The narcotics deserve to be mentioned.  They are all service-
 able  in relieving the symptomatic irritation,  arising from  the
 local  derangement.   I confide in opium, others prefer conium
 and hyoscyamus.
   Of the local treatment of scrofulous tumor and inflammation.
 In some  of  its developments it needs active depletion by leeches
 and cupping.  Glandular swellings on the neck,  &c, should at
 first  be soothed by soft  poultices,  and  may afterwards be  dis-
 cussed by the application of iodine ointment, or if very hard and
 indolent,  by blistering and stimulating embrocations.
   The prophylaxis.—A child born of a scrofulous mother should
 be placed in the care of a healthy wet  nurse.   Removal from
low  damp  situations  must  be advised.   The residence  and
 especially the sleeping apartment,  must be  well ventilated  and
kept  neat.   Children should not only live much in the  open air
but should always have free access to abundant sun-light.  The
importance of light  to the due development  of both animal and
 vegetable life,  cannot be exaggerated.   Precise  cleanliness  of 
103
person and clothing must be enjoined—bathing frequently prac-
tised—exercise in the fresh air is essential to health and vigor—
the diet must be plain and generous.   Warm clothing in winter
must  be worn—sedentary occupations avoided.

                       MARASMUS

   I place here, because it is rare comparatively to meet with any
other  form of atrophy,  than  that  which depends on scrofulous
disease.  Marasmus rarely attacks  adults; children are generally
affected at  the time of weaning—hence the  phrase  Atrophia
ablactorum.  It seems reasonable to account for  this, by the sup-
position, that their imperfect digestive organs are unable to bear
a change of food, yet it would rather appear to be independent of
the change, and a mere result of their arrival at  this age, for it is
of no benefit to keep them at the breast beyond the ordinary
period.  It is almost exclusively confined to children of scrofulous
parents, or such as are subject to  the causes formerly detailed,
which tend to develope scrofulous  disease.
   Marasmus comes on with  general  languor, paleness of coun-
tenance,  anorexia or capricious appetite,  bowels irregular but
soon  becoming loose, with stools  thin, discolored, offensive and
acrid.   The  tongue is  furred, with  occasional vomiting—the
inside of the  mouth  and corners of the lips ulcerate—the gums
are spongy,  the  belly is  tumid, the  flesh of the limbs soft and
flabby, the  emaciation progressive, and at last extreme.   The
duration of the case varies, but it is often exceedingly protracted.
   Autopsy.—Dissections show  the  intestines  empty and  con-
tracted, or containing dark ill-conditioned secretions;  the liver
perhaps firmer and heavier than usual, and the mesenteric glands
enlarged and indurated.
   The last circumstance denotes  the character  of the case with
sufficient  clearness.   The treatment is such as has been already
indicated, with certain modifications,  hereafter to be pointed out
under the head of Cholera Infantum. 
104
 DISEASES OF  THE  ORGANS  ENGAGED  IN  THE
           PERFORMANCE  OF  DIGESTION.

                       DYSPEPSIA.

   This term is expressive of a definite disorder of the stomach;
 it is not  synonymous with the word indigestion.   The stomach
 under a great variety of morbid influences, refuses to dissolve or
 digest food taken into it;  in fevers, it is common to see among
 the matters vomited in the early stages, articles of diet swallowed
 many hours  previously.   Mental emotion has the same effect;
 but  the transient and symptomatic derangement of the stomach,
 which in" these cases unfits  it for the  solution of food, differs
 notably from that condition of  the  organ of which we are to
 treat, and which is among the most frequent of the diseases of
 civilized and refined  life.   Dyspepsia, when it  occurs as an
 independent and idiopathic affection, is the result of an imperfect
 secretion of the  gastric  fluids, so important to the physiological
 and  chemical changes of  food taken.   When this occurs as the
 effect of previous disease of  the stomach, as for example, inflam-
 mation, it clearly comes under another head, Gastritis,  acute or
 chronic;  and hence the incorrectness of confounding them, as
 has  been  done by Parry, Broussais, and Wilson Philip.  Inflam-
 mation is  a very frequent consequence of dyspepsia, and the last
 mentioned writer has treated of it as a sort of second stage.
   It is idle to assume  hyperexcitation as the only cause that can
 impair the power of any organ.  When an organ has been sub-
jected to  the action of  an excitant, two sets of effects follow,
 though not necessarily diseased, may be equally njorbid in nature
 and ultimate  results.   It is first stimulated; its capacity for action
 is, in the second  place,  impaired  by exhaustion—enfeebled,
 relaxed.   Hence  the direct  agency of a sedative,  may produce
 results closely analagous to, if not identical with, the influence of
 a stimulant.  We find dyspepsia, in conformity with these views,
 common to two classes of persons; sedentary men,  on  the one
 hand—literary persons,  students, the poor who live on scanty 
105
innutritious diet;  and on the other, debauchees,  the intemperate
and  gluttons.   It is not probable that the pathological condition
of the stomach is exactly the same in these ; but the symptoms
exhibited, are very similar and strikingly analogous.
   Dyspepsia  may be  then  defined as a local  disorder of the
stomach, manifesting itself by the imperfect,  slow, and painful
solution  and digestion of food taken.   Acid eructations, heart-
burn, a sense of painful fullness or distention and weight, nausea
and  frequent  vomiting,  gastrodynia,  emaciation,  anorexia or
defective and  irregular appetite,  are among  the most  general
symptoms.   From the universal sympathies which connect the
diseased  organ with the rest of the system, we have an infinite
variety of morbid phenomena in the cases which present them-
selves.   There is flatulence, with severe colics; in many, obsti-
nate  constipation;  in some, diarrhea  of various  character;
muscular debility and languor, great depression of spirits, vertigo,
headache,  dim, depraved and (rarely)  double  vision, obstinate,
vigilance and nocturnal  restlessness,  vapors and hallucinations,
palpitation  of  the  heart, with slow and  sometimes intermittent
pulse.
   One of the most ordinary results of a continuance of dyspepsia,
is the development of a chronic  gastro-enterite, which is con-
sidered indeed by W. Philip as a second stage, and the symptoms
of which are often,  but improperly, (as even by Parry himself,)
enumerated under our present head.
   Dyspepsia proper is purely a functional disease.  Insufficient
excitement of the organ, as  in persons ill-fed,  and in students,
who  labor  under  undue determination to the brain,  occasions a
defect of determination to  the organ, imperfect innervation, and
impaired or depraved  secretion.   The same state  of deranged
innervation, results from irregular and excessive excitement, as
in sots and gluttons, and in many others, who without any im-
putation  of moral impropriety, commit  inadvertent excesses in
quantity and quality of food and drink.
   Another consequence of  defective innervation—want of deter-
mination to the stomach, deficient or  exhausted excitability, is
the impairment of the contractile power of the organ.  Hence its
peristaltic motions, upon which depend the due movement, mix-
                              14 
                            106
     • - r
ture,  and solution of food, are feeble and ineffectual.   All these
conditions are comprised in the meaning of the word Atony—the
phrase,  loss of tone of the stomach—and constitute the form of
derangement, which we call dyspepsia.
   The  causes of dyspepsia  are numerous and  varied.  With
Cullen, I divide them "into—1st.  Such as act directly and im-
mediately upon the  stomach;  and 2d. Such as act  upon the
whole body or particular parts of it, but in consequence of which,
the stomach is chiefly or almost only affected."
   Under the first head, I mention  imperfect mastication of food.
The  hasty  eating,  which all  foreigners  regard  as  strikingly
characteristic of Americans, helps to account for the frequency of
dyspepsia, and for the badness of  the teeth—a cause in turn, as
well as an  effect, of gastric derangement.   Quantity of food—
excess,  as well in eating, as in the use of stimulating drinks.
Quality of food—as when improper and innutritious articles are
used,  or badly cooked diet.   Comparatively speaking,  however,
the quality  of food is very rarely a cause of dyspepsia, as  may
be inferred  from the immensely varied diet of different nations
and tribes of men.
   Under the second,  modes of life  and  occupation may be enu-
merated.  Indolence—a sedentary habit—undue determination
to the head, as in students—indulgence of the passions—labor in
oppressive postures, and connected with confinement to close and
impure air, subjection to care, and protracted anxiety.
   Treatment.—Most important to remove the.cause;  this done,
the disease  disappears.  Diet should be nutritious,  moderately
stimulant, plainly but perfectly cooked, and taken at distant in-
tervals.   Too great abstemiousness may injure as much as excess.
The power of any organ  is  improved by its moderate exercise.
A reasonable variety of food should be allowed,  as the appetite
palls  under  a wearisome monotony.  Nor is it possible that one
uniform and exclusive diet, whether of bran, or milk, or porridge,
or beef-steak, should suit all subjects and every condition of dys-
pepsia.  The fluid taken should be plain, and in moderate quan-
tities.  Narcotics and stimulants must never be used habitually
though  they may be occasionally and transiently serviceable,
when judiciously prescribed. 
107
   Studies, and sedentary and confined occupations must be aban-
doned—exercise taken freely and  actively in the open air,  and
conjoined with amusement.  Medicines should be used sparingly,
and only for transient purposes.   Costiveness  may require occa-
sional  and mild cathartics, or may be obviated by enemata and
frictions over the abdomen.  Acidity with heartburn, may be
relieved by alkalies, or the mineral acids in small  doses.  Gas-
trodynia is relieved by aromatics;  or if these fail, and the pain is
severe, by anodynes.   Tonics are  much  employed; the metallic
are best, such as iron and bismuth.  It is  satisfactorily ascertained
by Beaumont and others, that the hydrochloric or muriatic acid,
is  an essential constituent of the  gastric or digestive fluid, and
we thus account for its  utility in  dyspepsia.  The same remark
applies also, but with less force, in respect to the acetic acid, and
the chloride of sodium or common salt.   Mercury has been used
with advantage, when there was a defect of secretion, but ptyalism
does harm.   Prussic acid is highly recommended by Elliotson.
   The  mineral springs—those which contain purging salts, and
carbonic acid, and the chalybeate are often of service.

                        GASTRITIS.

   Acute gastritis is recognized by the presence of severe  pain at
the epigastrium, with a sense of heat or burning, nausea, thirst,
oppression, usually repeated vomiting.  Pressure on the stomach
cannot be borne;  the pulse is hard, tense, frequent, small and
contracted ;  the skin hot and dry, the tongue red or covered with
a thin white coat; there is much anxiety, with mental dejection,
sighing, restlessness, and prostration of strength.  As the  case
progresses, the tongue, cheeks and esophagus inflame and ulcer-
ate, the pulse sinks,  the  eye  is red  and suffused—there is low
muttering delirium.   Black vomit is often ejected—respiration,
as well as deglutition, is difficult, and death soon  follows.
   Prognosis unfavorable.  Depends somewhat upon  the cause.
Is  more likely to terminate fatally, when  supervening on previous
disease.
   Causes.—The  acrid poisons, whether mineral or vegetable—
mechanical violence  externally applied, exposure  to severe alter- 
108
nations, violent passions, and  the  metastasis of other inflamma-
tions, as in gout, &c.
  Inflammation  of the stomach may produce suppuration,  it is
said, and gangrene.   I have seen  no instances of the kind.   In
death, from gastritis,  the  mucous  tissue is found deeply injected,
softened as by maceration—sometimes, but  rarely, eroded.
  Treatment.—The indications are obvious and undisputed.  If
it is known that any poisonous or acrid matter has  been taken
into the stomach, the organ must be relieved by the employment
of a quick emetic, or the stomach-pump, and the proper antidote,
if at hand, administered.   Beyond this, and from the beginning
in spontaneous gastritis, the most  prompt and energetic depletion
is called for.  Venesection must be carried to the utmost extent
that can be borne, and local abstraction of  blood by leeches and
cups, at and near the epigastrium, assiduously resorted to.  Warm
poultices should be applied over the belly, while ice and cold flu-
ids are allowed to quench  the thirst of the patient.  We may thus
at once subdue the disease  in some cases.  If not promptly and
completely successful by these  means, we must  soon have  re-
course to the mild and unirritating cathartics, such as calomel,
Epsom salt, and oleum ricini.  The first will often remain upon
a stomach  so irritable, as to reject almost every thing else ; and
as soon as it operates actively, will be found to be highly benefi-
cial.  The cathartic  action  must  be aided by large enemata.  If
the patient sink rapidly, and life seem ebbing away, I would not
hesitate to exhibit stimulant  and  nutritious fluids.   Spirit, tere-
binth, has  been highly extolled.   Camphor, suspended in muci-
lage,  may be given.   Opiate preparations are often soothing and
useful.   I have succeeded  in bad cases by endermic medication
with  the preparations of morphine, sprinkling them upon the blis-
stered surface of the  epigastrium.   The infus.  cinchone is unob-
jectionable as a tonic.  In the mean while we aid in sustaining
the feeble powers of life, with wine whey,  milk punch, &c.
  During convalescence,  great care and prudence are necessary.
The  diet should be  fluid  or semi-fluid, and consist chiefly of
vegetable materials, with  the exception of milk, which if properly
diluted, may  be taken safely by almost any one ; and of eggs, raw
or very slightly boiled.   Flannel  should  be worn next the skin, 
109
and all exposure and excess abstained from with resolution and
perseverance.
   Chronic gastritis  may supervene so gradually, and develope
itself so obscurely, as to exist for a great length of time without
being detected,  the sufferer being supposed to  labor under dys-
pepsia or hypochondria.  It is, as I have said, often a consequence
of the former disease,  and is hence frequently met with in the
studious and sedentary, though prudent and temperate, as well as
in the glutton and the sot.
   Autopsy shews, that it may proceed even to the extent of ero-
sion and ulceration of  the mucous coat of the stomach, without
having  been suspected.
   Symptoms.—In general the patient complains of a sense of dis-
tention, increased after a meal, especially if of stimulating food—
increased also after long fasting.  In its farther progress there is
nausea  and oppression, extrication of gas, thirst, a tongue smooth
and fiery red, and ultimately covered with aphthous ulcers, as on
the lips, cheeks, and  gums—these latter being also swollen and
spongy.  The  pulse is small and weak;  a febrile  exacerbation
may be observed at  night, with restlessness, and jactication, and
hot dry skin; there is  emaciation  and muscular debility,  with
dejection and vacillation of mind.  There is often, but not always,
pain at the epigastrium, augmented by pressure.  Death is pre-
ceded by atrophy and diarrhea.
   Treatment.—If  the patient's strength will  admit, we resort to
the lancet; but his debility and emaciation will often render this
resource improper and  unavailable.  Topical  depletion by cups
and leeches is indicated, and should be repeated as often as it can
be borne.  Abstinence from solid and stimulating food, must be
strictly enjoined, and the diet consist  exclusively of the mildest
and most unirritating  articles.  The mucilages are generally ad-
vised,  but in some cases produce great distress, by occasioning
fermentation, flatulence, &c.  Here,  as an alternative, I allow
milk diluted—eggs raw or slightly boiled, and thin gelatinous
broths.  The bowels must be kept soluble, but by gentle means.
   Calomel,  in  small doses, will scarcely disturb the most irrita-
ble stomach,  and will do much service both as an evacuant and
an alterative.   Ptyalism, if slowly induced, and not carried too 
110
 far, will prove highly beneficial.  The alkalies are almost always
 useful, whether by their chemical properties alone,  or through
 other influence, I will not pronounce.  The combination of carb.
 sode with rhubarb, will suit many patients, and seems to exert a
 tonic and restorative power, in addition to its laxative and antacid
 quality.  We should not fail to advise, when it is in the power
 of the sick, a resort to our chalybeate, saline and carbonated min-
 eral springs; but it is to be carefully recollected, that in the lat-
 ter stages of these cases, where chronic diarrhea  has come on,
 and the intestines have  lost their tone, all laxative waters will do
 immediate and irreparable injury.
   The mur. tinct. ferri  is among our best tonics  here;  the acet.
 plumbi is used,  in union with opium in proper doses; the mist.
 cretacea, with kino, will be of service.

                        ENTERITIS.

   Inflammation of the  intestines,  often combined with the sub-
ject of the previous lecture, forming the gastro-enterite so much
talked of at the present day—occasionally, yet perhaps not very
commonly, met with separately.
   Symptoms.—Comes on usually with pain about the navel, fixed
and extending over the  whole abdomen, and attended with nau-
sea and a sense of heat and burning, with great dejection of mind
and prostration  of bodily strength.  The patient lies on his  back,
with his knees drawn up,  rarely tossing  the body,  and  shrinks
from any pressure made  upon the belly.   This test, however, is
not so  strictly diagnostic, as some have affirmed.   I  have seen
two fatal cases  in which pressure was borne with  indifference.
The countenance expresses great distress  and anxiety.  The
pulse is frequent, tense,  chorded, contracted.  I have seen black
matter ejected both  by vomiting and by stool.   Constipation is
almost always  present at first, but is succeeded by an  irritating
diarrhea in bad cases, and  with varied and, highly offensive dis-
charges.  At last, the strength and pulse fail—the abdomen  be-
coming distended and tympanitic, and exquisitely tender to  the
touch;  the tongue is  red and smooth and  dry, or covered  with
ulcers;  the breath is fetid,  and  the patient  sinks with low  mut-
tering delirium. 
Ill
  Diagnosis.—Enteritis may be confounded with colic and pe-
ritonitis—from the latter of which, indeed, it is difficult to distin-
guish it; but this  is a matter of less importance, as the indica-
tions of cure, and even the details of the treatment, are so similar
in the two sets of  cases.  In peritonitis,  the pulse is more volu-
minous__there is less prostration and nausea, the abdominal ten-
derness is more urgent from the first,  and the alvine evacuations
of less  morbid character.   In colic, the pain is less fixed—there
are intervals of ease more distinctly marked—the pulse is little,
if at all, affected—and more immediate and greater relief is expe-
rienced from alvine evacuations and discharges of wind.
   Autopsy.—Like gastritis, enteritis  brings on the fatal termin-
 ation,  in  a majority of  instances, by its oppressive  influences
 upon  the general constitution, and the local lesions are not very
 remarkable.  They consist in engorgement or congestion of the
 vessels of the  mucous intestinal  membrane—the  duodenum
 among the small, and the colon among the large, being most
 obviously affected; the  membrane is softened usually in propor-
 tion  to the discoloration.  It is sometimes, however,  pale and
 soft,  as if macerated.   Ulceration sometimes occurs, and the
 intestinal parietes are  now and then entirely perforated.   I have
 known two instances of extensive gangrene of the  colon and
  rectum.
    Causes—the same as those which produce  gastritis.  Intes-
  tinal inflammation more frequently follows exposure to cold and
  moisture, and is less likely to be brought on by acrid ingesta.
    Treatment.—Venesection boldly resorted to, but still with due
  caution.   Topical blood-letting by  cups and  leeches over the
  whole abdomen; ice and cold  fluids allowed internally, while
  warm fomentations and poultices are assiduously used externally.
    The question as to the exhibition of cathartics in enteritis, has
  been  long and warmly contested.  I have no hesitation in em-  /
  ploying purgatives, carefully selecting such as are least likely to/
  irritate and annoy.   Nothing seems to give more prompt  relief y£
  to an inflamed mucous membrane, than abundant  secretion from j
  its own surface.  I prefer to administer the  Epsom salt,  in alter-"
  nate doses with calomel—a combination at once mild and active.
  When the bowels have been well moved, I discontinue the salts, 
,r
  •M.
                       ./„,/<   -^%  m    '  /^7 —/

                 but persevere in the use of the mercurial until a gentle  ptyalism
                 is induced, which is invariably beneficial.  Large enemata in the
                 mean while, will aid our purgative, and render smaller quantities
                 more effectual.
                   When topical depletion can no longer be borne, and the patient
                 has  become familiar with  the fomentations, revulsion may be
                 farther accomplished by the irritation of a blister, which should
                 be large enough to cover the whole abdomen.   Others may with
                 the same view, be applied to the thighs and legs, if necessary.
                   As in the latter stage of gastritis, stimulants may be occasion-
                 ally employed with obvious advantage.   The spirit, terebinth, is
                 chiefly preferred.  Camphor and opium are also of unquestionable
                 benefit.
                   Chronic enteritis sometimes occurs  spontaneously, and  often
                 follows as the consequence of the acute form.  It is characterized
             m ^by the same symptoms as described above, but developed more
    ■Mt'±s*.■*■<-■     gradually and with less intensity.
   r\   U*l j«> '  The causes, results, and treatment, are likewise similar.
    /,\  „■'  ZKZ     Convalescence from intestinal inflammation, must be watched
         «.<■. /'•    with peculiar care,  as there is no disease which  leaves on its
 : -x      -j, ,  subsidence a stronger tendency to recurrence.   The clothing
><</H<iA Jfiu/t **  should be warm, with flannel over the abdomen ;  the diet care-
                 fully regulated, and all excess strictly avoided.
 :/£" Jjl>ttitt ^-   ■ >•     ^  '■■     , -«-  --■  <  ■        /Av.   .,,   r,  > ■■
               • .  ^^^^^riLK-^ICl/NESS^<V    ':"
                                       U
                   This  is a peculiar form of disease,  met with chiefly in the
                 mountainous districts of the southern and southwestern states.
                   The cause is not clearly made out, but whether aerial, mineral,
                 or vegetable, seems to be limited in its production and influence.
                 It never directly affects  the human  subject, but attacks chiefly,
                 though not exclusively, the cow and the horse.   The  latter soon
                 dies if not efficiently aided ; the cow may live, and is more likely
                 to do so, if giving milk ; but the milk,  butter and flesh become
                 poisonous, exciting in those who make use of them as food, a
                 combination of symptoms indicative of an inflammatory affection
                 of the stomach and intestines—a true gastro-enterite.   The local-
                 ities  subject to  the  presence of this undetected agent, are well
,4- •;
:-*J: 
113
known and  may be defined,  and fenced in against the intrusion
of cattle ; it  is said, that when cultivated, they lose their poison-
ous qualities.
  Symptoms of milk-sickness.   Within a  short time after the
patient  has  taken the  deleterious milk, butter or flesh, he is
oppressed with languor and lassitude—soon followed by nausea
and vomiting, with pain, burning and oppression at the stomach.
The thirst is urgent,  the skin hot and dry, the eyes are red and
suffused  and glassy;   a peculiar odor  exhales from the  body.
The bowels are obstinately constipated.   The pulse, at first little
changed, becomes  frequent  and contracted.   Fever, with low
muttering delirium,  supervenes,  and  the patient sinks  with
symptoms closely resembling  those of Typhus  gravior.  The
convalescence is slow and  imperfect, and apt to be followed by
long debility, by dyspepsia, and other gastric disorders.
   The  treatment does  not  seem to be well agreed  on.  The
stomach, if  not thoroughly cleansed by spontaneous vomiting,
should  be  well emptied of  its injurious contents by ipecac, or
other mild  emetic, with draughts of warm water.  If the pulse
and strength admit, venesection must be resorted to; and at any
rate topical  depletion, by cups and leeches, will  be required.
The  bowels must be actively moved by mild purgatives.  The
oily are preferred ; and in neighborhoods subject  to this disease,
bear's oil is confided in as  a  sort of specific  remedy.   Oleum
ricini and  calomel will  answer in combination,  or  alternately,
every purpose ; and if the disease be not fully subdued, the mer-
curial should be urged to the extent of a light ptyalism.
   During convalescence, and indeed for an indefinite period after
it,  great care  must be taken  as  to diet,  and all exposure and
excess rigidly abstained from.

                          COLIC.

   This is one of the most frequent and painful of human diseases,
but is,  fortunately, among the  most manageable and least fatal.
It has been  divided and subdivided into a great number of species
and varieties, in reference to  the causes  which  give rise to the
attack, and  the consequences which may attend it.  I shall treat
                              15 
114
of it under three heads—1. Flatulent colic ; 2. Bilious colic ;  3.
Colica pictonum.
   1. Flatulent colic presents the following symptoms:  pain in
the bowels, with a sense of twisting and griping, especially about
the navel; nausea, costiveness,  a feeling of distention, which  in
most cases,  really  supervenes after a  time  with  tympanitic
resonance of the belly, giving rise  to  much general distress,
dyspnea, &c.  The pulse, unaffected at first, becomes in  a few
hours quick and frequent—pressure, which early in the attack was
sought for, cannot  be  borne—the vomiting is more and more
urgent—and if stools have not been procured,  fecal or stercora-
ceous matter is ejected from the mouth, forming the iliac passion;
nay, this inversion of the intestinal peristaltic action is occasionally
so complete,  that glysters are vomited up;  cold sweats exude
from the skin, and the patient sinks, worn out with his intolerable
sufferings.  Or the  irritation   runs on  into  the production  of
exquisite enteritis, with gangrene or ulceration.
   Post mortem examination shows sometimes little or no alter-
ation in the  parts affected—sometimes constriction of a portion
of the intestinal  tube,  with distention of the  part immediately
above it, and sometimes distention without any such constriction.
Not  unfrequently there  is found intussusception of one portion
of the  tube within  another, with  strangulation of the part re-
ceived, and its consequent mortification.
   The causes of colic are numerous and much diversified.   The
presence of crude, acrid, indigestible food—long fasting—expo-
sure to cold and moisture—vegetable matters specially liable  to
fermentation.   But  the secretion of gaseous and aerial matter,
or of a fluid having such affinity for caloric,  as to take on the
gaseous form instantly on its secretion from the  intestinal surface,
seems  highly  probable  in  colic, besides  the extrication of air
from fermenting vegetables.
   While treating a  patient for scarlatina in 1831, I saw three
violent paroxysms of flatulent colic  brought on at intervals  of
twenty-four hours, by enemata of the simplest character—nothing
but  water, and that in very  moderate quantity, having   been
taken in the mean while by the sick man, who had been man-
aged strictly on the expectant system. 
115
  Pathology.—All  circumstances seem to me,  to establish the
belief in the essential and invariable presence of spasmodic con-
striction of some  portion of  the  intestinal tube.   The mere loss
of muscular power and the cessation of peristaltic action, with the
consequent distention of a  section of  the  tube, as supposed by
Abercrombie, does  not account for the symptoms—the pain, the
constipation,  the  obstruction of  the passage of  air, the intussus-
ception and strangulation of the received portion of gut.   Nor is
the  occurrence of  stercoraceous vomiting or   the  ejection of
enemata by the mouth,  at all capable of explanation  upon Aber-
crombie's doctrine of mere  muscular paralysis  with consequent
passive detention, for this would as  much impede the reversed or
anti-peristaltic as  the normal or peristaltic movements  In hernia,
where the phenomena are  very similar, we know they depend
upon such a stricture, and are readily relieved by its mechanical
division.
   To these  arguments, a priori, we add the following, a poste-
riori:  If distention be the essence of the disease, it is impossible
to account for the undoubted utility, nay,  the immediate efficacy
of relaxants and anti-irritants in its removal; yet the lancet and
opium are our principal remedies, and the warm bath  and tobacco,
and the antimonials, are highly recommended by Abercrombie
himself.
   Treatment.—In  the early stage,  the domestic administration
of aromatics,  and so styled  antispasmodics, often succeeds com-
pletely,  as mint, ether, camphor, &c.   If the stomach  have
recently received any suspicious  articles of food, or if it be loaded
with a full meal, it should be emptied by an active emetic.   The
warm bath and opium are almost universally indicated.   Purga-
tives, at this stage, are hurtful, but enemata are highly serviceable.
If the  pulse rise,  and the abdomen become tender on pressure,
the  lancet  must be  used  freely, and cups or leeches applied to
the  abdomen, which should be covered with warm fomentations
or poultices.  Mild laxatives are now proper—oleum ricini with
tincture of opium,  or calomel and opium in moderate doses, will
be of evident benefit.  By such  means as these, assiduously
and perseveringly employed, we may  almost always prevent the
obstinate constipation, and  violent  intestinal and gastric disturb-
er   •'
             i 
116
ance so often described, and which most frequently appear to be
consequences of harsh and ill-judged management.   If relaxation
be aimed at, it can be most efficiently accomplished by the em-
ployment of tart. ant. and tobacco in enemata.  Croton  oil
rubbed on the  belly, or on the  tongue, will, it is said, operate
actively on  the obstructed  bowels,  in  difficult cases.  I  have
succeeded in De Haen's  method, by the mere  mechanical dis-
tention of the lower intestines, by large quantities of tepid water
thrown up  steadily from a syringe or inverted stomach  pump.
The use  of  mechanical deobstruents by the mouth, such as gold
and silver pills and crude mercury, I mention only  to reprobate.
  2. Bilious colic, a modification of ileus, which owes its char-
acteristic peculiarities  to the cause producing it, to the state of
the system of the subject, and to the season of the year in which
it occurs.  It is met with  in  summer and autumn—attacks per-
sons of "bilious habit;" those, namely, who are subject to hepatic
affections—and is attributed to the influence  of malaria.   The
immediate irritation of the intestines is, probably, excited by the
entrance  into them  of a  vitiated  and acrid  bile;  and in all the
attendant circumstances, there is an  obvious analogy with ordi-
nary autumnal remittent.
  The access of bilious colic is often accompanied  with a febrile
chill, which is succeeded by flushing of the  face, heat, and dry-
ness of the skin, great thirst, and a full, hard, and frequent pulse.
The vomiting, which is  urgent, brings up bile, with morbid  se-
cretions,  and there is great heat and  oppression at  the pit of the
stomach, with intense pain over  the whole abdomen;  obstinate
constipation often attends, with tormina and  tenesmus.
   Treatment.—Venesection is obviously required,  and must  be
promptly carried  to  as full an  extent as the strength will allow.
Opium cannot be dispensed with,  and is demanded in free doses
to relieve the sufferings of the patient.   Cathartics  may be given
alternately, or in  combination;  but there is much difficulty in
procuring their  operation.   I prefer to employ  large quantities of
calomel and opium together, aiding their  effect by proper ene-
mata.  In the mean while, the  warm bath should  be resorted to
—the abdomen  cupped,  and fomentations  or poultices applied.
When  the intestinal  constriction  and obstruction  are overcome, 
117
the case  usually  requires  to be  farther treated  as  a  bilious
remittent.
   3. Colica pictonum—Rachialgia—Painter's colic.—This gas-
troenteric affection is always attributable to the poisonous influ-
ence of some of the salts of lead—a metal  so widely employed
in the  arts of civilized life, that all are liable to be, in  their turn,
acted upon by its peculiar effects, which are in many cases devel-
oped very gradually, and in a chronic form.
   Symptoms.—Rachialgia commences  with a dull pain at  the
pit of  the stomach, extending downwards and fixing  with great
severity at the navel.  The abdomen  becomes  tender, and  is
drawn backward and flattened, with much pain in the loins and
back.   There is obstinate costiveness, with occasional  inclination
to go to stool, and usually, but not always, nausea and vomiting.
The pulse is small and tense and  frequent,  with headache, rest-
lessness, and dejection of mind.   The patient is emaciated and
feeble, and prefers a bent posture, leaning forward.   Epilepsy
supervenes occasionally—but much  more frequently,  a peculiar
paralysis of one or both of the upper extremities, with flaccidity
of the wrist and  hand, and wasting of the arm.
   Autopsy presents no uniform appearances.  The mucous sur-
face of the intestines is generally pale.  Sometimes, but not often,
the usual results  of inflammation of  this tissue, and of the perito-
neum, are met with.   The bowels are in some places  contracted,
in others, irregularly distended.
   Treatment.—Opium is the principal remedy, and must be em-
ployed freely from the first—given in  full doses by the mouth,
mixed in enemata, and applied to the  surface in poultices and
fomentations.  After a time, cathartics  must be  used  alternately
or in combination with it—the mildest being, for that  reason, the
best, if at all efficient.  Oleum ricini, Epsom salt, and calomel,
are usually preferred.  If the pulse and strength admit, the lancet
may be employed, and the belly cupped or leeched.
   In protracted cases, alum and powdered  nutmeg,  have been
highly recommended.  Epispastics are also  advised to be put on
the abdomen and thighs successively.   During convalescence, a
flannel fold and bandage should be worn around the trunk of the
body,  and the diet carefully regulated. 
US
   The paralysis of the arm and hand, above  described, is  best
 relieved by supporting the limb in a carved splint, well fitted to
 it; while we administer calomel and opium in small doses, and
 with perseverance, until a gentle ptyalism is induced.
   In obstinate  cases,  strychnine  is said  to have  been exhibited
 with a favorable result.  The nitrate  of silver has received simi-
 lar eulogy also.  Locally, the cold affusion may  be of service;
 but more is hoped for from the assiduous employment of electri-
 city and galvanism.

                        CHOLERA.
               7      ' •        • - '-'" ■
   It is necessary to treat of this affection of the stomach and bow-
 els under the separate heads of—1. Common or sporadic cholera;
 2. Epidemic or malignant cholera.  The first  is among the most
 ordinary diseases of all climates and seasons, and though alarming
 by its suddenness and violence, yet fatal in but a small proportion
 of cases;  the second, on the other hand, though generally regard-
 ed  as identical  in nature and pathology, has spread the utmost
 dismay throughout the civilized world, by its fatal  malignity and
 the wide  extent of its career.  Since, in the  early part of the
 present century, it attracted attention in British  India, it has every
 where exhibited a proportional mortality almost beyond example.
   1. The symptoms of common cholera are, to every one, famil-
 iar.  Vomiting  and purging,  with pain and cramp of the stomach
 and limbs, great prostration  of strength,  cold  and clammy skin,
 and extreme anxiety and dejection of mind.   Death may some-
 times occur from the immediate loss of strength,  which follows
 the immoderate evacuations  upwards and downwards; it some-
 times happens too, that when these have subsided spontaneously,
 or have been checked, a true gastro-enteritis  supervenes, with
 fever of low irritative type.
  The causes of cholera are numerous.   Crude or indigestible
 food taken into the  stomach, raw or half-cooked or putrescent
 vegetables, fruit in excess or  unripe,  and  some fruits by their
 acrid quality, ices  and confections in  undue quantity, shell-fish
 to those unaccustomed to use them, a  supper of mixed materials
taken just before going to bed, exposures to alternations of tem-
perature, and to cold with  moisture.   From its more frequent 
119
occurrence in autumn, and in low hot regions, it is usual to speak
of malaria as among its causes,  and to regard it as occasionally
the effect of the flow of a vitiated and acrid bile  into the alimen-
tary canal, and facts seem  to me to justify the opinion.  Many
of our medicines (as tartarized antimony, &c.) produce it readily;
and a very severe form of it supervenes upon repelled eruptions,
and follows sudden and careless exposure  after the subsidence of
the exanthemata—measles  especially.
   Autopsy displays nothing uniform or  explanatory.   When  the
case has been of brief duration, little trace of disease is left.  If
more protracted, there are  obvious marks  of inflammatory irrita-
tion of the gastro-enteric mucous surface,  with occasional exten-
sion of inflammation and its results, to the peritoneum.
   The  prognosis  is, for the most part favorable,  provided  the
patient  be of ordinary vigor, and the case be early treated with
proper attention.   If, on the other hand, it has been neglected or
injudiciously managed, and especially,  if symptoms of gastritis or
enteritis have  made  their appearance, the danger has become
serious.
   Treatment.—In a great majority of instances, opium is of itself
sufficient to calm the gastric irritation, from whatever cause aris-
ing, and to subdue the disease.  With Sydenham I prefer "liquid
laudanum" to any other formula; it should be given in full doses,
and if not retained when swallowed,  should  be thrown up  the
rectum  in a mucilaginous enema, while fomentations or poultices
mixed with it, are applied to the  belly.   Sinapisms should be
laid to the wrists and ankles; and if the strength fail, stimulants
may be required, as ammonia, ether, camphor, and brandy.  In
general these remedies will be  found sufficient;  but if the relief
thus secured be imperfect,  some febrile excitement  manifesting
itself with menace of gastric and  intestinal inflammation,  the
treatment  already advised  under such circumstances,  must  be
promptly and assiduously instituted.
   2.  M^alignant or epidemic cholera.—To the symptoms above
recounted, as belonging to cholera  generally,  we are to add, in
the description  of this terrible pestilence, certain striking phenom-
ena, which some consider indeed as peculiar to,  and characteris-
tic of it. 
120
   The evacuations are of almost uniform appearance, consisting
of a well known serous fluid, with minute whitish flakes, strongly
resembling rice water or thin gruel.  The spasms are extremely
violent, contracting with severe cramps, almost every muscle of
the body.  The blood, when drawn from a vein and examined
with chemical reagents,  is found to be deprived, in great propor-
tion,  of  its serum and the  salts usually contained  in it.   The
stage of collapse, into which patients often sink, is remarkable.
It seems  to me to be a state of true  capillary paralysis.  The sur-
face is quite blue or livid, or as I saw  it in one case, of dark ma-
hogany or bronze color; the skin is as cold as after death, with
a clammy moisture, while the patient  often complains of intense
heat; the hands and feet are shrunken and corrugated, as if sod-
den a long while in water.   The urinary secretion is, in bad cases,
very much diminished or even totally abolished.  The voice fails
or sinks to a husky whisper, described as the vox cholerica.   The
progress  is fearfully rapid, patients  often  dying within a few
hours, and  in some few of the malignant attacks, in a still shorter
period.
   The form  assumed is somewhat modified in the  different!
localities invaded.  In some places, we find spasm more prom-
inent ; in others, the serous evacuations are more profuse ;—some
are favored with a benign alarm from  premonitory symptoms, as
diarrheas,  &c.;  while  others  are overwhelmed  with  fearful
promptness into collapse.  The consecutive febrile stage was in
France and England, a more common sequela;  in other countries,
it  has been met with but seldom, comparatively.  Instead of it,
I have noted  in many instances a strange and  peculiar condition.
The  patient  is drowsy,  but not comatose; dull, but not inco-
herent.   The pulse is very soft, full and slow;  the pupil of the
eye somewhat dilated ; the tongue and  mouth dry, with much
thirst.  Respiration is extremely slow, and the breathing some-
times  stertorous, with  moaning  or  muttering.   No  pain is
complained of; the stomach and bowels are quiet; the strength
fails rapidly, so that the subject is apt to fall into syncope on bein<*
raised  from the recumbent  posture.  He must be called loudly
or shaken  to arouse  him,  but when awaked  speaks  with unex-
pected promptness, clearness and alacrity.  Blood, when drawn, 
121
 isvery dark, coagulating slowly, with  little or no serum.   Dr.
 Keir, of Moscow, describes a similar set of symptoms, which he
 regards as denoting " a congestive sub-inflammatory state of the
 brain and spinal cord.'L
   Causes.—A peculiar  distemperature  of the atmosphere,  in
 nature and origin absolutely unknown, is assumed to be the gen-
 erating cause of cholera, when prevailing  in this  malignant and
 epidemic form.   I  am of those who regard it also as contagious,
 and attribute its extension,  chiefly to this  power or quality.
 The question is hotly contested, but there are certain facts which
 can be explained and understood no otherwise than by reference
 to such a  property of communicability.   We do  not, however,
 doubt or deny the atmospheric distemperature supposed, although
 the  mode  in which such  contamination arises,  or is effected,
 has not yet been  explained.  This pestilence is, to a degree,
 unprecedented in the history of epidemic diseases—independent
 in  its prevalence,  upon any of the ordinary influences of place,
 season, or climate—pursuing its ravages with equal sway "under
 the burning line," and amidst the wintry snows of Russia.
   Prognosis.—The  danger seems  to   be proportioned to  the
 collapse—that is, the circulatory stagnation and general loss of
 strength.   The inordinate evacuations are sometimes well borne,
 and do not show the greatest degree of risk,  unless attended by
 notable prostration.  The  absolute  non-secretion of urine  is
 among  the  most fearful  tokens, and its  resumption, on the other
 hand, shows a change for the better.   So, also, does the recovery
 of  the  natural tone of voice,  when it  has been  much altered.
 The intensity of spasm  has sometimes  proved fatal; but we are
 not to draw favorable inferences from its subsidence, unless there
 is,  at the same time, increased fullness of pulse and warmth of
 skin.   Such vascular reaction affords the best hope of recovery,
 but requires to be carefully watched, and depletion, if necessary,
 to be cautiously graduated.
  The  diagnosis can only  relate  to the distinction between
ordinary and Asiatic cholera; for this purpose, the  history of the
preceding and attendant circumstances will usually suffice, though
 there are cases of the one so mild, and of the other so severe, as
 to resemble  very  closely.
                            16
v th&
/ 
122
  Autopsy.—The  external appearance of the body is striking.
The solids  are  sunk,  the surface is livid, bronzed or blue, the
skin of  the  hands and feet corrugated,  the  fingers often rigidly
contracted  by spasm, which,  indeed, in cases of short duration,
may continue  to affect  the  various  muscles several hours after
death.   We are warned  not to pronounce hastily, in such cases,
that death has taken place, as several singular instances of recov-
ery have  been  recorded  under the  circumstances.   There  is,
occasionally, congestion  of  the .vessels of the brain, and some
extravasation within the cranium.  Magendie describes a ghastly
transparency of the sclerotica, as occurring even a short time
before  death, or immediately after it.   The lungs and heart are
usually  healthy,  but gorged  with dark  blood.  The  mucous
coat of  the stomach and intestines is, for the most part, pale or
blanched in those who die in  the early stage of an attack, while
the other abdominal viscera  show  the  marks of  congestion.
Horner describes a species of vesicular eruption as showing itself
upon the  gastric and intestinal surfaces,  and regards this exan-
thematous  affection of the mucous membrane as constant and
characteristic.   When the case has been protracted, the congestion
of the liver and spleen has disappeared, and the villous intestinal
tunic exhibits traces of various degrees of inflammatory irritation.
The stomach  and bowels axe found often filled with a serous or
gelatinous fluid, identical with that discharged by vomiting and
purging.  The quantity  thus  excreted, is sufficient to account
for  the  defect of serum and the salts dissolved in it, in the blood
of choleric patients, the  analysis of which has been made with
great nicety by Clanny, O'Shaughnessy, and others.
  Treatment.—In mild cases,  seen early, and in subjects warned
by the slighter  precursory symptoms, I would promptly exhibit
the tinct.  opii in sufficient doses, putting the patient to bed, and
covering the abdomen with warm fomentations and poultices,
and  the extremities with sinapisms.   These  means failing to
relieve,  I would perhaps resort to the lancet, watching anxiously
the effect of the loss of blood on the pulse and strength.   I would
cup the epigastrium and  belly, and apply  leeches to  the back of
the neck  and  behind the  ears.   I would depend  upon  the
influence of calomel, which I would combine with opium, pro- 
123
portioning  the  dose to the urgency of the  case.  If the pulse
sunk, and exhaustion threatened to supervene, I would administer
capsicum and camphor; and if the prostration increased, employ
unhesitatingly,  though with reluctance, the most  energetic of
the  diffusible stimulants.   Ice ad libitum should  be allowed
during all the stages of the attack, if agreeable and asked for.
   The  true  collapse, not a state of congestion or concentration,
but a complete capillary paralysis, is an almost hopeless condition,
and  fairly beyond  the resources of our  art; but we must not
abandon our patient;  and  in  our embarrassment, I  would de-
cidedly prefer the  stimulant,   rather than the opposite class of
measures.  A mustard emetic with  salt,  followed by free doses
of turpentine, capsicum, laudanum and ether, with the applica-
tion of heat and irritants  to the surface, seem  to me the most
promising remedies.
   In the consecutive fever,  topical and sometimes general blood-
letting, the application of leeches  especially to the temples and
occipital region,  mild cathartics, with the mercurial treatment
carried  to the extent of a light ptyalism,  are the measures most
obviously indicated.
   I  scarcely need say, that I have little confidence in the exhibi-
tion of saline medicines, in large quantities, as recommended by
Stevens—or in their introduction into the veins, as practiced by
Latta and others—or in the inhalation of oxygen—or the deluging
the  stomach with  either warm or  cold water, in the indefinite
draughts lauded by Shute and his antagonist on either hand—or
in the  tobacco  enema of  Baird—or the  frictions with ice, pro-
posed by Jackson.

                        DIARRHCEAX

   Inordinate frequency and fluidity of the alvine evacuations.
Very generally, though  not always,  there is griping  pain pre-
ceding and  accompanying each motion,  and relieved by  it for a
time.   Anorexia attends, with nausea sometimes, and vomiting—
the  tongue  is  furred  and whitish—fever is rarely present, and
does not by any  means form a part of the ordinary history of the
disease.  If the case be protracted, there  is emaciation and great 
124
debility—the lips, cheeks, gums, &c. become aphthous, and the
patient sinks at  last, exhausted by the unceasing drain, and the
atrophy which of course results.
   Diarrhea  has  been subdivided into many species, in reference
to the alleged  sources and  the morbid peculiarities presented in
the  stools, but the pathology is in all the same.  The mucous
membrane lining the  digestive canal, is irritated and excited to
morbid and  unnatural  action ; its vessels pour out  an increased
amount of secretion, variously changed, according to the circum-
stances, and a symptomatic or consequent urgency of peristaltic
movement ensues.
   Causes.—Indigestion, whether from excess in quantity of food,
or any other  circumstance disordering the stomach, is the usual
commencement of attacks of diarrhea.  There are indeed many
substances, which by some peculiar property bring on transient
diarrhea,  as the whole class of laxatives and purgatives, several
articles of diet, as for example preparations of Indian corn, many
fruits, ripe and unripe, molasses, confections, ices, &c. &c.   The
disease results also from sudden exposures to atmospheric vicissi-
tudes, and  to  cold and  moisture.   It  arises from impressions
made directly or  indirectly upon the liver, occasioning an undue
flow of vitiated bile into the duodenum.  It occurs from repelled
eruptions, and at the  subsidence of the exanthemata—from
irregular gout and rheumatism, and in some cases of fever, when
the evacuations are spoken of as " critical."
  Prognosis.—If early and judiciously prescribed for,  diarrhea
is not generally difficult of cure ; but if neglected or aggravated,
as is often the fact, by the  employment of inappropriate med-
icines, it  may terminate fatally, though this  is rare; or it may
run  on into  a chronic  .stage, in which it assumes a singular
obstinacy, enduring for months, and even years.
  Treatment.—It has been too much a general rule, to begin the
management  of diarrhea, by the exhibition of an emetic or
cathartic, or perhaps both.   This is seldom proper.  Where foul,
crude, irritating  ingesta,  have been recently taken  into  the
stomach, a mild emetic of ipecac, may be premised; and  if the
stools have,  from the first, contained little or no feculent matter,
giving reason to suspect their retention, a gentle cathartic of oleum 
125
ricini, pulv. rhei, or calomel, may do service by the removal of
such oppressive accumulations.   For the most part, however,
the evacuations have been sufficiently free;  and it is best to
commence at once with the administration of opiates and diapho-
retics.   The Dover's powder, or  the tinct. opii camphorata, will
with few exceptions, put an end to ordinary attacks.  If soreness
of the abdomen exist, or febrile excitement be present, it may be
proper to cup or  leech  the belly.  Fomentations and poultices,
mingled with  mustard  or other stimulant,  are always useful.
Alkaline and astringent medicines are next to be prescribed.   Of
the former, the carb. potass., cret. ppt. and aqua calcis, are  much re-
lied on.  Kino is  preferred to all the astringents, and has received
high eulogies from Pemberton and  Bally.  The cretaceous julep
is a familiar and very extensively applicable combination of the
mucilage of gum arabic, with cret. ppt. and kino, and an opiate.
   In chronic diarrhea, the sulphates of alumin, zinc and copper,
have met with zealous advocates.   The latter is much employed
by Eiliotson.   The acet. plumbi is deserving of confidence. The
nitrat. argent, is often useful in protracted cases, and is specially
adapted when  the red or aphthous tongue shows an inflammatory
and ulcerous condition of the digestive mucous membrane.   The
diet should be nourishing, but plain, with little fluid of  any kind,
and all stimulants avoided.  The trunk of the body should be
enveloped in flannel, and a journey or sea voyage undertaken.

                        DYSENTERY.

   Pain and disorder of the bowels, with fever—tormina and tenes-
 mus, with alvine discharges of mucous or muco-purulent or muco-
 sanguinolent matter ; these are the general  symptoms which oc-
 cur in the designation of dysentery.
   It presents itself often sporadically, and not unfrequently as an
 epidemic—is notably modified by season, climate, and  other cir-
 cumstances, and exhibits occasionally a contagious disposition ;
 nay, Cullen and others regard  contagion as one of its uniform
 characteristics.
   Dysentery comes on with some gastric uneasiness, for the most
 part with griping and frequent calls to  stool;  the evacuations are 
126
scanty and unsatisfactory, and give no relief, being attended with
much straining, and consisting at first of a  mere bloody mucus,
fecal  matter being very seldom  discharged, and in  very small
quantities.   Febrile excitement runs high, with heat and dryness
of skin, and full hard pulse—or  in other cases partakes more of
the characteristics of typhus, when we have sudden  prostration,
with  feeble circulation and low muttering delirium; the belly
becomes more sore to the touch—the tongue is fiery red, at  first
covered with  a  thick fur,  but  clearing off after a time with a
smooth epithelium-like surface—there is great restlessness, with
much  anxiety and oppression  and  sighing.  The alvine  dis-
charges are now very frequent and exceedingly offensive,  and
much and variously changed in appearance and qualities.  Small,
round, hardened  fecal lumps (technically denoted Scybala) are
occasionally passed by the patient, and always with notable re-
lief; lumps of sebaceous matter are also sometimes voided.  The
stomach often  becomes,  in  these latter stages, irritable—debility
and emaciation rapidly increase—the abdominal pains having
reached an intolerable intensity,  sometimes  cease suddenly  and
entirely, and death soon follows.
  Autopsy.—Dissections uniformly reveal  the results  of inflam-
mation—o.ften showing constriction of some part of the intestinal
canal.  These lesions have been most frequently found in  the
colon.  Ulcers are seen of various sizes, eroding the mucous coat;
and gangrene is occasionally met with of greater or less extent.
  Diagnosis.—Dysentery has been confounded on the one hand
with diarrhea, and on the other, with mere  intestinal  inflam-
mation, whence  it  has  been styled  by Ballingall and others, a
Colonitis.  From diarrhea it is  distinguished by the essential
presence of fever  and of spasmodic  constriction.  Dysentery is
uniformly a pyrectic affection ; and we cannot doubt of the mor-
bid constriction of some part of the tube,  as in colic, when we
reflect  on  the difficulty with which  fecal evacuations  are pro-
cured, and  the relief which  always follows  at once when they
do happen.
  That the intestine is inflamed in dysentery is obvious  and cer-
tain ,'^but the nature of this inflammation *is  peculiar, and it is
uniformly combined with  circumstances and  conditions which 
127
are characteristic. Thus in enteritis we have no excitement of the
peristaltic movements of the bowels, so urgent in dysentery;  nor
is there present the  tenesmus,  nor  griping, nor the hemorrhagic
transudation, nor the tokens of spasmodic  constriction  met with
in the latter.
   The pathology of dysentery presents several complicated con-
ditions which separate it (in practice readily enough) from all
other  disease.   Pain,  fever,  and  inflammation, ulceration  and
hemorrhage, increase and morbid alteration of the  intestinal se-
cretions, with urgent vehemence  of  the  peristaltic actions,  all
combine in each individual case.
   Causes.—Dysentery may occur sporadically at  any season of
the year, like cholera and diarrhea, from the irritation of the ali-
mentary tube, by improper, crude  and acrid ingesta, or by expo-
sure to cold and moisture, and sudden  alternations of temperature.
   It may arise  as an endemic, in localities subject to the influence
of malaria, and in the autumn especially.   This form,  called by
some tropical dysentery,  is supposed to be closely connected with
hepatic derangement and effusion of vitiated bile.
   It occurs not  unfrequently as an epidemic,  spreading  rapidly
and extensively, by means of some unknown atmospheric con-
tamination.  It assumes  probably a contagious  character under
certain circumstances,  as when it  invades a jail, hospital, ship or
camp, crowded and ill-ventilated places, and where the attendant
fever is of typhoid type.
   Prognosis.—The general  prognosis in vernal and winter dys-
entery, and  in sporadic attacks, is favorable—not so mueh so in
epidemic  and  autumnal dysentery,  and  decidedly the  reverse
when the fever is of typhoid  character.
   In particular cases,  the danger may be  considered as in pretty
exact proportion with  the urgency and frequency of the calls to
stool; and a diminution of this frequency is one of the most pleas-
ing symptoms.  The nature, too, of the discharges is of some im-
portance.  Hemorrhage is a sign of evil, as showing the erosion
of some vessel, or extreme force of vascular determination  to some
part of the internal surface; purulent fluid, as resulting from high
inflammatory excitement, not unlikely to  be productive of ulcer-
ation ; so also fibrinous shreds or pieces of membrane,  similar to 
128
that found  in the larynx in croup; and ichorous or sanious and
highly offensive matters, as giving reason to dread the superven-
tion of gangrene.   Relaxation of the sphincter aui is almost cer-
tainly a fatal prognostic.
  Recovery is probably at  hand when the fever  subsides, the
tormina are less severe,  the tenesmus less urgent, the alvine evac-
uations assume a fecal  odor and appearance,  and the tongue be-
comes  moister and less  red.
  Treatment.—Blood-letting is very generally indicated—less fre-
quently, I think, in the epidemic and autumnal dysenteries ; it is
of course unsuited  to cases of feeble constitution and typhous
combination.   Topical  depletion, by cupping  and leeching the
belly, is also generally useful; after which, fomentations and irri-
tating  poultices should be applied.  Emetics  have been highly
lauded, but I have seen little benefit from them.  Cathartics are
not always  required; but if properly selected,  will often do good
service.  In such  attacks as occur in winter and spring, (which
have been regarded as catarrhal and rheumatic,) and  in epidemic
dysentery, I do not think them necessary, but would commence
the treatment by administering an opiate and diaphoretic, as Do-
ver's powder or tinct. opii camph., in full dose.   We may proceed
to combine  a few  grains of calomel,  if the cases threaten to pro-
tract themselves;  and under this simple  management they will,
in a vast majority of instances, yield promptly.
  In the other forms of the disease, those namely, which  result
from acrid ingesta, and such as depend on the impression of mala-
ria, we must employ the class of mild purgatives.  In the first, it is
usual to prescribe the oleum ricini alone, or with a small amount of
ipecac.; nor can we advise a better formula.  After its operation,
the belly should be  well fomented, and an opiate exhibited.
  In tropical, autumnal, malaria or bilious dysentery, the best of
our cathartics is the  mercurial; and  the experience of  all practi-
tioners, in hot climates, is in favor of its prompt and unshrink-
ing administration.  From one scruple upwards of calomel is the
dose, which should be repeated with a frequency proportioned to
the violence and danger of the attack.  I give unhesitating testi-
mony to the remarkable success of this  method of treatment.
Ptyalism need not be aimed at, and may usually be avoided, the
patient's life being secured without it.


                                   y/\         ..    $ 
0           /   ,           129

   It would be unwise to omit in the mean while the use of the
 lancet, if the inflammatory symptoms run high—the opiate, which
 conduces so admirably to the relief of the suffering,  or the cups
 and fomentations so beneficial locally. Epispastics  are by some
 physicians very much trusted to as adjuvant means of revulsion,
 when the earlier stage of the case is past.   They are applied both
 to the abdomen and the extremities, and sometimes effect striking
 results.
   The employment of enemeta of various formule and qualities,
 may tend much to the comfort and advantage of the sick.   Cold
 water, unmixed, is among the best, as diminishing pain and irri-
 tation.   Mucilages,  with opium,  subdue the griping and tenes-
 mus.   The acetate of  lead  is administered with obvious  good
 effect,  both in clysters and  by the  mouth, where  hemorrhage,
 whether venous or arterial, has occurred.
   The general management of the patient is of great importance.
 He should be kept as quiet as  possible in a recumbent posture,
 rising as  seldom  and with  as  little exposure  as may be.  He
 should  be instructed to resist with his utmost resolution the
 urgent calls  to stool which annoy him, and  the  reiteration of
 which is susceptible  of  unlimited increase  by indulgence.   His
 chamber must be kept specially clean and pure,  and his evacua-
 tions always removed on the instant.  His diet  should consist of
 the lightest mucilaginous infusions, as toast-water, and thin gruel.
 Pure water is the best drink, though he may be allowed to acid-
 ulate it a little, with either a vegetable or a mineral acid,  accor-
 ding to his fancy.   Every thing  he takes  should  be offered in
 small quantities at a  time, as the disposition to stool, is apt to be
 suddenly augmented by a large draught.
    Chronic dysentery sometimes comes on slowly as a primary
 affection, or results from the irritation of protracted diarrhea; but
 is far more frequently a consequence or continuance of the acute
 form.  A similar  management of the case is necessary, modifying
 the energy of the treatment, and the doses and  repetition of the
 remedies employed,  in reference to the less urgency and violence
 of the  symptoms, the  debility so  universally  present, and the
 tenacious  obstinacy  which the attack has acquired  from the
 influence of the habit of morbid action.  The nitrate of silver is




                                                   4.{ 11\
Jr
1 
130
well adapted here;  it seems to exert a special influence in pro-
moting the healing of intestinal ulcerations.  The diet should be
carefully regulated—nourishing but unirritating—and the flannel
roller should be worn around the trunk of the body.   The acet.
plumbi, opium,  ipecac,  in  small  doses,  kino,  and  the  other
astringents, mineral and vegetable,  may be tried in succession or
combination, and with  perseverance ;  but our best hope is m a
long journey or sea voyage.

                 CHOLERA INFANTUM.

  Under this title physicians have treated of every varied form
of derangement of the digestive system and  function which can
affect early childhood,' including besides true  cholera—dyspepsia,
diarrhea, dysentery, scrofulous marasmus, atrophy from whatever
cause, verminous disorders,  and  even infantile  remittent and
hydrocephalus.   I intend  by the appellation,  cholera infantum,
when  strictLy applied,  that  modification of  bowel  complaint
which is met with  in spring and  early summer,  and while the
process of  dentition is  going on.  I shall,  however, follow, in
some degree, the general custom, and take the opportunity to
notice the  modifications which the tender age and the habits of
body of  our juvenile patients may render necessary, in  the
treatment of the  diseases to which in them  the alimentary tube
is liable.
  Cholera infantum is  most  frequently met with in cities,  in
warm climates  and low flat situations,  during the sudden  heats
of coming summer.
  Its causes are dentition—improper food  in all its varieties,
including  the milk of a pregnant mother, and of an unhealthy
nurse, thick paps, &c.;  general bad management, as want  of
proper cleanliness of skin, clothing  and  bed chamber, pure air
and sufficient exercise—heat and malaria.
  History.—It  is not my purpose here  to  describe again the
cholera, diarrhea, dysentery, enteritis,  &c., which may attack
children as well  as adults, at  any season and under any circum-
stances.  I shall  merely recount the train of symptoms which
occur at the age and under the contingencies above specified, in 
131
early summer  and during dentition, as I attribute all the pecu-
liarities which demand remark, whether in  the course  of  the
attack,  the  prognosis,  or the  treatment, to the predisposition of
the season, and to the irritation of the teeth in coming forward.
   The invasion of cholera infantum,  if it be not preceded by,  and
the sequela or remnant of some of the more acute forms of intes-
tinal disease,  is gradual, though not slow.   There is fretfulness
and uneasy restlessness, with moaning—the hand  being often
applied to the  mouth or face, or upon the gums, which are perhaps
red and swollen ; the lips and tongue also exhibit a higher than
the  natural color.    The  stools are  loose  and frequent,  and
changed from  the ordinary appearance; there is thirst, and es-
pecially at night, more or less febrile excitement.   The stomach
becomes disturbed, or perhaps vomiting may be one of the earliest
symptoms; and the  organ  is, at last,  so irritable, that nothing
can be retained.  The stools are attended with pain and strain-
ing—are more morbid  in character and acrid,  so as to inflame the
skin about  the  anus.  The abdomen  is tender on pressure  and
becomes tumid, while the limbs emaciate, and the countenance
grows  haggard and ghastly—the mouth is covered with aphthous
ulcers,  and great languor and feebleness supervene.  In some
cases,  the sufferings  are  unremitting,  and the child cries inces-
santly, tossing its arms about and drawing up its feet.   In others,
the patient lies in a state approaching to coma, with its eyes shut,
and so insensible to every thing,  that flies have been  seen to
light upon  the  cornea, or enter the open mouth, without being
noticed.   In some instances,  death is preceded by convulsions.
The duration of the  attack is very uncertain.   I have seen a
child carried off by cholera—vomiting and purging—in less than
twelve hours,  but the chronic form I  have portrayed, may last
from ten days to six or eight weeks.
   Autopsy.—The appearances after death, vary with the duration
and form,  and  are such as have been described, successively,
under  former heads.
   Prognosis.—Cholera infantum, so called in accordance with
the definition given  above,  although  not  mortal in very large
proportion,  is a disease of difficult cure,  owing to the permanence
of the  causes  which give rise to it.  Transient relief is  readily 
^Uaa^iijKfa^MjK*^    7^1
                            132

within our reach, but the symptoms are exceedingly apt to recur.
The chances of perfect recovery are greatest, where the smallest
number of teeth remain to be " cut"—when the constitution of
the parents is good, and the child has been previously healthy.
On the other hand, we dread the result in weakly children—those
born  of  scrofulous or otherwise infirm parents—those attacked
early in spring, and  having a large proportion of teeth yet to cut—
such as live in low,  damp, and ill-ventilated situations—children,
whose mothers  have become  pregnant, and are forced to wean
them, or change  their nurses at this unfortunate age and season.
The  case has  an unfavorable  aspect when the stomach is ob-
stinately irritable, or the bowels are urged with severe tenesmus,
and  the  stools mucous or bloody or sanious;  when the tongue,       j
lips  and cheeks  are fiery red or ulcerated,  the belly tumid, the
emaciation specially great, and when  coma or  convulsions
occur.
   The treatment varies  with the several forms of disorder inclu-
ded  under the  present  general  head.  When the vomiting and
purging of ordinary cholera assail an infant, they must, as in an
adult, be restrained   by proper doses of anodyne, while fomenta-
tions and poultices are likewise applied to the abdomen.   I often
prescribe a  combination of  the  tinct. opii camph.,  with an
alkali, the carb. potass, for  example, in small doses, repeated pro
re nata.  When diarrhea exists, I administer the mist, cretacea,
with or without the tinct. kino.   The  rind of  the  pomegranate,
and  the  root of the  high blackberry, are also very useful astrin-
gents.  When  dysentery is present, I resort to the combination
of Dover's powder with calomel and  cret. ppt.  in doses carefully
adapted to the age of the child,  aiding the effect with soothing
mucilaginous and anodyne enemata,  while the belly is  well
fomented or poulticed.
   In the chronic case now under special discussion, the obstinacy
or reiterated occurrence of the attack, will render all our resources
necessary.  In  the first place, the general regimen must be care-
fully attended to.  The clothes, person,  and the chamber must
be  kept  scrupulously clean, and fresh  air  and  free exercise       I
allowed.   If  the child has been weaned while  teething  at the
coming  on of summer,  he must be put back to nurse;  if the       j
tj
\~g| 
^■7,  '/
133
mother  be pregnant or ill, a sound breast  must be procured.  If
this cannot be done, an exclusive diet of milk and water, with a
little  sugar, must  be enjoined.  This is the food most readily
assimilated by a child unable to masticate, and whose digestion
is impaired.  If his residence be in a city, an occasional ride into
the country, or a temporary change of abode will be of service.
The gums, if swollen, should be scarified freely from time to time.
Vomiting, which will happen occasionally throughout the case,
must be  checked  by anodynes and  alkalies; the latter will be
very frequently called for,  the prevailing acidity of the contents
of the. alimentary canal being shown both in the breath and the
stools.  The warm bath  will be found a valuable auxiliary in
procuring comfort  and tranquillity;  when,inconvenient, fomen-
tations  and  poultices  must  be employed.   Constipation will
sometimes render  necessary a cathartic—the most gentle of the
class should be chosen.   Oleum ricini is  usually and justly pre-
ferred.   Calomel is also easy and mild in  its operation, and there
is little or no danger of ptyalism in infants, even when we persist
in the  exhibition of small  doses of the mercurial; this is called
for, when the stools are chalky and show deficiency of the proper
feculent  and  bilious admixture.  Diarrhea should be restrained
by the astringents mentioned above; the  kino has won an exten-
sive preference, but the acet. plumbi is used, and alum is highly
 extolled by Miller.
   The prophylaxis or preventive management of children is, in
reference to their liability to bowel complaints, a matter of great
importance,  and  comprises a very extensive regulation of early
 physical  education.  Cleanliness, free ventilation, and  exercise
 in the open  air,  should  be enjoined upon all.  No child should
be weaned  in  spring or  early summer, who has  not passed
 through  the perils of teething. I am disposed to think that no
 child should be taken from the breast until he has teeth in suffi-
 cient number to break  up and masticate his food, or,  where
 dentition is long delayed, has learned to do this with his gums.
 Much is said of the evils of keeping a child too long at nurse—the
 opposite  evil is at least equally dangerous.   After weaning, the
 diet  must  be plain, but abundant.   No great variety should be
 allowed, and all such things as tempt to excess in quantity should
 be strictly prohibited. 
134
                 INTESTINAL WORMS.

  Vermes—Helminthia.—As all plants are liable to be preyed
on  by parasitic plants, so  all animals  are  infested  by para-
sites.   Some of these, probably numerous species, are of them-
selves  and  in  the  nature of their usual connection innocuous,
and  become hurtful, if  at all so,  merely by their  inordinate
increase.   Others  are  either  products  of  disease,  or occasion
disease uniformly by their presence.  Examples of  each  kind
may be offered  among the subjects of the present discussion.
The worms which ordinarily affect the human intestines are the
lumbricus,  the  ascaris, and the tenia.  The first of these would
seem  to  be  always,  or  almost  always, an  inhabitant  of the
alimentary  tube, exciting  no disturbance,  and attracting  no
notice whatever, unless when unduly multiplied in number, or
when,  from  some foreign  cause  of  derangement,  the body to
which it  has attached itself has lost something of its proper tone
and vigor of health.  The  tape worm on the other hand is
always annoying, and sometimes fatally irritating,  while the
ascaris may be considered as in a certain  degree hurtful wherever
it exists, though its power to disturb, greatly depends upon its
multitude.   The other varieties of intestinal worms described in
systematic works, I  shall  not regard;  they are very rarely met
with,  and  deserve  to  be  ranked rather as  objects of scientific
curiosity  than of pathological interest.
  The lumbricus is round,  thickest in the middle, and tapering
to both extremities—of white or slightly greenish  hue,  with a
wrinkled or annular surface, and from five to twelve inches  long.
It enjoys distinction of sex, is  of social habit, and chiefly infests
children from two to ten years of age, being rarely found in any
large number in infants while at the  breast, or in adults.   They
are so universally to be detected in the bowels, that  Parr, Rush,
and others, considered them as regularly belonging to the healthy
animal economy.
  The symptoms which are supposed to result from their pres-
ence and injurious agency are in general somewhat  as follows:
the child is languid and  loses flesh, the appetite  is irregular, 
135
sometimes voracious, but often deficient, the tongue is furred, and
the breath fetid, the  bowels are usually  loose with griping and
straining, and the stools morbid  and offensive, the abdomen is
hard, and tumid and painful, the skin of the face and feet puffed,
the little patient picks his nose and  sleeps uneasily with starting
and sometimes  screaming, irregular irritative  fever may super-
vene, there is cough perhaps with dyspnea, and not unfrequently
convulsions quasi epileptic.   " There  is scarcely a  disease  or
symptom of disease," says Rush, " belonging to Cullen's class of
Neuroses, which is not produced by worms."  I had rather refer
to them as  among the most potent exciting causes of all forms of
intestinal and nervous  disease,  to which the subject may have
become predisposed in any manner whatever.
   When the above train of phenomena,  or  any notable number
of them concur in a given case, it will be proper to manage it by
a prompt  resort to  anthelmintics or vermifuges.  Of these, the
best are the Spigelia Marilandica, Melia azedarach, camphor, and
spts. terebinth., and  it is worthy of  remark,  that  they often put
an  end  to the appearance of disease, even when they fail to expel
worms  as we had expected.  Camphor is especially deserving of
our confidence ;  it is distasteful to all tribes of insects, worms, &c.
In  a dilute aromatic infusion it is also a good tonic, and is readily
taken by children.   The  others are in  very extensive domestic
use, and  very  serviceable.  After  a brief  exhibition  of any of
them, it is  usual to administer a cathartic. I see no advantage in
the usual selection of the drastics, but  prefer the mildly efficient
articles, such as the oleum ricini, with or without mere. dulc.
I dislike the promiscuous and repeated administration of anthel-
mintics, merely  as  such.   Where  the  symptoms of irritation
point chiefly to the  brain and nervous  system, I would depend
upon the incidental vermifuge effect of purgative formule, with
such other remedies as may be indicated.  When the digestive
tube is  much disturbed, I would resort  to the narcotics, Spigelia,
Melia azedarach, &c.  Of course, there are cases in which a com-
bination of these plans may be called for.
   The  ascaris,  thread worm,  maw worm,  inhabits  the  rectum
chiefly, though  it is said to be found in the stomach.   It is small,
filiform, slender, tapering  to both ends,  of  white color, and ex- 
136
 ceedingly vivacious.  They create  an intolerable pricking and
 itching at the anus, but are occasionally found in the child's bed,
 having crawled from his body in great numbers, without any no-
 tice of  their presence being  previously given.   In the  stomach,
 they excite distress and oppression, the cause of which cannot
 be  known, unless they are expelled by vomiting, or by stool.
  Aloes is the best vermifuge here,  being noxious and disgustful
 to the ascaris.  It is used both by the mouth and enemata.  Or
 a small candle or bougie, smeared with mercurial ointment, being
 passed  into the rectum,  will dislodge them.   Castor  oil with
 camphor, is also useful in getting rid of them.
   Tmnia, or tape worm, is distinguished into three  or four sub-
 species—is in form flattened, separated into numerous joints, each
 containing an ovary;  its color is whitish or light yellow.  It is
 hermaphrodite—attains a great size,  some  hundred feet having
 been expelled from a patient.  I,  myself,  have  seen  ten yards
 brought away at once.   It is difficult of dislodgement—the head,
 which is toward the upper part  of the  intestine, being furnished
 with fangs or hooks, which it fixes  into the mucous membrane;
 it  is,  probably, also, reproduced—inhabits chiefly the smaller
 intestines, and is found almost exclusively in adults.  The other
 worms die soon after leaving the body, but  the tape worm is ex-
 ceedingly tenacious of life.  Its presence is productive of very
 great pain and uneasiness in the belly, with diarrhea and  ema-
 ciation, but we  have no diagnostic until the gourdseed-like joints
 are  detected in  the stools.  Many remedies  are offered  to procure
 its expulsion.   I have most confidence in  the bold and free use
 of the spts. terebinth, either with or without oleum  ricini.  Cal-
 omel, filings of tin  and  of pewter,  an amalgam of mercury and
 tin, the male fern,  the Dolichos pruriens, pomegranate rind, the
 min. solut. Fowleri, camphor and aloes are used, and a great many
other articles, but, I fear we are bound to acknowledge,  with no
 flattering success.

                       HEPATITIS.

  The liver is,  apparently, the most important of the collatitious
viscera, which aid in the digestion and  assimilation of  our food j 
137
and although the special  uses of its secretion,  the bile,  are not
known with precision, yet the importance of the organ must be
great, as it is the largest in the body, is one of the most uniform
of the animal structure, and its diseases always affect the  general
health in a remarkable manner.   It is  subject to  inflammation,
acute and chronic, and it has been much disputed, whether the
difference announced  in these terms may be merely referrible to
the time occupied by  the morbid action and its results,  or consist
in some specific distinction of nature or locality.
   Acute hepatitis has been attributed by one class of writers, to
a diseased state of the ramifications of the hepatic artery,  the nu-
trient vessel of the organ ; and the chronic form to a similar con-
dition of the minute branches of the vena porte,  supposed to be
engaged in the business  of secretion.   Others regard the first as
an inflammation of the investing serous membrane of the  viscus;
and the second as an inflammation of the parenchyma of the liver.
   Acute hepatitis commences usually with febrile rigors, followed
by flushing of the face, with hard, abrupt,  quick  pulse.  There
is a sharp pungent pain in the right side under the margin of the
ribs, shooting to the  back and to the top of the shoulder.  The
pain is permanent, but is increased by a deep inspiration; it is
sometimes, though not often, attended  with nausea.  The respi-
ration is hurried and uneasy, and a short dry cough comes on and
harasses the  patient;  there  is much thirst; the  skin  is hot and
dry ;  the tongue is thickly furred with a yellow crust;  the bow-
els are usually costive and difficult to be moved.
   Diagnosis^.—May  be  confounded with  pleurisy,  which also
presents severe pain in the side, with dyspnea, cough and fever.
In pleurisy, however,  the cough is one of the earliest symptoms,
while it does not invade until some time after the access of hepa-
titis ; nor is there in the former the pain at the top of the shoul-
der,  so usually attendant on inflammation of  the  liver; the seat
of pain in the latter,  is also lower  down the side, and may be
traced by the hand under the cartilages of the ribs.  Exploration
of the thorax by auscultation and percussion, if properly attended
to, will  preclude all chance of error.
   Causes.—The predisposition seems to be built up by high and
long continued heat,  the influence of  which upon the liver, is
                             18 
138
attempted to be accounted for by various speculations.  The or-
dinary exciting cause is almost always a notable alternation of tem-
perature, exposure  to  damp or comparative coolness.  Excesses
of all kinds, it is said, may bring on an attack.
   Prognosis generally favorable.  The  principal  danger lies in
the tendency to recurrence, succeeding attacks becoming less and
less manageable.   The acute is, also, very liable  to  run into or
produce the chronic form of hepatic disease.  It may, however,
terminate the life of the  patient,  like other inflammatory affec-
tions, by exhausting  the  vital  powers; or it may  run promptly
into suppuration.  This last result is known by the repeated chills
or rigors  which supervene; there are sweats about  the face, with
a pulse small and very frequent; there is, also, a sense of weight
or heaviness in the right hypochondrium.  The event is usually
unfavorable ; but the abscess may empty itself—1st, by the lungs,
adhesions connecting  the  inflamed viscus with  the diaphragm,
and the portion of the lung above it, and  absorption or ulceration
making an outlet for the  pus which is coughed up;  or 2d,  by
similar adhesions  to the stomach or intestines,  when it may be
passed by stool or vomiting;  or 3d, it may adhere to the parietes
of the abdomen, and point externally, as I have seen in two at-
tacks in the same individual, a female.  In all these cases, though
life may be  preserved, the health  of  the patient is irretrievably
impaired ; digestion and fecification are always afterwards imper-
fect.
   Treatment is very simple,  and consists almost exclusively of
active  depletion.   Venesection  should be carried  to  the fullest
extent, and  leeches or  cups  applied to the  right hypochondriac
and epigastric regions.  The saline  purgatives are to be freely
administered; and after their abundant operation,  the skin is to
be kept moist with perspiration, and the pulse low by the  use of
antimonials.  Should the hepatic  pain continue after this deple-
tion, and fomentations fail to give relief, a large blister should be
put over the part.
  When  the patient is seen  early in the  attack, these measures
will rarely, if ever, fail to  remove it.   But if his strength should
sink, or suppuration intervene^ we must change our plan of man-
agement, and support him by the cautious employment of tonics 
139
and stimulants, and a generous diet, until the matter be discharg-
ed in one of the modes above alluded to.
   Chronic hepatitis is a form of disease of not unfrequent occur-
rence among us.  It is sometimes, as has been said, a sequela of
the acute variety, but more commonly developes itself indepen-
dently,  gradually and obscurely.   With much  disorder of the
general health, such as has been described under the head of dys-
pepsia,  there is a sense of weight and fullness in the right  side,
with some  uneasiness or pain at the top  of the right shoulder, or
as the left lobe of the liver may be affected,  these may be felt on
the left instead of the right side, though much more rarely.   The
complexion is sallow,  and the tongue encrusted with a whitish
or brown fur, while the sides and edges  are of a dark red, or the
organ may have a contrasted flabby and pale appearance, looking
soft  and sodden and somewhat  swollen.   The strength fails, and
there is extreme dejection of spirits, with ennui and morbid  vigil-
ance.   The bowels are irregular,  costive, or loose,  with ill-con-
ditioned evacuations.  The pulse is quick and chorded, though
small.   A febrile exacerbation,  more or  less marked, takes  place
every evening, and a dry hacking cough often attends.
   Cause.—Heat and malaria predispose to  this affection of the
liver, which, indeed,  almost  exclusively belongs to  warm cli-
mates ;  it occurs in persons who have been subjected to no  other
special or notable mode of excitement.  It follows violent or ob-
stinate attacks of intermittent and remittent fever.   It is,  how-
ever, most  commonly met with in the intemperate.
   Prognosis is unfavorable.  Perfect recovery of health, after a
liver complaint of  any duration, is not  frequent,  the  patient re-
maining dyspeptic,  and liable to a recurrence of  his hepatic dis-
order.   Among  its ultimate  consequences  too,  are icterus and
dropsy.  It is more apt than the acute form  to run into suppura-
tion ; besides which, it has a peculiar termination in a sort of per-
manent enlargement with  induration, technichally spoken  of as
Schirrhus.   This is readily discoverable on  examination by the
hand, the fingers being bent and  turned upwards, while the pa-
tient is  leaning slightly forward to relax the  abdominal parietes.
   Treatment.—If the strength  admit, venesection should be em-
ployed, but with some caution.   Topical blood-letting is almost 
140
always advisable, and may be repeated pro re nata.  The bowels
should be moved from time to time—if constipated, by mild but
efficient cathartics.   Beyond this,  we must  hope for permanent
advantage  in an  alterative course.   The mercurials  are almost
universally confided in.   The  blue pill or calomel in small doses,
should be administered until a moderate ptyalism is induced, and
this should be kept up for a time, during  which the morbid symp-
toms will generally be found to yield.  Oiher alteratives have also
been proposed, as taraxacum, and the nitrous and muriatic acids;
the combination of  the two, the nitro-muriatic,  has  been much
used in India, both internally and as a bath.   One of the best of
our alteratives is iodine, in very dilute solution.
  When the liver is tumid and  heavy without pain, epispastics
may be repeatedly applied over it,  and  the galvanic and electric
currents  passed through the hepatic region..
  In an obstinate case, we should advise a visit to some of our
watering places.   Those fountains which like Ballston and Sara-
toga, unite a moderate purgative effect, with the tonic pungency
of the carbonic acid  gas,  and  the mildly alterative influences of
iodine in minute proportions, are most useful in hepatic diseases.
There is  much good done  by the journey and voyage thither and
homeward.  In the mean  while the strictest  temperance must be
enjoined, and the patient cautioned against indulgence in improper
habits of every kind.  He must  live on the  plainest food, retire
early to rest, abstract his mind  as much as possible from care, and
guard against all passion  and emotion.  His clothing must be
warm and judiciously adapted to protect him from the vicissitudes
of weather.

                         ICTERUS.

  Jaundice.—This term is used to comprehend the series of symp-
toms which result from obstruction of the passage of bile from the
liver into the alimentary canal.
  The importance of this fluid in the process of alimentation, the
perfect digestion and assimilation of chyle,  and the fecification
and  expulsion of the rejected portions of  food  taken,  is well
known.  The want or deficiency of it,  is productive of  serious 
141
evils.  But it is supposed  that bile is not only a useful secretion,
but also an indispensable excretion, containing certain  essential
constituents which are required to be regularly and unceasingly
eliminated from the system.  Its non-secretion, or at  any rate
the re-absorption of its ingredients into the vessels, and their ad-
mixture with the circulating mass, is hence assumed to be atten-
ded with injurious and well ascertained consequences.
   These evil  effects are still farther liable  to modification,  and
additional suffering may result from the cause and nature of the
obstructions present; all which demand in turn a careful consid-
eration.
   1. When the function of the liver is interrupted, and bile no
longer enters the duodenum, the  patient labors under anorexia,
dyspepsia, costiveness;  the stools, when  any are passed, being
unnaturally pale or  of clay color.   The complexion and eyes are
yellow.   The tongue is covered with a thick brownish fur, and
a bitter taste pervades the mouth.   There is extreme mental de-
jection, with physical inactivity and feebleness.  The suffusion
of the skin and eyes deepens to an orange hue, and every solid
and fluid of the body is of the like tint,  " except," says Heberden,
 " the milk."   Poets and philosophers have affirmed the fact, and
 made it a subject of frequent allusion,  that jaundiced persons see
 all objects yellow.  This  is a rare circumstance, but Good affirms
 it to have been true in  his own case ; here  the very humors of
 the eye must have  been tinged by the  resorbed bile.
   There may or may not be certain  local symptoms denoting
 hepatic  disorder,  such as a sense of weight and fullness in the
 right hypochondrium, pain at the top of the shoulder, &c.  These,
 though dwelt on by authors, are not essential, and indeed are total-
 ly wanting in  the great majority of such cases as I have met with.
    In the simple form of icterus just described,  I  suppose the
 obstruction to the  flow of bile into the intestinal tube, to result
 from a torpor or loss of tone and  defect of action in the biliary
 ducts, which fail to take up and transmit thither, as is their office,
 the  fluid secreted  by the sanguineous capillaries—the ultimate
 ramifications of  the vena porte or of  the hepatic artery.   It is
 therefore of necessity re-absorbed by the radicles of the hepatic
 veins or lymphatics, and passes into the circulatory current. 
142
   The causes of this condition of the  liver are very various.  It
 may result from chronic  hepatitis, or  follow  the congestions
 which  form so prominent a part of the history of malaria fevers.
 I have seen marked cases occur  during  the convalescence from
 bilious  remittent and intermittent;  nay,  it  may  prevail, as if
 epidemically, in certain unhealthy seasons, showing the influence
 of febrile miasm upon the liver and its functions.  In the autumn
 of  1824, great  numbers of persons, including a majority of the
 convalescents from  bilious and yellow fevers  of that year, were
 attacked with jaundice.
   Prognosis, generally favorable.  This mild grade of icterus is
 seldom dangerous or fatal, and for the most part easily cured.
   I am inclined to the opinion, however, that some at least of
 the  more serious of these attacks are owing to a closure, more or
 less complete, of the valvular opening of the ductus communis
 choledochus, by swelling and thickening of  the mucous lining
 membrane of the intestinal tube,  in obscure chronic or sub-acute
 Duodenitis.  Of course, such cases will be more obstinate and
 tenacious,  not  admitting of relief until  the  original duodenite
 has been removed by proper measures.
   Treatment.—In the early stages of the  simplest cases, an active
 emetic will generally procure entire  relief.   If any thing farther
be  necessary,  a mercurial  or  aloetic cathartic,  with  energetic
exercise and cheerful occupation, should  be  advised.  Horse-
back riding is to be selected.   Frictions with  the hand, or a
flesh-brush, on the right side and over the abdomen, are service-
able.   A current of galvanic or electrical fluid  may be directed
along and through the region of the liver.
  2. The  most important  modification of icterus, and  one not
unfrequently met with,  is that characterized  by the presence of
biliary calculi.
  Here the attack is sudden and full of extreme suffering.  The
patient  complains of intense pain, coming on without warning,
often after a full meal, at or  near  the  pit of the  stomach, ex-
tending across toward the right side, with nausea soon increased
to violent vomiting,  and accompanied  by a sense of abdominal
distention.   The pulse is  little  affected.   There is  extreme
anxiety and despondency.  The  epigastric pain is usually per- 
143
manent,  and  intolerably  severe, and  pressure  at that  region
cannot be  borne.   It may in some  instances subside or remit
after a time, and return with great  violence, and  this may be
repeated until  the sensibility  of the duct is worn out;  or inflam-
mation may be excited and transmitted along the duodenum and
intestines  generally.   The  bowels  are  costive  and  flatulent.
The skin and  eyes soon become deeply suffused.
  The symptoms  thus described are attributed to the passage
through the duct leading from the gall  bladder to the duodenum,
of biliary calculi, or concretions of various constitution, size and
form.  These  bodies are often found in great numbers in the
gall  bladder,  and  even in the  bodies of individuals  who  have
never shown,  during their lives, any symptoms of jaundice.  We
find them occasionally in the stools of  our patients, which ought
with this view to  be carefully examined.   They are divided
into—1st.  Cholesterine  calculi,  composed   almost entirely of
cholesterine, an animal substance somewhat resembling adipocire
or spermaceti; these are white, lamellated,  shining and crystal-
lized.  2d.  The mellitic, the  most common;  brownish, composed
of cholesterine with picromel  and other animal matters, contained
in bile deposited in concentric layers.   3d. Calculi of inspissated
bile, of dark yellow color and somewhat rare.   Besides  these I
have seen calculi of a beautiful green,  so dark as to seem almost
jetty black,  with highly polished surfaces—others still  have  been
described.   They are seldom round, but polygonal and angular.
It is  not known how they are propelled from the gall bladder,
where they are comparatively harmless, into the duct which they
so vehemently irritate.  We  must not omit  to remark, that the
very same symptoms occur in many instances in which the  most
careful examination of the stools has failed to detect the passage
of a calculus, and  when  fatal no such concretions have  been
found  either in the duct or  the gall  bladder.  They are  here
attributed then, to  mere spasm or constriction of the duct, occa-
sioned probably by the irritation of vitiated and acrimonious bile.
  Prognosis,  doubtful.  We cannot explain the formation  of
these concretions;  but they are seldom  deposited singly, and
they  seem  to be connected with a condition of the  liver and
certain alterations of  its secretion, which, as we do not  clearly 
144
comprehend, we cannot readily remove.   Such attacks  are apt
to recur in the same person.   I saw the repetition in one patient,
productive of enteritis, and in this way indirectly fatal.
   Treatment.—It is not merely the mechanical distention of the
duct,  to which we must ascribe  the  sufferings endured by the
patient, but more probably a spasmodic constriction of its irritated
coats, which close upon and thus detain the gall-stone.   To relax
this constriction, we use the  lancet promptly and freely—admin-
ister opium  in the largest doses, and  place the patient in the
warm  hath.  The bowels  are  to be well  moved, by efficient
though mild cathartics  and  enemata, and large fomentations or
poultices kept to the abdomen.   To meet the first threatenings
of inflammation, we must apply cups or leeches to the right side
and epigastrium, and continue the effect of purgatives moderately.
This last  measure must indeed be persisted in for a few days in
a majority of cases, to remove the gastric and general uneasiness
left by the attack. To prevent a  recurrence of  the symptoms, it
is necessary to restore the liver to  its proper condition and action,
in order that a healthy bile may be  secreted and poured into the
intestines.  For this purpose no better  means are in our hands,
than those recommended in the remedial management of chronic
hepatitis.
  In ancient times, icterus was divided into species in reference
to the color of the bile discharged, and of the body of the patient.
Thus,  even Good, recognizes yellow, black, and green jaundice;
and Marcard and Baillie sanction  this view.  I have met with a
case of this last named variety, well marked.  The adnata of the
eye was green—the alvine evacuations, the saliva, and the bron-
chial mucus, were also  deeply green.  My patient was a black
woman, convalescent from small pox.  The event was fatal, as it
is asserted to be, uniformly, by the writers above alluded to.

                       SPLENITIS.

   Enlargements of the spleen are common in all hot and malarious
regions, and more especially frequent as connected with intermit-
tent fevers.   They are  generally regarded as congestive—the
result of repeated succussions of the cold stage.  But some of the 
145
French pathologists deny their passive character, and hold that
they are rather  the causes than effects of intermittents.   The
ague-cake, or ordinary indolent enlargement of the spleen, occa-
sionally puts on an inflammatory condition, rarely acute ; I have
seen  one case  terminate  promptly in suppuration,  the  spleen
becoming vehemently inflamed during  an attack of scarlatina,
following a  protracted intermittent.   I have  met  with  two
instances of very great enlargement and chronic inflammation of
the  spleen,  independent  of any .malaria fever.  The  dilatable
tissue of this organ is liable to rapid and monstrous intumescence,
and  extremely varied degeneration.  It  has been seen from ten
to thirty-three pounds in weight.   It is indurated,  tuberculated,
softened, dissolved, merely hypertrophied, schirrhous, full  of
abscesses.   Some of the victims of the famous " Walcheren fever"
had the spleen—a mere pulpy bag of three to five pounds weight—
filled with a liquid like tar;  and a similar dissolution occurs in
the malignant fevers of Italy.
   Splenitis,  in  all  its forms, is tenacious  and  difficult of cure.
Topical  depletion at first, and afterwards persevering counter-
irritation by blisters, &c, purgatives of mild character frequently
repeated, mercurials  cautiously  used—such  is the  prescribed
course of treatment.  Iodine is sometimes serviceable.  I prefer
the  deutiodide  of  mercury and potassium.'.The  ungt.  iodinii
may be rubbed on  the side.   The  Hindoos^ we are told, admin-
ister vinegar and steel.  I have found advantage in the exhibition
of the tinct. acet. eth. ferri.

                       PAROTITIS.

   Cynanche parotidcea—Mumps.—By this appellation, we de-
note a peculiar inflammation of the parotid, one of the salivary
glands.   It  is  attended  with fever,  headache,  thirst,  furred
tongue,  restlessness, and  depression of spirits.  The parotid is
swelled  and painful,  impeding speech, deglutition, and mastica-
tion.  One side  only is affected in a majority of  cases—now and
then  both  sides.  It  rarely attacks the same  subject more  than
once, and shows a peculiar tendency to metastasis, or translation
of inflammation, from  the part first affected to remote parts.  In
                             19 
146
females, the mamma, and the testis in males, are apt to be severe-
ly attacked ;  in both sexes the brain, also, suffers occasionally.
This is denied by some writers; but I have myself known three
instances of  violent phrenitis occur  on  the subsidence of the
original swelling.
   Cause.—It is contagious, and sometimes prevails epidemically.
   Prognosis  favorable.   The inflammation  usually terminates
in perfect resolution, suppuration of  any of the glands affected
being  extremely uncommon.  In a few there has remained an
indurated enlargement of the part; and rather more frequently, a
certain degree of softening of the testis, and loss of bulk has been
observed.  The greatest danger is to be dreaded where phrenitis
has supervened.
   Treatment.—In children, the swelling should be rubbed gently
with a mild stimulating embrocation, and kept lightly covered.
In young and robust adults, venesection and topical blood-letting
by leeches may be required.  This is absolutely necessary where
there is  metastasis to the more delicate and important organs
above indicated.  Here, also, the free  use of the active cathartics
is  demanded ; and when this has  been carried to the full extent,
the undue force of the circulation  must be still farther reduced
by nauseant diaphoretics, as ipecacuanha and antimonials.
   The glandular indurations, when they remain, should be treated,
while tender  and irritable,  by leeching and soft tepid poultices;
when  they have become indolent, by iodine lotions and embro-
cations.  Iodine should also be exhibited internally, in  diffused
aqueous solution.
   When metastasis has occurred to the brain, as shown by wild
delirium,  &c, the case must be  managed  by the energetic
application of the treatment recommended under the  head of
Phrenitis.
                     SORE-THROAT.

   Pharyngitis—Cynanche angina.—This  malady,  which after
all the attempts  to  give it a name,  is  best  designated by its
ordinary  appellation,  is  one of our most frequent diseases.  It is
essentially pyrectic, and is properly  divided—in reference to the
type of fever attendant upon it, and the state of the  general
system in which it occurs—into inflammatory and malignant. 
147
  Inflammatory sore-throat  is  farther divided into  Superficial,
Ulcerative, and Phlegmonous; the first affecting the lining mem-
brane of the posterior fauces  and isthmus, the uvula,  tonsils,
pharynx,  and upper part of the esophagus, without lesion of the
surface;  the second affecting  the  same tissue, with ulcers more
or less deep and extensive ;  while the third, as the phrase imports,
affects not the surface merely of the lining membrane, but the
tissues beneath, exhibiting  abscesses  in the tonsils, and on the
back of the pharynx.
   1.  Superficial inflammation of the throat, is  attended with red-
ness of the diseased part, its vessels being enlarged and distended,
as in Conjunctivitis.  There  is a sense of dryness, with pain in
swallowing—the uvula is relaxed, and sometimes edematous, oc-
casioning a tickling and disposition to cough.   When the inflam-
mation  is  great,  there is sometimes Otitis, with severe pains in
one or both ears, attributed to its extension along the lining mem-
brane of the Eustachian tube.
   It occasionally happens, whether  from  any peculiarity in the
nature of the inflammation  present, or merely from its intensity,
that a layer of whitish or yellow lymph is thrown out upon some
part  of the  surface, to which it  adheres,  but  perhaps  not very
closely,  and is usually taken for an ulcer.   It resembles the
membrane formed in croup, in diarrhea tubularis, &c.   It seems
to be connected with an obstinate and tenacious form of morbid
action, which may run into a chronic state.  Again, there is often
a  thick, condensed,  and highly  offensive mucus, collected in
small hard lumps in the fovee or crypts,  which indent the sur-
face of  the tonsil.  They are  apt to be mistaken for ulcers.   I
sometimes press them  out with a probe, to the great relief of the
patient.   If they remain in the cavities in which they are formed,
they occasion swelling and pain, and perhaps  are  loosened by  a
slight suppuration and hawked out.
   2. Ulcerous  sore-throat, Cynanche ulcerosa, presents also vari-
ous modifications, the  ulcers  assuming very different aspects in
different cases.   Some of these varieties, it is well known, are
peculiar and characteristic,  in  accordance with  the  specific state
of constitution of the  patient, as in scrofulous and venereal mal-
adies.  But of  these I do not  propose  to  treat in  detail.  That 
148
which is the subject of present discussion, and is connected with
ordinary inflammation, under common circumstances, is  at  first
irritable and very sharply painful;  its surface is gray or whitish,
with red points—the edges being swollen, it seems excavated ;
it is disposed to extend itself,  in  all directions,  with a rapidity
proportioned to the  intensity of the inflammation connected with
it.  After a time, if the ulcers do not heal, they become indolent,
stationary, and  chronic;  while the sympathetic constitutional
irritation subsides wholly or in part.  They occasionally extend
slowly down the esophagus, healing at some points and spreading
at others—the cicatrices where they heal, contracting and render-
ing deglutition exceedingly difficult and painful.
   3. Phlegmonous sore-throat—Cynanche tonsillaris—Quinsy.
—On looking into the throat, if we find one or both of the ton-
sils projecting forward, with a fiery red and smooth surface, we
have  reason to fear the  formation of abscess within their  sub-
stance.  This is to be dreaded,  as occasioning  great and pro-
tracted suffering, by the  impediment thus offered to deglutition
and respiration—so great, indeed, as sometimes to threaten suffo-
cation.  Even when  we  succeed in procuring resolution, there is
often  left  an enlargement and induration of the tonsils, which
impair both the speech  and hearing.   There is, now and then,
though rarely, abscess formed at the back  of the  pharynx; and
we have  on  record a few terrible  instances of abscesses  even in
the esophagus.
   Causes.—Sore-throat,  in its several varieties, is excited by ex-
posures to vicissitudes of weather and alternations of temperature
—to currents of cool  and damp air, showers, &c.   In some indi-
viduals and families,  there is special predisposition to it.
   Prognosis, generally favorable.   In the adult  of good  consti-
tution, there is little danger, though fatal  instances are now and
then met with.  Chronic ulcer of the throat, may wear out the
powers of life by  the* constant irritation, and by its extension
along  the esophagus.
   In the  child—the infant—sore-throat is a more serious disease.
Even  the superficial  inflammation is not without some risk, be-
ing, at this age, readily convertible into the ulcerous;  and if the
ulceration extend into the larynx,  the case becomes a very serious 
149
and  alarming one.   Diphtherite,  the membranous sore-throat
described in a former paragraph, is perhaps even more dangerous.
I scarcely know a more formidable disease than this modification
of laryngitis or croup, combined with sore-throat.   I do not re-
collect  to  have met with the phlegmonous form—quinsy—in a tfM* Vjrw**.
child.                                                              '
   Treatment.—In a robust  adult, it may be necessary to bleed
freely from the arm.   Local blood-letting by leeches,  is almost
always useful.  Crampton and others propose  to  carry them to
the inflamed spot.  Emetics are  often  given in the first stage,
and with advantage, if the stomach is oppressed, the tongue  foul,
and the breath fetid, without vomiting.   Cathartics, especially
the saline, are almost universally required.   They may be com-
bined  with diaphoretics, as, at first,  ipecacuanha  and antimony,
 and afterwards with the infusion of serpentaria or seneka.   W hen
 farther depletion is unnecessary, we  may reduce the force of the
 circulation by moderate doses of  nit. potass., combined during
 the day with an antimonial,  and  at  night with Dover's powder.
 Various local applications are recommended.   I disapprove  of
 gargles in  the early stage, as painful and  irritating.   The steam
 of water at a moderate heat may be inhaled, to relax and soothe
 the parts,  and procure a flow of saliva and  mucus.  After a  time,
 the sedative and mildly astringent solutions may be of some ad-
 vantage, more especially where  there is ulceration.  Nit. potass.,
 alum, sulph. zinc, acet. plumbi, and the mineral  acids, are much
 used.   Infus. cinchone and myrrh  are among  the best.   This
 may require special attention in the  case of children, the foul se-
 cretions from whose ulcerated fauces, it  may  be necessary to
 cleanse with a syringe, or a bit of lint attached to a probe.
   The employment of the stimulating gargles, so much in vogue,
 requires a nice judgment and some experience.  It cannot be de-
 nied, that there are cases in  which,  even from the first, the  infu-
 sion of Cayenne is beneficial, but it  is difficult to point them out ;
 and it is a good  general  rule to  abstain  from the  use  of  these
 washes, until the ulcer has become obviously indolent, and the
 case assumes a  clearly  chronic  character.  In  such instances,
 good  is sometimes done by washing with  the  solution of the
 sulph.  cupri, and by touching the ulcerated surface with the ni- 
150
                trate of silver.   These cases farther  demand the administration
                of alteratives and tonics.  A mild mercurial course,  as  of blue
                pill or  mere,  corros. sub., may be alternated or combined with
                the use of the bark and the mineral tonics, of which the best is
***•*«*!* ytfK&t'he tinct.  mur. ferri.
}                The  uvula is sometimes permanently elongated or relaxed, so
                as to fall upon the back of the tongue, and keep up an harassing
                cough, which, in some cases, has  been the precursor  of phthisis.
                To prevent this, it should be amputated.   When the  tonsil is so
                much enlarged as to impede the respiration, we must not hesitate
                to pass a lancet freely into and across it.  If an abscess has form-
                ed,  we  evacuate the matter at once; if  not, we give relief by
                diminishing the  bulk of the tonsil, and reduce its  inflammation
                by emptying its  vessels.  If the tumefaction be so great that the
                patient is in danger of being suffocated, an opening  should be
                made in the trachea, until the  tumor subsides or  suppurates.
                The tonsils remaining  indurated  and enlarged, they should be
               freely scarified in all directions, or completely extirpated.
                 Malignant sore-throat, Cynanche maligna, may be described
               as a combination of inflammation  of  the throat with  the  lowest
               grade of typhous fever.   Sporadic cases  are  occasionally met
               with, but  it is apt  to appear as  an  epidemic.   Its proportional
               mortality is frightful.  Its subjects are  generally young persons
               and children, from infancy to puberty.
                 Symptoms.—The attack is ushered in with nausea,  and  some-
               times vomiting; there is oppression,  restlessness, anxiety—the
               voice is  hoarse or husky, the skin dry and  constricted—there is
               thirst;  the pulse  is  small, compressible, very frequent—there is
               great languor and prostration.   It is not in every case that there
               is any pain or difficulty in swallowing, but in examining  the
               throat we find a  dusky redness overspreading the whole surface
               of the pharynx, fauces, tonsil, and uvula.  One or more ash-col-
               ored ulcers may appear, which  spread rapidly, with  little  or  no
               pain ; or, as is much more common, there is an exudation of plas-
               tic lymph  covering  the  inflamed surface, to which it adheres
               pretty firmly.  Pieces of this membrane are frequently thrown
               off,  dark colored and offensive, with a foul discharge  from the
               surface.   An efflorescence often shows itself  on the skin, but by 
151
no means uniformly or even in the majority of cases, as affirmed
by European writers,  who often  confound Scarlatina anginosa
and maligna, with our present subject.  As the disease progresses
the inflamed parts may assume a gangrenous disposition, becom-
ing livid or even black,  with great fetor.  Diarrhea comes on,
and the patient soon sinks exhausted.
  The  cause of this  malignant  pestilence  is unknown.  It is
usually epidemic in its prevalence.  It is alleged, also, to be con-
tagious.
  The prognosis is highly unfavorable.   The younger the sub-
ject, in  general, the  greater the danger.  In early life there is
special liability to the  extension of the ulcerous action and effu-
sion of lymph into the larynx, a combination almost always fatal.
  In older subjects we judge of the degree of risk as in typhous
fever, with less reference to the local affection.
   Treatment.—The general management of the patient is simi-
lar to that recommended under the head of typhous fever.  It is
the general practice to premise an emetic.  Ipecac, is perhaps  the
best, but some prefer the antimonial, as  more active, and  others
regard the sulph. cupri as exerting a special efficacy.  I see no
great objection to either.   Our  permanent  reliance is upon  the
class of stimulating diaphoretics, which may be employed in turn
—the infusion of serpentaria or seneka,  the combination of carb.
potass, with the  tinct. opii camphorata, the  acet. and carb. of
ammonia,  the nit. ether and the infus. cinchone ; while a gener-
ous and  stimulating diet is allowed,  with wine in proper amount
if necessary, the bowels in the  mean time  being gently acted
upon by some  mild cathartic; I prefer to all others the combina-
 tion of mere. dulc. with pulv. rhei in small doses, and at  proper
 intervals.
   Of local applications, I regard the blister and  the leech, to be
 alike of equivocal effect, and prefer the mustard poultice to either.
 The throat and mouth must be kept scrupulously clean.  The
 gargles  should be somewhat stimulating.   The infus. cinchon.
 with myrrh or camphor, with the  mineral acids, is much to be
 confided in.  The infusion of Cayenne pepper is greatly in vogue,
and often does good  service.  Besides this very useful local ap-
 plication as a gargle, it is  perhaps our best internal stimulant,  and 
152
should be administered freely.  The infusion should be preferred,
as strong as the patient can take without suffering, and contain-
ing a small proportion of common salt.  When the pungency of
this  drink cannot be borne, it should be prescribed in substance,
made up into pills or covered in capsules of jelly.
DISEASES  OF  THE  RESPIRATORY SYSTEM —THE
   LARYNX,  TRACHEA, BRONCHI, LUNGS, &C.


   examination or exploration  of the thorax.

   The  knowledge of the phenomena from which we infer the
condition of the thoracic viscera, is highly important to the prac-
titioner.  These physical signs are various in their character, and
are to be ascertained by the modes of investigation of which I
proceed to speak.
   I.  Inspection of the outline and the surface of the chest.   One
side  may be flattened—may be enlarged—the  intercostal  spaces
may be protruded—it may remain still and passive, unaffected by
the motions of respiration.  The subject  may be  more or less
malformed—chicken-breasted, &c.
   II.  Investigation of the capacity of the thorax.   This may  be
ascertained in several ways.  A. By mensuration.   One side may
be contracted, or unequal to the other in circumference.   B. By
expiration into a gas-holder or bell-glass turned down over water.
This  is a good comparative test of the capacity of the lungs at
different periods during  a chronic pulmonary disease.   C. By
counting seconds during inspiration or retention of breath.
   III. Hyppocratic succussion, or  brisk agitation of the trunk by
the shoulders,  for the purpose of detecting fluctuation  in the
chest.
   IV. Percussion—performed by striking  the  chest with the
finger, or the points of three or four together, smartly.   A notable
reverberation or hollow sound is  returned, on striking a  thorax
which is healthy and full of air.  If the reverberation does not 
153
 occur, or if the resonance is impaired in part of the chest, we infer
 the presence of some impediment to the entrance of air into the
 portion of lung immediately beneath, either by effusion of fluid,
 or  by the solidification of the lung itself.   Percussion is  some-
 times performed  mediately,  a " pleximeter"  being interposed
 between  the finger and the chest.   A flat piece of ivory is used
 for the purpose, a bit of leather, of caoutchouc, or a finger  of the
 hand.  The latter I prefer, and usually employ.
   V. The hand laid upon the  several portions of the thorax, gives
 very distinctly the perception of vibrations occasioned in breath-
 ing,  speaking, coughing, &c, and any impairment or increase of
 the natural and healthy degree of vibration is readily recognized.
 Thus, also, we examine the impulse of the heart, and determine
 upon  its  enlargement or hypertrophy, and  its situation or dis-
 placement.
   VI. Auscultation.  This is immediate, as when we lay the
 ear to the several regions of the  thorax, and listen to the sounds
 within.   It is mediate when we  employ the stethoscope.   This
 instrument shown and described in its several varieties of form
 and composition.  I  prefer a  tube  made  of wood  not  dense or
 heavy, and in one  piece.  I dislike its division into more than
 one piece, to be screwed or jointed together.  If the bore is suf-
 ficiently large, I do not think it of great consequence whether it
 be of paper, ivory  or caoutchouc,  but prefer wood.
  Respiratory sounds described.   1.  Healthy sound or respira-
 tory murmur.  A. Vesicular.   B. Bronchial.  C. Tracheal.  D.
 Puerile respiration.—2.  Morbid sounds.  A.  Crepitous xk\e.  B.
 Mucous rale.   C.  Metallic tinkling.   D.  Gurgling or bubbling.
 E.  Cooing or purring.  F. Sibilant or whistling sound.
   Vocal sounds described.    1.  Healthy sound.  A.  Broncho-
 phony.  B. Diffused thrill or vibratory murmur.—2. Diseased
 sounds.  A.  ^Egophony.   B.  Pectoriloquy.
  Sounds  occasioned by the  motion of the heart described.   1.
Healthy.   A. Auricular.   B.  Ventricular.—2. Morbid.  A. Bel-
lows  sound, (bruit de soufflet.)  B. Saw sound, (bruit de  scie.)
 C. Rasp sound, (bruit de  rape.)  A solid stethoscope  is said to
 convey to the ear, most distinctly, these sounds produced by the
 action of the  heart.
                             20 
154
  VII. Insertion of flat trocar—a means of exploration proposed
by Marshall Hall, to be used in doubtful cases to ascertain the
presence of air, serum, or pus in the sac of the pleura.  Not to be
lightly employed,  if ever—and suited  only to  cases in which
paracentesis is contemplated and proper to be resorted to.

                          CROUP.

  Laryngitis—Cynanche  trachealis—Trachitis.—Croup  is
one  of  the  most common maladies of children,  in whom it is
rarely met with  before they have been weaned.   Occurs seldom
in mature life, though a few individuals remain  subject to it.
It consists in a well known and peculiar dyspnea, attended with
cough and febrile excitement.  The voice is exceedingly husky,
and  the cough is characteristically harsh, stridulous and ringing.
The access is usually towards evening, when the  child presents
the ordinary appearances of catarrh or common cold; with sneezing,
&c.   His breathing becomes rapidly more and more difficult,
and  fever comes on, with flushing of the face and suffused and
watery eyes.  He sits up in bed, and his struggles for breath are
frightful.  If  not  soon relieved, his face is swollen and turgid,
and  his countenance livid or very pale, while his  eyes protrude
and  his skin is bedewed with  sweat.   Expectoration of a thick
tenacious mucus diminishes his sufferings, and he sinks exhausted
to sleep.  His respiration is still  hurried and croaking,  and a
mucous rattle is soon heard over the whole  thorax.  Portions of
a flaky membrane are sometimes coughed up,  with great allevia-
tion  of his dyspnea.  His paroxysms recur, if art has not arrested
his disease,  and he sinks, worn out with his violent exertions to
continue the process of respiration.
   Cause.—Exposure to the vicissitudes of weather,  to changes
of temperature, to cold and moisture, to  particular winds, as with
us the east and northeast, give rise to attacks of croup.  In some
children the predisposition is so strong that any exposure to night
air will bring it on.   It  sometimes arises  from the extension of
inflammation or ulceration of the throat into the larynx.  I have
seen it, I think, produced by gastric disorder and irritation. 
155
  Pathology.—Croup consists in an inflammation of  the lining
membrane of the larynx and glottis, which by its swelling closes
the rima—or by the effusion of thick tenacious mucus endangers
suffocation,  unless the  patient  is  able  to  expectorate—or the
deposition of flakes of fibrine, plastic lymph,  (the  "false mem-
brane"  so often spoken  of,  and  incorrectly considered by some
writers as uniformly present,) which clogs up the passage of air
into the lungs.  Some authors contend  for the existence of a
spasmodic croup, in which there is a spasmodic  constriction and
closure of the glottis, but this is not established.
   Autopsy.—The appearances vary with the duration of the case.
If death occurs early,  we find the lining membrane of the larynx
thickened and highly colored;  if there be greater protraction of
the attack, this state of the membrane is continued down through
the trachea and its ramifications, forming true bronchitis, and the
air tubes are clogged up with a thick mucus.  In such instances,
we find  more or less  inflammation of the pulmonary  tissue, the
lungs being to a considerable extent hepatized or solidified.   The
membrane above mentioned is sometimes found  in small flakes
adhering  to parts of  the  surface, or in the shape of a complete
tube, or in  solid mass.  There  is sometimes  ulceration of the
surface, in cases connected with sore-throat.  I have a preparation
of a larynx  which exhibits, at different  points of its surface, the
adhesion of flakes of lymph and an extended ulcer.
   The  prognosis is generally favorable.   Croup,  though alarm-
ing  in  its onset, is,  if seen early, very much under medical
control.   The  danger is  in  proportion  to the  dyspnea, except
where there1 is ulceration of the larynx.   Such cases are insidious,
but  prove almost uniformly fatal.   Free expectoration is a good
symptom—a hard, dry,  ringing cough, the reverse.  The exten-
sion of  the  morbid irritation to the bronchi and lungs, of course,
adds to  the danger.
   Treatment.—We  may sometimes succeed in arresting  the
threatened attack of  croup  in subjects  predisposed, at its com-
mencement, or during  what may be called the catarrhal stage,
by immersing   them in  the warm bath, and administering a full
dose of the tinct. opii camph., which proves stimulant, diaphoretic
and anodyne.   As soon  as the peculiar cough is heard, an active 
156
emetic  should be given, which will often put an end to all the
uneasiness  suffered.   I  prefer the combination of ipecac, with
tart, antimon.,  and if there were  much dyspnea, would admin-
ister it  while the child is seated in the warm bath.   If febrile
excitement  have had  time to develope itself, with full pulse,
flushed cheek, and sparkling eye, the lancet should be employed,
and perhaps leeches may be placed about the throat.  The emetic
should be  repeated,  and the  bowels  moved by uniting with it
some cathartic.   Calomel may be chosen, but I would not con-
fide  in  it alone, or  to the exclusion of other remedies.   Squill
and  seneka are  much and justly  extolled, as combining obvious
expectorant  and diaphoretic effects with their emetic property;
they may, in protracted cases, be exhibited repeatedly at intervals
with advantage.  As soon as the leeches are removed from the
throat, large poultices should  be applied, at first made irritating
by the addition of a little mustard.  At a later stage, they should
be made to cover the  whole thorax.  No disease is more generally
managed by domestic  means  with success.  A plaster of Scotch
snuff is mentioned by Godman, as highly efficient in  arresting
it in the former stage.  The alkalies are much employed. Com-
mon ley internally, and as a bath, is serviceable.  Some parents
give the volatile liniment, spt. corn, cervi, with olive or lamp oil
and molasses.   Others administer  indigo,  which operates harshly,
both by vomiting and purging.
  With regard  to  the operation of tracheotomy,  so much  dis-
cussed, I would offer  this rule.   If a child were in imminent dan-
ger of suffocation, in  the earlier period of croup, from sudden  clo-
sure of the glottis, either by swelling of the lining membrane, or
by the deposition of  membranous flakes,  while  yet the air-tubes
beneath were permeable, as inferred from the absence of the mu-
cous rale, and from the respiratory murmur being heard through-
out the lungs, I would open the windpipe.   But it is idle and use-
less to do this when the inflammation, engorgement and effusion
of mucus,  have extended into the thorax; the case is now bron-
chitis as well as laryngitis, and the operation can give  no relief. 
157
                CHRONIC  LARYNGITIS.

  Laryngeal phthisis.—This form of disease has of late attract-
ed muqbj^ta^ho.n^.andalthough it is not absolutely a new mala-
dy, as somesUBposejiis certainly more frequently met with in the
last few  years than formerly.  It is  known without  difficulty.
The sound of the voice is peculiar, or the aphonia  is entire, the
patient being able to speak only in a hoarse husky whisper,  and
with a painful and  fatiguing effort.   The  larynx is the seat of
uneasy sensations, and suffers when handled or pressed.  There
is a sibilant weak cough, usually dry and teasing;  in some cases
there is expectoration of  a thin tenacious mucus, sometimes of a
little  pus.   Dysphagia is occasionally the most annoying  symp-
tom,  from  inflammation  of  the  epiglottis.  There is dyspnea
and much  panting, after muscular exertion.  As the  case  pro-
gresses,  the ordinary symptoms of phthisis supervene—emacia-
tion,  hectic, colliquative sweats, and diarrhea.
   Its causes are not clearly defined.  It attacks  most frequently
the scrofulous constitution.   Clergymen are observed to be  sub-
ject to it, especially such  as read discourses in  public.
   Autopsy.—The  local  changes after  death  are—1.  Edema of
the glottis.   2.  Inflammation of the mucous  membrane  of the
larynx,  with redness and swelling.  3. Ulceration of this sur-
face.   4. Ossification, caries and- necrosis of the cartilages.   It is-pM******^
rarely fatal, however, without the extension of the morbid action^  *
downwards along the trachea and bronchi,  and the supervention
of pulmonary inflammation with its usual results.
   Treatment.—In  the first  instance blood-letting, both general
and local, is demanded, with the application of poultices and sin-
apisms to the throat.  Emetics are often serviceable in relieving
paroxysms  of dyspnea.  Mercurials are strongly recommended
by Trousseau and Belloc in  France,  who urge them  to the pro-
duction of  ptyalism,  and by M. Hall in  England.  I have not
derived much benefit from them.
   Narcotics are always  useful.  The  Dover's powder,  if  well
borne, is to be preferred;  the salts of morphine  are among the best
palliatives.   They may be applied to blistered surfaces with ben- 
158
 efit.   Inhalations of vapor, simple and mingled with ether, cam-
 phor, chlorine, &c.  have  been recommended.   In cases of dys-
 phagia,  I find the nitrate of silver highly serviceable as a gargle
 or wash to the throat, but have not been able to  introduce it in
 any mode into the larynx, as some cuppaec

                       BRONCHITIS.

    By this term is meant the  inflammation of the mucous mem-
 brane which invests the air-tubes—the trachea and bronchi, and
 the cells of the lungs.  It is divided into acute and chronic.
    Acute bronchitis  resembles closely, in the  first instance,  an
 attack of catarrhal fever, from which it is then only distinguished
 by a more special prominence of the tokens of  local and thoracic
 irritation and inflammation.   Its access is usually with a chill,
 accompanied  by a sense of soreness and stricture  in the trachea,
 and a tickling, dry,  and frequent cough;  fever soon follows, with
 harsh hot skin, flushed face, thirst, pain in the back  and limbs.  In
 some  cases the dyspnea is urgent, with a distressing tension
 across the chest, and much pain in coughing.   The patient can-
 not lie down—a crepitous rattle is heard and felt throughout the
 thorax;  but though oppressed with the accumulating mucus,  he
 cannot expectorate.   Resonance upon  percussion is dull, and the
 respiratory murmur  is impaired very generally over the thorax.
-.If these symptoms be not pre party relieved, he may sink exhaust-
 ed by his struggles ; or the expectoration becomes somewhat freer
 and fuller, and the disease subsides,  or passes into  a chronic con-
 dition.
   Post-mortem  examination shows the mucous lining membrane
 highly injected  and thickened, the  tubes and air-cells  being
 filled with a secretion of varied appearance, sometimes a tenacious
 ropy mucus, again a thick purulent  fluid,  mingled  occasionally
 with a serous, ichorous, or sanious effusion.   The substance of the
 lungs partakes of the results of the inflammation, and its tissue is
 solidified, or as the phrase is, hepatized, and  incapable of collapse.
    Causes.—Exposures to cold, moisture, and alternations of tem-
 perature, are  familiarly  known to  produce bronchitis.   It has
 been excited by inhalation of some of the irritating gases.   It is
/w.,.. 
159
more frequently met with among persons engaged in certain oc-
cupations—millers, cotton-ginners,  needle-grinders, &c.
  The prognosis is readily inferred from the degree  of dyspnea,
and the apparent ability of the  patient to struggle with the im-
pediment to his breathing, and to bring out from the air passages
the offending mucus.  Free expectoration is therefore favorable,
and a hard dry ringing cough the reverse.  Very old and infirm
persons, and young children, suffer the most serious risks.
   Treatment.— Venesection is in most cases  an indispensable
remedy, and must be promptly carried to as great  an extent as
can be  borne without injury.   Emetics are highly serviceable,
both as expectorants and  diaphoretics, and  are peremptorily de-
manded in the cases of infants  and the very aged.  They may
be repeated from time to time.  Ipecac, squill and seneka are
preferable;  if  these are not sufficiently active, tart, antim. may
be added.  Cathartics are useful.   I select  the saline, and com-
 bine them with diaphoretics, as the infusion of serpentaria or sen-
 eka.   Much has been said against the  employment of cathartics
 in thoracic diseases, but these objections  are speculative—expe-
 rience shews them to be, in the early stages, not only safe, but
 admirably beneficial.  In the  advanced periods  of such cases
 they are not required, but the bowels should be kept regular and
 soluble throughout.  Nauseating doses of antimony and other
 diaphoretics are much extolled.   I am not fond of the  practice,
 but prefer to  use  the same remedies in less amount, so as to re-
 duce the undue force  of  the circulation.
    When the  febrile  excitement  is in some measure  subdued,
 opium  is an  invaluable medicine.   Dover's powder is  a good
 combination, to ensure its effect as diaphoretic and  anodyne.
    Of topical applications, after cupping I prefer warm poultices,
 with which I  envelope the throat and cover the chest.   Leeches
 imply  too much exposure.  To relieve  the cough,  demulcents
 are required;  mucilaginous mixtures with  opium form the basis
 of the most valuable.  Spermaceti, formerly so often prescribed,
 is now too much neglected.
    In the bronchitis of infirm old people—the Peripneumonia No-
 tha of writers of the last age—stimulating diaphoretics and stim-
 ulants are demanded, and must be given freely.  Camphor and 
160
ammonia are among the best.   Opium must be  prescribed with
some caution.   The strength must  be supported with wine-
whey, wine, &c.   We cannot detract  blood from  such patients,
but dry cupping will often be of service—the mustard  poultice
should  be  applied—and  here also  blisters will be found well
adapted.
   Chronic bronchitis is usually a consequence of the acute form,
but may occur as a primary affection, in which case it is devel-
oped slowly and insidiously.   There is cough, with slight sore-
ness of the trachea and thorax—a sense of stricture and tight-
ness, increased on drawing a deep breath ; the voice is  somewhat
hoarse, and  a crackling or rale is felt and heard in  breathing.
The cough becomes more harassing and severe ; the  expectora-
tion, at first scanty,  increases in amount, and changes from  mere
mucus to a muco-purulent consistence, sometimes colored with a
little blood.   In a few cases hemoptysis may happen, but this is
not frequent.  Respiration is hurried,  and panting  attends any
muscular exertion,-or the  ascent of a stair.  The  pulse is tense
and frequent, and a  febrile  exacerbation shows itself  at  first in
the evening, going on to a full development of hectic, with night
sweats, emaciation and great loss of strength, diarrhea, &c.
  Autopsy.—The bronchial mucous membrane  is  high  colored
and thickened, and occasionally eroded with ulcers.  The lungs
are found  hepatized or solidified—the  air-cells and tubes filled
with  muco-purulent matter,  mingled with a  frothy and  bloody
serum.
  Prognosis.—The  unfavorable indications  are  chiefly drawn
from the degree of dyspnea in the early stages, and at a late pe-
riod from the atrophy and emaciation which waste  the  patient.
An extreme frequency of pulse is unfavorable—so is the absence
of the respiratory  murmur in a considerable portion of  the lungs,
with a loss of the proper degree of resonance on percussion.
  Diagnosis.—The distinction between chronic bronchitis and
tubercular  phthisis  is often  difficult.   In the latter there is less
crepitus or rale—less soreness of the trachea  and thorax—more
tendency generally to hemoptysis, and less expectoration in the
early stages.  In  their latter  progress we can draw no line be-
tween them, except from their previous history. 
161
  Treatment.—The lancet is in  most cases required, but must
be  employed  with caution.   We derive  most advantage from
small bleedings repeated.   Leeches may be applied to the throat,
and cups to the chest, with benefit.   Even  after we can no
longer detract  blood, dry cupping the thorax is useful, as revul-
sive.   Emetics are much confided in,  and great stress laid on
preference due to particular articles.  Ipecac, is generally chosen
—some combine it with tart,  antimon. and others with the sulph.
cupri.   The utility of emetics is unquestionable ;  they are expec-
torant,  diaphoretic,  and in  most instances move  the bowels
sufficiently.  To  soothe  pulmonary irritation  and   keep up a
constant determination to the  skin, we may exhibit a  combination
of the  nitrat. potass, with Dover's powder,  allowing a full dose of
anodyne nightly at bedtime.   A  choice of the numerous prepar-
ations  from opium  may be made to suit each particular case.  I
do  not think any other of the  narcotics, as  the lactucarium, hyos-
cyamus, &c.  entitled  to our  confidence.  The digitalis may do
service when the pulse is particularly frequent.    Squill is highly
prized by some as  an expectorant.
  The infusions of serpentaria and seneka, afford good bases for
the mucilaginous,  demulcent  and anodyne  solutions, administered
to relieve the troublesome cough.   In threatening cases, I would
advise an  unhesitating resort to an alterative mercurial course.
Calomel in small  doses, or the blue pill,  may be so given as to
produce  highly beneficial results, while it should not interfere
with  the proper employment of  such other remedies as may be
demanded.  Inhalation of various airs and gases has been pro-
posed ;  but after  a  fair  trial, I  have abandoned  them.  The
vapor  of ether,  in which conium has been  macerated, that of
burning tar and of resin, iodine and chlorine, have been extolled.
  The several balsamics were formerly much in  vogue.   Myrrh,
tolu, and copaiva,  are the best of them.   "Pine-gum pills" and
"lightwood rum," are common  domestic prescriptions in  the
south and southwestern states.
  Tonics may be  made of great benefit, by a proper selection of
the period for their exhibition, and the cases  to which they are
adapted.  I would use them  when the tokens of muscular debil-
ity  and general relaxation were  more prominent than those of
                             21 
162
 local irritation or  febrile excitement.  The infusion of cinchona
 with mucilage, is  lauded by Broussais and Hastings.   The elixir
 vitriol and tinct. mur. ferri, are also useful.  They aid in restrain-
 ing nocturnal sweats.
   The persevering application of counter-irritants to the chest and
 arms, will be of great advantage.  I prefer to blister successively
 one  and  another  portion of the surface.   The tartar emetic is a
 favorite  irritant with many physicians, while others still prefer
 setons and caustic issues.
   The convalescent must take as much exercise in the open air
 as he can undergo, without fatigue.  A long  journey or a sea
 voyage should be advised, and an equable climate chosen.  Flan-
 nel should be worn next to the skin, and all undue exposure
 avoided.

                        PLEURITIS.

   Pleuro-pneumonia—Pleuro-pneumonitis—Pleurisy.—Under
 this  head  I  propose to  treat of Acute Pneumonia, as well as of
 inflammation of the pleura, in all its extent, and its various local
 connections and subdivisions.   In their access and early stages,
 it is not  possible  to distinguish inflammation of the pulmonary
 tissue  from that of its  investing  membrane,  although in their
 results and consequences there may be some ultimate difference.
 Besides this, they  never occur separately or entirely independent
 of each other;  and in a  practical point of view, the diagnosis is as
 unimportant  as it is confessedly difficult—the indications of cure,
 and the details of treatment, being precisely the same in both.
   Pleurisy is a common and  well known disease; usually met
 with in winter and spring, and frequent in occurrence in propor-
 tion  to the  degree  and  suddenness of the  changes  of  these
unsettled  seasons.   It comes on with pain in the thorax—most
often perhaps the right side—fixed and circumscribed, and much
increased  by a deep  full inspiration;  the breathing  is  therefore
hurried, short and catching, and the patient assumes a bent pos-
 ture, leaning to the affected side.  Fever  soon  supervenes, with
sharp and rapid pulse,  a skin hot and  dry, and a harsh cough,
which aggravates intolerably the thoracic pain. 
163
  The results or " terminations" of this inflammation, if it pro-
gress unchecked, are somewhat various, but from the importance
of the organs attacked are  full of suffering and danger.  The
most common is the effusion of fibrine or lymph, (in layers upon
the serous membrane,) which becomes organized and causes ad-
hesion between the opposite surfaces of the pleura pulmonalis,
impeding somewhat the movements of respiration, and occasion-
ally giving pain.  Under this faMe  membrane are occasionally
seen  streaks  of purulent  matter.   The ' pulmonary tissue  not
unfrequently becomes solidified, losing its light cellular texture ;
this change is spoken of as hepatization of the lung, which seems
granulated and assumes a livid brownish color.  Allied to  this
condition, is  the establishment of chronic inflammation of a por-
tion of  this  tissue, tending  to the  formation of abscess,  and
perhaps the development of tubercle—chronic pneumonia, one of
the recognized forms of phthisis pulmonalis.   Cullen speaks of
a sanguineous infiltration into the cellular structure of the lungs
as  a eommon termination of pneumonia when it  proves fatal.
This differs  little, if at all,  from the pulmonary apoplexy of late
French pathologists.
   Chronic pleurisy, with effusion of sero-purulent fluid, is men-
tioned as an ordinary result or sequela of the acute form.  It is
known by the continuance of dyspnea after the  earlier acute
symptoms have subsided—by fullness of the affected side of the
thora*x, perceptible to the eye and ascertained by measurement—
by want  of resonance or  percussion, and of the natural vibration
of the chest, felt by the hand applied, while the patient breathes
or speaks, and by the  absence or dullness  of  the respiratory
 murmur.
   Hydrothorax—Hydropleura—is regarded by some as a termina-
 tion of pleuritis, acute and chronic.  I have discussed* the subject
elsewhere in speaking of  hydropic affections.
   The causes of pleuritic and pulmonic inflammation have been
already pointed out, as  exposure  to cold  and moisture, and to
sudden  changes of temperature.   External violence  may  give
rise to it; the puncture from spicule of a fractured rib occasion
 it  and a fatal case is on  record  where the pleura was injured by
 a needle employed in passing  a ligature  round the  subclavian
 artery. 
164
  Prognosis.—In our warm climate, pleurisy may be regarded
as a highly manageable disease,  and attended with little danger
if the  patient is seen early.  In  the  first  stage, the  degree of
danger may be inferred from the extent of  the inflamed portion
of surface, the violence of access, and the capacity of the patient
to bear the necessary remedial measures.   As the case progresses,
the increase or obstinacy of the dyspnea is unfavorable.  By ex-
ploring the thorax, we derive ffcfinite information of the condition
of the thoracic  viscera.   All tokens of effusion or deterioration of
structure, are of course to be dreaded.
  Autopsy.—In speaking of the results or terminations of pleu-
ritis, we  have anticipated a description of the changes found post
mortem.
  Treatment.—The  lancet,  used promptly and boldly at  the
onset of  the disease, will often put an end to it at once.  It is to
be resorted to at all stages while the breathing is painful, unless
the pulse is specially feeble,  and the strength of the patient has
notably  failed.   Topical  depletion  by  cups,  which  should be
applied on and  near the seat of pain, is next  proper; after which,
large  warm poultices  should be laid over  the thorax.  At this
stage a full  and free dose of an anodyne diaphoretic,  will often
put an end to the attack.   Dover's powder is perhaps to be pre-
ferred, but the tinct. op. camph. has frequently succeeded in my
hands.
  Cathartics are highly useful;  and in severe cases, those which
are somewhat  drastic and irritating, should  be chosen.   No pre-
judices have less foundation than those which exist against the
use of purgatives in pulmonary inflammation.  They are among
our best  revulsives,  but  their employment should be confined to
the early periods of acute cases.  It is advantageous to combine
an antimonial or other diaphoretic, as in the  common formule of
jalap with  pulv.  antimon., or of the nit. potass, with  jalap and
antimon. tart.   I have seen little or no benefit from the exhibition
of emetics, so  strongly recommended  by  some.   Among  the
vegetable diaphoreties, the infusions of seneka and serpentaria,
and  the Asclepias decumbens,  are deservedly  extolled.   The
combination  of ipecac,  with opium in Dover's powder,  is an
invaluable remedy; a full dose of it should be given nightly, and 
165
it may often be added at regular intervals to such other medicines
as may be prescribed through the day.   The demulcent drinks,
formerly spoken of,  may be  taken to relieve cough.  Where
some pain remains after the febrile symptoms have been subdued,
and  the pulse  has lost its force and tension,  the part should be
repeatedly blistered.   Where effusion is ascertained to have taken
place in the cavity  of the  pleura,  the  urgency of the dyspnea
may demand the operation of paracentesis.
   Bilious pleurisy.—The  thoracic inflammations which  occur
early in winter and spring, in  our low miasmatic regions, are apt
to be  combined with notable spmptoms of gastric and hepatic
disorder.   I have been disposed to attribute the modifications to
the impression of malaria ; an  English writer of some authority,
speaks of it as owing  to an atmospheric and epidemic influence.
In this form less vigorous depletion by the lancet is required or
admitted of, than in  simple pleurisy.   Emetics are more useful—
cathartics are prescribed more  freely, and the mercurials selected.
Blistering  is earlier  resorted to.   The bark is said to be service-
able in  protracted cases.
   Convalescence from pulmonary inflammation, requires great
care and  prudence.    The  clothing  should  be  warm, and all
exposure cautiously guarded against.

                PHTHISIS  PULMONALIS.

   Under this head I  include chronic pneumonia and  tubercular
imflammation of the lungs.   Dr. Duncan divided consumption
into  three kinds.    1. Catarrhal  consumption,  identical   with
chronic bronchitis already treated of.  2. Apostematous consump-
tion, our present subject; and  3. Tubercular consumption, which
shall be considered next in order.
   Chronic pneumonia, with abscess, is not so rare a disease as it
is represented to be  by Laennec and some others.  It  has been
alluded to as among  the sequele of  pleuro-pneumonia, and may
perhaps  follow catarrhal  fever and bronchitis.  I have seen it
twice occur from gun-shot wound of the lung;  in one case  it was
fatal, the other recovered after long protracted illness.  Wounds
of the lungs, however, often heal  kindly.  It  may  supervene 
166
upon asthma,  and results  from tenacious gastric and hepatic de-
rangements, constituting  the  dyspeptic  phthisis of W. Philip.
Hemoptysis is said to produce  it, but is in general only a coinci-
dent effect from the  same cause.  Some of the exanthemata, as
measles and small pox, render the patient  exceedingly liable to it.
It has been brought on by the  suppression of itch and other cuta-
neous eruptions.
  An obvious  predisposition is supposed to be found in a flat or
narrow or otherwise ill-constructed thorax.   Sedentary occupa-
tions, which exclude from fresh air and free exercise, predispose
to it; so do all such trades as subject the respiratory organs to
mechanical irritation, as  with millers, needle-grinders,  cotton-
ginners, &c.
  The  formation of pulmonary abscess is  attended by a fixed
heavy pain in the thorax, pulsatory, or at intervals sharp and lanci-
nating.  There is dyspnea which does not  admit of muscular
exertion, and  is increased also on lying down,  especially if the
patient  attempts to rest on the sound side;  but this rule is not
without exceptions.  The  cough is severe,  but at  first  without
expectoration.   The abscess sometimes  empties itself  through
small openings and gradually, but in general bursts and discharges
its contents freely and suddenly, pus  being coughed up in quan-
tities, varying from ounces to pounds.   There is great relief at
the time,  and   the expectoration continues abundant for a while
after, consisting of pus mixed with mucus and  sanious serum.
Recovery  sometimes happens at once from  this state, but more
commonly hectic supervenes,  in place of the inflammatory type
of fever which had attended the formation of the abscess; there
is great  emaciation and muscular debility, the voice is weak and
hoarse,  and colliquative sweats and diarrhea terminate the tedi-
ous train of suffering.  The pulse is at first tense and quick, and
in some cases  full; after the abscess is matured,  it becomes very
frequent and more contracted.   The  digestive  system in many
instances remains unimpaired until the last stages, diarrhea then
coming  on, with redness and ulceration of the lips, cheeks, gums
and tongue.
  The prognosis is unfavorable, holding,  perhaps, a middle rank
between bronchitis and tubercular phthisis.   When a case occurs 
167
in a person of well-formed chest, previously healthy,  and from a
transient and  notable cause, there is good  hope of  restoration.
  The worst symptoms are great emaciation and debility.  By
careful exploration of the chest, we can ascertain the extent of the
pulmonary disorganization, to which the danger is  pretty regu-
larly proportioned.
  The  duration  of apostematous consumption is very various,
from a few weeks to many months.
  Autopsy.—Laennec and Andral declare it to be quite uncom-
mon to find pus in a circumscribed cavity in the lung in this form
of pulmonary disease, the frequent mention of abscesses by other
pathologists, being attributed to their having mistaken tubercular
vomice (to be hereafter spoken  of) for abscesses.  They describe
purulent infiltration as supervening  upon hepatization, the color
being changed from red  to gray,  and the matter being diffused
through the lungs, the  texture of  which is broken  down and
softened.   There is, however,  good proof that encysted or cir-
cumscribed abscess  does occur.  A large  one is described  by
Laennec  himself.  Nor can  we otherwise account for the fact
of large and sudden evacuation of pus,  after pulmonic  inflam-
mation,  cough, &c have existed for some time.   Such cavities
are lined by a false membrane,  or layer of organized  fibrine.
   Diagnosis.—Apostematous phthisis is attended with more pain
and dyspnea, than chronic bronchitis or tubercular phthisis, and
with less expectoration than the former, for some time from the
commencement.  If a considerable  amount  of purulent matter
be suddenly discharged,  we infer that it must  have  collected hi
an abscess.   The physical  signs of this state of the  lungs are,
the lessening of the capacity of the thorax,  the dull sound upon
percussion over the pained part, and the loss of respiratory mur-
mur there, and after the abscess is empty, pectoriloquism.
   Treatment.—While pain urges, and until  the  failure of pulse
and strength absolutely  prohibit, venesection  to small amount
should  be repeated  occasionally.  Cupping the  affected side of
the chest, at first with, and then without, the scarificator, will be
of much service.  Large warm poultices are  also useful.  Blis-
ters applied in long succession are among  our best remedies.
When in any way unsuited, the ung. ex tart,  antimon. may be
substituted. 
168
   Emetics have been much  employed by different  physicians,
 and with very different  views.   Some suppose  them  specially
 adapted  to  procure  resolution  and  absorption of any deposit;
 others use them perseveringly as the  most efficient revulsive.
 Some prefer ipecac,  alone; others  prescribe  it  in combination
 with the sulphates of zinc and of copper.
   The antimonials have been highly eulogized,  by some as the
 best emetics, by others, for  the  property  of reducing the  pulse
 and exciting  protracted nausea; while  Laennec and  many con-
 tinental physicians, look upon the tart, antimon. as gifted with a
 specific remedial influence, and give it  in large  and increasing
 doses as a contra-stimulant.  These consider it as most beneficial
 when alone and uncombined.  In this country, it is  often exhi-
 bited in combination with nitrat.  potass.,  to reduce vascular ex-
 citement and determine to the surface, or with  the  infusion of
 seneka and serpentaria.  With similar views and as  exerting a
 tranquillizing influence of great advantage, I employ the Dover's
 powder, both before and after purulent expectoration has appeared.
 Mercury, in small doses, is occasionally  administered with much
 benefit;  but it is not adapted to all cases, nor should it be carried
 to the extent of an irritating ptyalism.   In the first  stages, it is
 useful in moving the bowels gently,  and subduing any gastric or
 hepatic disorder that may be present.
   Digitalis has been the  subject of extravagant eulogy;  but I
 do not consider its remedial influence as well marked or striking.
It is best adapted to cases where great frequency of pulse exists,
and the tokens of inflammatory excitement are not particularly
high.  The prussic acid has been in like  manner extolled, and
some authentic  reports made in its favor; but it has not retained
the confidence  of the profession.   After  the abscess has  been
ruptured, as will be known by the sputa and pectoriloquism,  if
the expectoration be free and without pain, we may derive advan-
tage from the infusion of cinchona, with which  mucilages and
anodynes may be united.   The mineral acids are also serviceable
as tonics here.  On the other hand, if there still  remain tension
across the chest, with a harsh cough, it may be necessary to take
blood from the arm, and apply the cups and the poultices or vesi-
catories, and even to administer an emetic, which will  often give 
169
great relief.   If diarrhea should come on, it must be restrained
by the acet. plumbi, kino,  or  such other astringent  as  is best
adapted; while we indulge the patient with free doses of opium,
which will aid in checking the alvine disturbance, while it sub-
dues, in an unequalled degree, the pulmonary irritation and cough.
Among the numerous formule  prepared by modern chemists from
its constituent principles, some one will  surely be found without
objection.  The other anodynes  may be tried—thridace, lupu-
line, hyoscyamus,  conium—but I have no confidence in any of
them.   With a view to promote the  healing of the  abscess or
ulcer, inhalations of gases,  and even of finely pulverized bark,
and other remedies, have been advised.   Iodine  has  been tried,
chlorine, the vapor of tar, of resin—several of the gases less stim-
ulating than common air, as mixtures of hydrogen, nitrogen, car-
bonic  oxide,  &c.   I cannot  express any  confidence in these
measures.  The balsamics are also in ancient repute for the same
purposes.   If any good be done by such prescriptions, it must be
in an indirect way.   Our best hope is, in keeping the constitution
at its highest point of tone and vigor.  As soon as the patient can
bear it, exercise in the open,air must be advised.  He should take
a journey or sea voyage.   Flannel should be worn next the skin,
and a diet chosen for him, nourishing, but unstimulating.

                TUBERCULAR  PHTHISIS.

  This insidious and fatal  form of pulmonary inflammation de-
rives its name, as well as its other characteristic peculiarities, from
the presence of tubercles in the lungs.  It is therefore proper here
to enter into the consideration  of  their nature and origin.
  Tubercle is variously described by authors.  In the condition
most commonly met with, it is a pale  yellow or  yellowish gray,
opaque, inorganic substance, somewhat resembling cheese in ap-
pearance, soft and friable.  Carswell regards the  mucous and  se-
rous  surfaces and the blood "as the exclusive seats of tuberculous
matter"—it is principally found, deposited in  the  first of these
positions.   It is composed of albumen, gelatine and fibrine, with
a very small proportion of muriate of soda,  and phosphate and
carbonate of lime.   The majority of pathologists suppose it to be
                             22 
170
deposited in this solid form—Cruvelhier asserts it to  be at first
fluid.  Laennec contends that a tubercle grows by intussuscep-
tion, but the opinion of Andral prevails, that it increases by the
successive  deposit  of molecules around the primary granule.
When deposited, "each granule," says Morton, "retains its  ap-
propriate tunic of cellular tissue."  The deposition  may go on
until the mass  shall occupy an  entire lobe  of the lung.  The
softening of a tubercle is not well explained.   Laennec and others
contend that it  always commences in the centre—a view hardly
consistent with the acknowledged inorganic state  of the  mass.
It seems more probable that it results from  inflammation of  the
interstitial cellular  tunic above  spoken  of,  upon whose surfaces
pus is effused, mingles with and macerates  the tuberculous mat-
ter.  Tubercles are not constant in their form.  They are often
rounded and contained in a sort of circumscribed cavity, in a cyst,
the inner surface of which secretes purulent fluid.
  But tubercle, it  is well known, is not confined to the lung ; it
is met with, as mentioned in the lecture on.scrofula, in many
and various locations, and is so often connected with the other
phenomena of strumous disorder, that it is by many supposed to
be exclusively the  product of scrofulous constitutions.   Whether
this be absolutely true or not, it is certain that scrofula constitutes
an obvious and strong predisposition to the formation of tubercle,
and  that  tubercular  phthisis  is hereditary and of lamentably
common occurrence in strumous families.
  Some  pathologists still maintain  the independent vitality of
tubercles, regarding them as parasitic—a sort of hydatid perhaps.
  Another  question  of great importance is, whether  tubercle is
ever the result of  common inflammation, in a constitution pre-
viously  sound.   The  alarming  opinion that it can  be thus
developed,  is held by Andral and others;   but I am  inclined to
think, that inflammation is only to be regarded  as  the exciting
cause of the series  of symptoms which constitute phthisis.  The
deposition  of tubercle I believe to be independent of, and often
unattended by,  inflammation in any form or degree.   When this
deposition  has  taken place, it may go on, and by its bulk excite
inflammation round it, and thus develope  phthisis;   or it may
remain in  minute mass and indolent, until inflammation of the 
171
surrounding parts shall  be excited  by some  extraneous  cause,
when its interstitial cellular investment shall secrete pus, and by
this process soften the tubercular mass—pleuritis, pneumonia, and
bronchitis being thus converted into tubercular phthisis.
  Phthisis, by a large proportion of writers of a past age, and in
many countries  now, was and  is considered as communicable or
contagious; and within my own observation so many circum-
stances  have  occurred which seem  to confirm  the doctrine,
that  with  Cullen, " I dare not assert that  consumption  is  not
contagious."
  Symptoms.—The access of this fatal malady is often extremely
gradual and obscure.   The patient is scarcely disposed to com-
plain, though harassed by a dry hacking cough, with occasional
pain in the chest, heavy and deep seated.  There is languor and
debility, and after a time notable emaciation, though the appetite
is unimpaired and  the digestion good.  Hemoptysis  may now
and  then follow a fit of coughing, though the  hemorrhage is  not
apt to be very large.   As the case progresses,  the respiration  be-
comes hurried,  with frequent  pulse;  on ascending a stair,  the
patient pants and his countenance is pale or livid;  he cannot lie
down  at night  without uneasiness, or is confined to one side or
to his back ;  there is oppression or tension of the thorax, with a
disposition to  stoop or lean forward; hectic ensues, with its long
train of derangement  and  suffering,  colliquative sweats and
diarrhea,  the  tongue and  mouth  being covered with aphthous
ulcers, though the inclination for sapid food may hold out to  the
last; and the patient ultimately sinks, after an indefinite protrac-
tion  of his  tedious disease, into absolute atrophy or marasmus.
  Prognosis very unfavorable—recovery scarcely  to be  hoped
for.   It can hardly be possible that a single tubercle, or even one
mass of tubercles, exist  alone—if so, there might be a softening
and expectoration of them, and the patient would be in the state
described under  the  head  of  apostematous  phthisis,  after  the
rupture of  the  abscess.  It might heal.  But the formation of
tubercle  in the  lung is generally a mere portion of the general
diathesis or constitutional  derangement, and  similar deposition
goes on or is repeated from time to time.   It  is consoling, how-
ever, to know that in many instances, an indefinite protraction of
life is attainable by judicious and proper management. 
172
   Diagjiosis.—The unfavorable prognosis which a melancholy
experience enforces from us, requires from us great care in dis-
tinguishing this, from  more  hopeful  forms of  disease.  The
pathognomonic signs are not very clear.  The slowly progressive,
gradual increase of the symptoms will  attract  our  notice.  We
will inquire if  the patient be of strumous family, or have exhib-
ited in early life any scrofulous development; or if his parents or
ancestry have died of consumption.  His  expectoration will not
be  abundant,  and mixed with much mucus from the first, as in
bronchitis ; nor suddenly augmented, with pus,  as in the bursting
of a vomica.   The pain will not be at any time as acute, in any
part,  as it  is  from the  commencement of pleuro-pneumonia,
although it will in its progress be actually complicated with this
affection; nor  will there  ever be so general a soreness of the
respiratory tubes, as in the former.
  There is in these cases too,  a tenacious cheerfulness and reso-
lution,  and hope of recovery,  proverbially noticeable.   It lasts
until the impairment of the digestive function, which is often
delayed to the very last moment of life.   The physical signs are
rather negative than positive in the  first  stages;  the absence of
respiratory murmur may be remarked in  more  than one spot of
the thorax, and after a time pectoriloquy will be distinctly obser-
vable.
  We should  be aware that tubercular  phthisis may go on to a
fatal termination without pain in the  thorax, or dyspnea in nota-
ble degree, or cough.  I once saw a patient die, the nature of
whose case (from the absence of these symptoms) was not detect-
ed,  the right lobe of whose lung was found, after death, a mere
mass of tuberculous matter.   I attended, in the  last  weeks of his
life, an eminent literary gentleman, whose  physicians had treated
him for  chronic hepatitis and diarrhea.   He  was surprised at
learning that his lungs were at all diseased, as he had labored
under no difficulty of respiration, and almost no  cough, but desir-
ed  that his body should be examined.  In complying  with his
request, I found his liver little, if at all affected, and his lungs full
of tubercles.
  The relations of phthisis with other diseases should be noticed
here.  Its connection with other and  more obvious forms of scro- 
173
fula has been mentioned.  Children who have been specially sub-
ject to epistaxis, are apt to fall into  phthisis after puberty.  He-
moptysis is also a coincident effect of the same malformation and
defect of organization which predisposes to phthisis.
   Fistula in ano is very often observed in subjects  predisposed to
phthisis, and even after phthisis has commenced ;  in this case it
may suspend or protract the  progress of the latter indefinitely.
There is said by authors to be a similar connection or alternation
between  mania and phthisis, but I have  had no occasion to  re-
mark any thing of  the kind.  Intermittent fever  has also  been
supposed to exert a suspensive or protracting power over phthisis.
I doubt this—nay, I have seen our ordinary malaria fevers repeat-
edly develope phthisis, and excite it in subjects predisposed.  It
is well known that the condition of pregnancy will almost inva-
riably suspend, even in its advanced stages, the further progress
of phthisis, and that the feeblest patient will almost certainly live
until she  is delivered.  Lactation does  not, however, continue
the privilege, and such a patient will  sink sooner if permitted to
nurse her child.
   Treatment.—Little remains to be added, to what was said un-
der the last  head,  on this subject.  A tubercle is an  inorganic
substance, and so far as can be positively stated,  is not injurious,
otherwise than as a mechanical irritant, whose presence produces
chronic pneumonia, with  abscess, and sometimes excites, perhaps,
an attack of acute pleuro-pneumonia.   As we are not  able to  re-
move the cause, our principal indication is to palliate the effects;
and this is best done, as has been already shown, by blood-letting,
antimonials, digitalis, opiates, &c.  From the analogy  of its use-
fulness in other forms of scrofula with tuberculous deposite, iodine
is the subject still,  of  hopeful experiment.    I have been pleased
with the apparent benefit  derived in some well marked cases from
the deutiodide of mercury and potassium.
   In no disease can the general subject of prophylaxis be of greater
consequence.  Children of scrofulous or consumptive  parents, or
who have suffered  much from epistaxis, or who exhibit notable
malformation of the thorax, should select for their future occupa-
tion through life, such employments or situations  as shall admit
of, or require, the full development of muscular power,  by active 
174
exercise in the fresh air.   Phthisis can neither be prevented nor
cured, nor even long protracted,  otherwise than by exercise con-
stantly and habitually taken under the open sky.

                         ASTHMA.

  Defined to be a species of dyspnea, paroxysmal, spontaneously
remitting and recurrent.   Divided  by writers generally into two
forms—the dry, nervous or spasmodic, and humid or humoral asth-
ma—the distinction referring to the presence or absence of mucous
rale and expectoration.
  A paroxysm of asthma usually comes on at night—is often pre-
ceded by flatulence, a loose griping stool,  heartburn  and other
symptoms of indigestion.   The patient awakes from his first sleep
with a sense of uneasiness and constriction of the chest, difficulty
of breathing and cough.  He is forced to sit up,  nor can he bear
the weight or pressure of any clothing  or fastenings  about  his
neck or body.  Respiration is effected with wheezing  and pant-
ing,  and great muscular  effort.  At first the  cough is dry,  but
after  a time  a frothy mucus is brought up,  occasionally tinged
with blood—this  is  attended with relief.  In the  worst cases,
there is neither cough nor expectoration.  These symptoms, de-
pending on  the affection of the respiratory organs, are uniform;
those which arise from the sympathetic disturbance of the general
functions, vary with the  condition  of the patient.  In  the robust
and plethoric, and in recent cases, the pulse is full, hard and  fre-
quent—the  countenance  flushed and  turgid—the eyes suffused
and prominent, with much  tension and pain of  the chest.  On
the other hand, when the disease has become habitual, and the
patient is feeble,  the face is pale or livid, the surface cold and
moist, the  pulse small and weak,  and the tokens of gastric de-
rangement more marked and prominent.  The duration of a par-
oxysm is uncertain ; it remits usually at the approach of morning,
the dyspnea continuing,  however,  in some degree,  through the
day, with more or less cough,  and the exacerbation again recur-
ring at night; these changes go on for a few days before the en-
tire subsidence of the attack; it has endured for weeks. 
175
  The general prognosis is favorable as regards  the danger of a
fatal issue—few die;  it is unfavorable as regards  the hope of a
cure—few  recover.  Besides  the impairment of the constitution
universally, which  must follow the repetition of  paroxysms of
asthma, it  sometimes  developes hydrothorax, chronic bronchitis,
and phthisis pulmonalis.
  Autopsy.—Asthma is found accidentally connected with a great
many lesions of the viscera of the thorax, but is  clearly proved
to be essentially independent  of any of them.  The most fre-
quent organic change in the asthmatic, is emphysema of the lung,
the cells being found distended—several of them dilated into one
cavity—and  incapable of collapse.  Even this, however, is  far
from being constant;  and numerous cases are recorded, in  which
there was no notable deviation from the natural state of the lung.
  The pathology of asthma is difficult and obscure.   The diffi-
culty of breathing is  twofold, and urges  both during expiration
and inspiration.  It is hence plausibly suggested, either that the
muscular fibres of the  bronchi  are  every where  rigid, refusing
both to contract and to dilate; or,  that in some portions of the
air-tubes, these fibres are spasmodically contracted, resisting both
the entrance  and exit of air.
  Causes.—A predisposition is obviously derived from vicious
conformation of the thorax, or of  some of the organs contained
in it, either accidental or hereditary.  A first attack generates a
strong tendency to recurrence.   Paroxysms are excited by expo-
sures to change of temperature, or to cold and moisture,  to the
bad  air of crowded apartments, to certain of the gases, and to
some odors.  They come on after full meals, late suppers espe-
cially, violent muscular exertion, loud singing and  speaking, and
supervene on repelled eruptions.  It seldom appears early in life;
I have, however, seen a well marked case in childhood.
  Treatment.—During the paroxysm, it may be necessary  to em-
ploy the lancet, if  the pulse be full and hard, and the patient ro-
bust.  It is especially called for in the early stages of cases which
present marks of thoracic engorgement or inflammation.  Cup-
ping the chest is also  a useful measure, under these circumstan-
ces.   But  we must be cautious not to detract  blood in the op-
posite conditions—when the  patient is  feeble and the asthma 
176
habitual.  Emetics are highly beneficial in many cases; giv-
en at the beginning of the attack, they often cut it  short, and
if this fail, may be repeated after a time; they are among our
best expectorants, and  are indispensably necessary when  the
patient  has  indulged  in a full meal just before  going to bed.
It is well, too, to have the bowels opened by  a  purgative ene-
ma.   Many of the narcotics enjoy great  repute  for  the relief
of asthmatic  dyspnea.   Tobacco, stramonium, Lobelia  inflata,
the spider's web, coffee  and opium, have their eulogists.  I pre-
fer the last mentioned, and in combination with camphor, ether,
or ipecac, have seen it of immediate and striking advantage.   In-
halations of  various gases have  been tried, but with no very ob-
vious good results.  Galvanism deserves more general employ-
ment and confidence.  My experiments with it have been suc-
cessful and gratifying.
  In the prophylactic management of the asthmatic, we must de-
pend more upon regimen than medicine.  If any disorder of the
digestive system, or any chronic  pulmonary disease  exist,  we
must endeavor to remove it.  We must aim to restore the patient
to full and  perfect vigor of constitution, by  air and  exercise.
We must attend to the place of his abode, for there are particu-
lar localities  in which  asthmatics  suffer much, though in regard
to the situation best fitted  for each, no general rule can be laid
down.   The matter must, therefore, be decided by experience.

                       PERTUSSIS.

  Tussis convulsivus—Bexconvulsiva, Kink-cough,Chin-cough,
Hooping cough—these are all significant appellations for the well
known disease now to be spoken of.  It is one of the specific
contagions—often  becomes  epidemic—does not attack usually
more than once the same individual, although this rule is liable
to exceptions.   Hence  it is  most  frequently met with in  young
children.  It invades for the most part as a common cold or mild"
catarrhal fever.  After a certain duration the paroxysms of cough-
ing become more and  more violent, and protracted and convul-
sive.  Rapid and repeated expirations are made with vehemence,
and then a sonorous inspiration, whence the common name Hoop- 
177
 ing cough.   These paroxysms terminate with larg$ expectoration
 or vomiting.  The intervals between them are shorter or longer,
 and more or less perfect and free from uneasiness, in  proportion
 to the violence of the attack.   There is generally a considerable
 secretion of mucus in the air passages, with a  loud rale.   Pul-
 monary inflammation sometimes arises, with fever and great dysp-
 nea.  In other cases there is # notable and prominent  disorder
 of  the digestive system, with diarrhea, &c.  Not  unfrequently,
 too, there is much determination to the head, with convulsions.
   The causes which occasion or render more violent a paroxysm,
 are a full or indigestible  meal, any  forcible muscular exertion,
 mental emotion, exposure to cold and moisture,  &c.  The aver-
 age duration of hooping cough may be calculated at from six to
 eight weeks; it may be prolonged indefinitely  by a renewal of
 catarrhal affections, with which it readily  associates itself.   It is
 said also to assume sometimes a periodical character, which gives
 it a tedious protraction.
   Prognosis generally  favorable.   The  greatest  proportion of
 deaths happens among very young infants, who may die suffoca-
 ted by engorgement of  the air cells  and  tubes with mucus that
 they are unable to expectorate,  and children who are teething—
 a complication  which often gives rise to convulsions.  The su-
 pervention of any of the more ordinary forms of pulmonic inflam-
 mation, is attended with  danger; the diarrhea, which is some-
 times present, may become unmanageable and fatal.
  Autopsy.—The traces found in post-mortem examinations of
 this disease, are not regular or uniform.  It sometimes happens
 that no lesions or morbid changes can be pointed out.  Most gen-
 erally, however, the bronchial  mucous membrane is irregularly
 reddened and injected in patches;  while, at the  same time, there
 are marks of determination to the head and engorgement of  the
 brain.
  The pathology of hooping cough is not clearly made out.   Ma-
ny deny  the existence of inflammation as an essential condition;
the majority, however, believe it to be an inflammatory affection
of the bronchial membrane.  Some very respectable authorities
refer all the phenomena to cerebral and nervous disorder.  Others
still regard  both cerebral and pulmonary inflammation as neces-
                            23 
                            178

sarily present, and in some  manner connected.  Desruelles calls
it a "broncho-cephalite."  It cannot be a simple bronchitis, as
we infer from the spasmodic or convulsive character of the cough
which attends, and the peculiar manner of coughing.
   Treatment.—It is made a question whether we have the pow-
er to  cure an attack of this singular malady; and while some,
denying this power, use their efforts merely to palliate the symp-
toms, others are engaged in the search after specific remedies, of
which a large number is already accumulated.  I would  advise,
as the great majority of cases are in the first instance attended
with pulmonary  disorder and inflammation, that they be  treated      I
as catarrhal fever or acute bronchitis, by general and local blood-
letting, if severe; by emetics, purgatives and expectorants.  The
sulph. zinc has been supposed to deserve a special  preference
among emetics, and of the expectorants, squill and ipecac.  The      \
narcotics and antispasmodics are much used when the first stage
has passed.   I am much in the habit of combining with the cam-
phorated tinct. opii,  the tinct. mosch. fact., which I add to a so-
lution of the carb. potasse.   The warm bath should be employed
at night, and counter-irritation  by mustard poultices frequently
resorted to.   Assafetida is  much extolled  among the antispas-      I
modics.  Prussic  acid is supposed by some to be almost  antido-
tal ; and in the same way the acet. plumbi, nit. argenti and co-
chineal, are prescribed, without  any definite idea of the modus
operandi.   Of the tonics, cinchona and arsenic are justly prefer-
red, and are well adapted to the relief  of protracted attacks.
     DISEASES OF  THE  SENSORIAL  SYSTEM.

  The functions of this important system are performed  by the
brain, the spinal cord, and the nerves—the diseases of which or-
gans must be considered in succession.

                       PHRENITIS.

  Inflammation of the brain and its investing membranes, is divi-
ded into acute and chronic.  The latter is plausibly alleged to be 
179
the proximate cause of most of the diversified forms of mental
alienation or insanity, which varies in its history  and symptoms
in relation to the varying seats and nature of the cerebral affection.
   Acute phrenitis is not often met with as occurring idiopathical-
ly or independently, but many of its phenomena arise sympathet-
ically, in  the course of  other diseases; and in the class of fevers,
this is  so generally the fact, that  Clutterbuck and  others haye
maintained cerebral inflammation to be the primary location and
essential condition of fever properly so called.
   Acute inflammation  of any portion of the brain and its mem-
branes, commences with pain in the head, with a sense of fullness,
heat,  and throbbing ;  the eyes are red and suffused, and intoler-
ant of light; the face is flushed and turgid;  there is pain in  the
back of the neck, and  down the spine ;  the scalp is occasionally
tender to  the touch ; the stomach is in some cases oppressed, with
retching  and vomiting;  the pulse is full, hard,  and bounding;
there  is great anxiety and  mental dejection, or even from  the
first wild delirium, which at any rate seldom fails to supervene
early in the progress  of the attack;  the hearing is acute, and
ordinary  sounds  occasion distress;  there is  pervigilium;  the
tongue is whitish  and  lightly furred,  and the skin hot and dry.
If the disease advance unchecked, the patient  sinks into a soporose
state;  the eyes grow less and less sensible to light;  there is per-
haps  strabismus or a fixed state of the pupil,  at first contracted
closely and afterwards  widely dilated;  the hearing  is impaired;
there is sighing, grinding of the teeth, tremulous debility ; respi-
ration  and deglutition become difficult, and coma or convulsions
precede death.
   The predisposition is said to be  sometimes hereditarily trans-
mitted.   It is  found  to exist  in  men of irritable  and  violent
temper, and  morbid susceptibility to mental emotion ; in persons
of sanguineous temperament; those accustomed to free and  lux-
urious living; and  in the profound  student and ardent cultivator
of literature.
   The exciting causes are insolation, blows on the head, gusts of
vehement or prolonged passion, and intemperance or excess.
   Autopsy.—The appearances after death vary with  the duration
of the  case.  The vessels of the  brain and its  membranes are 
180
turgid—lymph is found adhering to the surfaces of the latter, and
connecting them  by adhesions—serum is often effused over the
surfaces and  in  the ventricles,  and pus not unfrequently found
mingled with it in considerable  quantity.  Gangrene is affirmed
to have occurred.
   Prognosis generally unfavorable.  We draw the most gloomy
inferences from  the  supervention of great  debility, while the
local excitement is unabated, and from the tokens of effusion and
mechanical pressure, as paralysis,  strabismus, deafness, stupor,
coma, convulsions.
   Treatment.—Blood-letting  is universally acknowledged to be
indispensable.  Some open the temporal artery—some the jugular
vein.   That vessel is to be selected from which  we can obtain
the fullest and freest flow of blood.  The head should be eleva-
ted,  and persevering affusions of cold water thrown on it from
some height.  The scalp should be shaved; cups or  leeches
may be applied  to the skull  and behind the ears; but our best
reliance is on the lancet and  cold affusion, which I  prefer to
pounded ice, &c.  The  most active purgative doses should be
given—a combination of  the  resinous and saline, I think should
be  preferred, and  used freely and  as long  as the strength will
bear.   In  the  mean  time the chamber should be kept  cool and
dark, and  absolute silence enjoined.  The  head  of the patient
should be elevated, and abundant cold drinks allowed him.  He
must be perfectly  controlled,  and by such means  as admit of no
struggle or resistance.
   The convalescence  must be for some time guarded most care-
fully.  The diet should be  low,  the mind kept free from care
and  anxiety, laxatives  administered  occasionally,  and a total
abandonment of such  habits as  may have predisposed  to or
excited the attack strictly enjoined.

                  CHRONIC PHRENITIS.

   Chiefly shown in  the  varied disturbances of the intellectual
functions, which are known  under the  head of Insanity.   It is
important to  draw correct  distinctions here, and separate from
insanity proper—which I regard  as uniformly depending upon 
181
cerebral inflammation—the numerous modes of mental aberration
arising sympathetically in the progress of many forms of disease,
as transient and  incidental conditions, and implying none of the
circumstances of phrenitis.
   The irregular and undefinable operations of the mind resembling
insanity, in the  absence of control,  are not easily distinguished
from each other, but must not be confounded—dreaming, reverie,
absence of mind, somnambulism,  exalted passion, enthusiasm,
intoxication,  modified by the  different agents which produce it,
delirium, melancholy, fatuity, idiocy and senile imbecility.  It is
impossible to define  insanity—difficult by any form of words to
describe it, so as  to separate it from either of the above conditions,
and yet  there is little danger of mistaking them.  In fevers we
have  delirium—in hysteria,  there is fatuity or  imbecility—in
intoxication there may be almost every variety of mental disorder,
disturbance and confusion—yet these are not insanity  properly
so called.  Neither is the amentia or the amnesia attendant on
epilepsy, apoplexy, and paralysis.
   Causes of chronic phrenitis, divided into the moral and phys-
ical—the predisposing and  exciting.  Of physical  causes, the
predisposing  are,  1. Hereditary  transmission of constitutional
peculiarities.   2.  Intemperance or  excess of any kind.   The ex-
citing are, 1.  The causes formerly enumerated of acute phrenitis,
or acute phrenitis itself imperfectly cured.   2.  Gastric and intes-
tinal disorders which, through the close and universal sympathies
affecting  the brain, act upon that  delicate organ.  3. Genital or
sexual affections which affect, in peculiar and inexplicable modes,
the various  portions of  the  cerebral  tissue.   4. Metastasis of
various  morbid  affections,  as on  the sudden disappearance of
cutaneous eruptions, of gout, &c.
   Of moral causes,  the principal  predisposing is found in educa-
tion, including within that comprehensive term all that conduces
to the formation of the character and habits.   The imitation of
parental peculiarities, eccentricities, and oddities, may thus be
enhanced in the child into a forcible predisposition to some mode
of insanity.
   The  exciting moral  causes are obvious.   The frequent and
 violent  indulgence of  passion, the fostering particular  trains of 
182
thought  and emotion, whether pleasant or painful, irritate  and
inflame  the  organ of thought.  Very sudden and great changes
of condition,  as  from wealth to  poverty, or vice versa, produce
similar effects.
  Pathology.—Bayle  refers  insanity  to  inflammation  of  the
meninges,  but Foville says, that  " as the traces of inflammation
are  more constant in the brain than in the membranes, we must
regard the former as  the  essential—the latter as the incidental
condition."
  Necroscopy indeed reveals  to us a great diversity of morbid
alterations.   The  membranes  are  thickened, injected, adherent
both on  their opposite surfaces and  to the  cerebral substance.
This  substance is injected,   thickened—"occasionally,"  says
Foville,  " intensely red.   The surface or  superficial stratum of
the cortical substance is firmer and denser than natural."  Gall
and Desmoulins  have observed what they call  "atrophy of the
convolutions—more frequent in the frontal regions; sometimes an
actual  absorption, leaving  chasms filled by serosity."   Esquirol
has described the presence  of a multitude of small cavities in the
brain, "from the size of a millet seed to that of a nut, containing
fluid."
  Diagnosis.—Insanity, as the sign,  token, or consequence of
chronic phrenitis,  does not necessarily imply the loss  or impair-
ment of  any  of the intellectual powers; for the brain is a double
organ,  and it is  rare that  the corresponding parts on both sides
shall be  diseased.  It consists in and  depends upon the loss of
the  power of precise association, through which the mental oper-
ations  are  conducted to definite  and calculable results.  This
inconsistency, irrelevancy,  or  dis-association, whether merely
speculative or practical—this uncertainty of relation and succes-
sion in  the intellectual actions, is the only uniform and essential
symptom of insanity.
  Mental derangement, as the effect or manifestation of chronic
inflammation of the  brain, may be divided into the  following
varieties.  1.  Incoherence.—Some of  the cases under this head
exhibit a ceaseless activity  of  the mind, marked by the absence
of all the principles and powers of regulation.  Even the instinct
and natural propensities seem often subverted, and the patient is 
183
forgetful or ignorant of the meaning of words, or the connection
between thought and action.  2. Mania, which has been often
called  moral insanity.  Here the destructive  and mischievous
propensities are highly excited, with great  cunning and contri-
vance  in adapting  means  to ends.  Among  these were the
demoniacs—the possessed of ancient times.  Here also the sub-
jects of erotomania, and the desperately profane and blasphemous,
are generally to be classed.   3. Melancholy.   4. Hallucination,
the form of insanity bordering most closely on delirium.  Some
of these hallucinations have been incorrectly, as I think, attributed
to false impressions made on the organs of  sense.   5.  Monoma-
nia—a perversion  of the  judgment on  one  subject  or  set  of
subjects, and consequent perverted course of conduct or behavior
in relation to them.  This is often complicated with the former,
but also exists  independently.
   With the disorders of intellect, there are always combined the
obvious marks of physical disease.  We find  headache complained
of by  a great  many—morbid vigilance,  with  restlessness.   In
many, the senses  are morbidly acute.  In a great majority they
receive almost no impressions but such as are unpleasant and
annoying.  Convulsions,  paralysis,  apoplexy,  not  unfrequently
supervene, in  the  progress of cases of chronic phrenitis.  The
tongue is foul and the breath fetid in most instances; sometimes
a viscid offensive  saliva is excreted  in great quantity.   There is
depravation of  appetite, and costiveness.   The pulse is generally
quick,  frequent,  and  tense;  in some melancholies it is  slow.
There is much inattention  to  changes of temperature, but the
hands  and  feet are  apt to be cold.  An unpleasant odor often
exhales from the entire surface of the body.
   The prognosis is unfavorable.   The tables published in regard
to the  proportion of  cures in different lunatic asylums are calcu-
lated to mislead.   Proper distinctions are not made between the
infinitely diversified  conditions of mental  aberration  resulting
from various causes.  Hysteric folly, delirium tremens,  somnam-
bulism, puerperal  mania,  &c.  are  easily  and in very large
proportions curable, and these are confounded with true insanity
or chronic phrenitis. 
184
   Treatment.—In the use of remedies we must be guided by the
 state of the general system.   If entonic, we must bleed both from
 the arm and by leeches and cups from the head and neighboring
 parts.  Purgatives are also useful here ; they should not be urged
 at any time into hasty operation, but a revulsive influence should
 be long exerted on the intestines.   The nauseating and depress-
 ing effect of antimonials may be made of much benefit, if perse-
 veringly kept up.   Mercurials are sometimes serviceable.  I do
 not depend on them in general, but  they may be experimented
 with.  They are best  adapted to cases  which exhibit  notable
 disturbance of  the digestive system.  Opium is indicated by in-
 ordinate restlessness with pervigilium, the patient often suffering
 much for want of tranquil and refreshing sleep.   In such cases,
 and those which exhibit, during the waking state, peculiar agita-
 tion, irritability, and other marks of general distress, I do not hes-
 itate to  administer anodynes,  premising such  precautions as may
 seem requisite—employing the necessary measures of depletion
 and revulsion, keeping the bowels properly open, &c.  Digitalis
 has been often found of advantage.  Cold  applications to the
 head  are frequently required.   I prefer the occasional affusion of
 cold water from a height on the head, to the constant application
 of cold in any way, as it often annoys and irritates the patient.
  I advise almost  always the removal of the patient, when the
 insanity threatens to become permanent,  to some well managed
 asylum.   In such institutions only can we find  and avail our-
 selves of the requisite means of physical restraint and moral con-
 trol, not only necessary to prevent the patient from injuring him-
 self and others, but positively and in a very high degree salutary
 in their  influence, and remedial in their Ultimate effects.
  In atonic cases we must be careful to support the strength of the
patient.   He must be warmly clad,  supplied with nutritious and
agreeable food, and occasionally, though with much caution, in-
dulged pro re nata in the use of diffusible stimulants.   Of these,
ammonia,  camphor, and opium are to  be preferred.  Tonics are
sometimes  serviceable, and I have  derived advantage  from the
exhibition of the sulph. quinine, with camphor in small doses, or
minute quantities of some of  the salts of morphine. 
185
                     MANIA A  POTU.

  Delirium tremens—Brain  Fever of Drunkards—La Folie
des Ivrognes, fyc.—Among the numerous appellations of this re-
markable malady,  I prefer to retain the  first of those set down,
as strikingly significant of the cause to  which it is attributable.
Until we have clearly designated its true pathology, we shall not
be able to give it a title absolutely correct and entirely unobjec-
tionable.  It is not properly a fever.  The line between delirium
and mania is not distinctly drawn, and there  can  be no special
impropriety in using the  latter phrase, where there is so much
mental derangement, with constant  hallucination.   Besides this,
it runs so readily into phrenitis, acute and chronic, as to give good
ground for this selection.  Indeed,  although I confess  its patho-
logy to be extremely obscure and ill-defined, yet I am rather dis-
posed to regard it as a peculiar form of phrenitis, modified—1st.
By the causes which produce it;  and 2d. By the morbid condi-
tion of other organs, with which it is universally connected.
  The cause to which it  is exclusively ascribed, is  intemper-
ance in the use of ardent spirits—distilled alcoholic liquors.   The
influence of these agents is slowly developed in the production of
Mania a Potu, which requires time, and which ultimately shows
itself in various  forms, according to the several diseases of other
organs which may exist in each case.  Some have maintained
the necessity of  a  transient discontinuance of  the  use  of ardent
spirit, and a consequent exhaustion or prostration of nervous en-
ergy  from the subtraction  of accustomed  stimuli.  The  fact,
however, is not so.   I have repeatedly seen attacks of the several
modifications of Mania a Potu, supervening  during the actual
progress of a "frolic," or while the sot was  living  in  his usual
manner.
  Symptoms.—In a majority of instances, the stomach  has yield-
ed long previously to the morbid effects of stimulating potations,
and the liver and all the other chylopoietic viscera have suffered.
There is total loss of appetite, with occasional retching and vomit-
ing, especially in the morning; the bowels are irregular,  usually
loose with acrid bilious  discharges; the  hand and tongue are
                             24 
186
tremulous, the latter thickly furred, with fetid breath, or smooth
and fiery red.   The mind is deeply depressed,  and the  state of
intoxication into which the patient plunges  for  relief from this
dejection, is often more gloomy and remorseful.  At last, the pa-
tient wanders—he mutters incoherently and with incessant rest-
lessness ; or if he sinks exhausted into a brief and unquiet slum-
ber, starts from it in terror which cannot be soothed.  The pulse
is weak and very frequent, his skin cool and clammy, his eye red
and suffused.  Convulsions may occur, but  are not usually met
with when the stomach is still disturbed with the frequent retch-
ing, so prominent a symptom of  this form of the malady.
  In some patients the brain suffers more immediately, and with
much less gastric disturbance  previously, or at the time.  Some
fit of intoxication, deeper and more prolonged than ordinary, ter-
minates in a horrid convulsion, followed by another  and another.
The unhappy subject may thus  die at once, or he sinks into a
state of exhaustion,  with cold skin, pulse indescribably rapid, and
so feeble  as scarcely to be felt, with countenance  haggard and
eyes half shut.  After lying  thus for some time,  his muscular
strength suddenly returns, and he becomes capable of prodigious
exertions; he  is haunted by some  frightful hallucination, and
becomes extremely  dangerous  to those about him, whom, in his
frenzied anxiety to escape, he will assault and pursue with vehe-
ment malignity.  This condition may run  into  acute  phrenitis,
and sometimes terminates in permanent insanity.
  Others again with less obvious affection of the digestive system,
and no acute cerebral disorder, sink into absolute imbecility, both
mental and physical, mingled with a peculiar shade of gloom and
despondency.   The skin in such cases is hot and dry;  the pulse
is small, corded and frequent; the patient takes almost no food,
and scarcely sleeps—seems always restless and uneasy ;  he affects
solitude, often mutters to himself, and appears alarmed causeless-
ly.  In almost all, there is a notable predisposition to suicide.
  The autopsy of  Mania a Potu, developes nothing uniform or
characteristic.   A variety of lesions have been noted, but are not
regular.  The "anatomy of drunkenness,"  shows marks of  ex-
tensive disease of the stomach, the liver, and the brain;  the pro-
gress of the several changes or steps of disorganization, is propor- 
187
tioned to the duration of sottish habits.   But all these  changes
may have taken place,  without the  production of this particular
form of disease.
  The  prognosis  is generally favorable.   Few die  in  Mania a
Potu, and those few rather of  the derangements of the constitu-
tion, which are the coincident effects of the cause which has pro-
duced the  attack.  The tokens of  a specially unfavorable case
are, obstinate pervigilium, which always threatens convulsions—a
repetition of the convulsions, with  brief interval—or the occur-
rence of coma.   It is also unfavorable to find the pulse rising and
becoming fuller and slower, while the mind continues perturbed.
We have here to dread permanent insanity.
  The  treatment must  be  modified to suit the condition of the
patient.   Venesection is seldom necessary or justifiable.  It may
be required to obtain a respite from  convulsions.  When a tran-
situs  has taken place to the symptoms of acute phrenitis, the lan-
cet must be freely employed; this is marked by fullness and hard-
ness and comparative slowness of pulse, by the cessation of trem-
bling of the limbs and tongue, and  by a change in  the manner
of the patient, who is now fierce and resolute, and no longer full
of tremor and vacillation.  If there be no doubt on this point, the
hair may be cut close,  and leeches and cups applied  to the tem-
ples and back of the neck.   But such cases, it should be kept in
mind, are not common, and this mode of depletion  is not to be
often  resorted to.   Cold affusion may be of advantage when the
face is flushed and the skin hot and dry; under opposite circum-
stances  I would  not advise it.  Emetics have been highly eulo-
gized, but they are of doubtful effect.  When the stomach is nau-
seated, with retching and ineffectual vomiting, with  foul tongue
and fetid breath, they may  do service.  They may also be occa-
sionally employed to arouse the susceptibility to the action of other
remedies, when we have found ordinary doses incapable of affect-
ing the patient.   Cathartics are often beneficial.   Calomel,  in
large doses, is the best.   The saline may be added, if the patient
be strong and robust.  In general, however, it is not advisable to
employ cathartics freely.   Opium is, unquestionably, our most
important  remedy.  It is applicable  to all cases of Mania a Potu,
and has only been subjected to doubt, by having been  erroneously 
188
prescribed, when the case has run into phrenitis of ordinary char-
acter.  I prefer the tincture, and prescribe it with unyielding per-
severance, in large doses, until the patient sleeps.  I do not like
to combine with it any other stimulant.   Camphor and ether are
the least objectionable,  if an addition be necessary.  Nor can I
assent to the propriety of exhibiting large masses of solid opium,
which may not dissolve at all when most needed,  and may lie
inactive in the stomach, until a period when its solution and con-
sequent absorption and active influence may be productive of in-
jury rather than benefit.  Digitalis is proposed as a substitute  for
opium, and the tincture is administered  in large doses, from one
to three drachms, every four  or six  hours.   Thus  exhibited, I
have seen it unquestionably useful.
  The management of the patient is a matter of much importance.
He should be kept under the most perfect control, by a sufficient
number of resolute attendants, or, which is often better, by soli-
tary confinement.  His diet, if he will take any, may be nourish-
ing and  well  seasoned.  His convalescence  must  be carefully
guarded.  His mind  must not be disturbed with care or business.
Tonics may be of use to him, but all stimulants (except those
already mentioned) must be positively refused.
   The prophylaxis of Mania a  Potu—the  reformation  of the
drunkard, is a topic of infinite interest.   The peculiar craving or
longing after ardent spirit is, in the sot,  the consequence of mor-
bid condition of the  stomach chiefly.  To remedy this, it is pro-
posed to combine the sulphuric acid with the  accustomed drink,
and the effect is said, in some cases at least,  to be strikingly  ad-
vantageous.  By others, it is suggested to combine with the sev-
eral forms of distilled liquors, the tart, antimon. or ipecac, or other
emetic,  in such amount as to nauseate  long and vomit severely.
These attempts may sometimes succeed;  but, in  general, they
either totally fail or produce only a transient influence.  Nothing
is to be hoped from any measure  short of perfect abstinence; nor
is any thing  to be feared from the abrupt enforcement of  the in-
junction.  I would scarcely allow, in any case, the use of a sub-
stituted  stimulant; but if such an indulgence seemed necessary
in a given instance, opium and camphor would suffice abundant-
ly, and the dose being rapidly diminished,  might soon be safely
withheld. 
189
                       APOPLEXY.

  Apoplexy may be defined to consist  in a loss or remarkable
impairment of the power of motion, with insensibility and stupor.
The patient cannot be roused, and gives little or no token of con-
sciousness.  The action of the  heart is usually little  disturbed at
first, but soon becomes feeble, and after a time ceases.   Respira-
tion is performed with some labor and  effort, and  with  stertor
generally,  the  difficulty increasing as the circulation is more
impeded.
   Causes.—A predisposition to apoplexy is found in a full pletho-
ric condition of body—habits of undue indulgence in the pleasures
of the table and venereal gratifications—in mental  excitability,
liability to gusts of anger, and other violent emotions.   Yet it is
not the luxurious only who are  thus predisposed; similar tenden-
cies are often found in the ill-fed, badly nourished poor.   As age
advances, the predisposition seems  to  increase.  It is commonly
believed to be connected too with a particular form, of which
" rotundity,  corpulence, with  thickness and shortness  of the
neck," is the description.
   The exciting causes which affect the  predisposed are numer-
ous ; all stimulants, a full  meal, especially if the subject place
himself soon  after in the  recumbent posture; insolation, vehe-
ment muscular exertions, ligatures round the neck, fits of passion,
stooping down for any length of time—all circumstances in short,
which either render active  the  cerebral circulation,  determining
to the brain, as the phrase is, or which impede the return of blood
from the head.  Apoplexy is said to be often connected with hy-
pertrophy of the heart, and to follow the sudden disappearance of
regular gout, and the suppression of accustomed evacuations.
   Diagnosis.—Apoplexy resembles profound sleep, but the sleep-
er may be aroused; it is distinguished from syncope, in doubtful
cases, by the respiration, which is almost always noisy and  labo-
rious—generally by the  pulse  also, which is  full  and slow, and
the  countenance, which is, in the majority of instances, flushed;
from epilepsy, by the absence of distortion or convulsions;  from
asphyxia, by the previous history of the case,  and in the same 
190
manner from the torpor of extreme cold, which closely resembles
it.   It is very difficult to distinguish it from intoxication, and it
is often most  perfectly simulated  by the hysteric paroxysm.
There is also a sympathetic loss of sense and motion from gastric
disorder, not easily separated from it.
   The prognosis is generally unfavorable—perfect recovery from
it is not  frequent; hemiplegia is a very common  result of the
attack; there is a strong tendency to recurrence of the paroxysm.
The best  hope of restoration is in the young and temperate, sub-
jects marked by no special bad habit, or other  token of  predispo-
sition, and attacked  under circumstances of transient  influence,
as from insolation.   In the old, and infirm, and  intemperate, the
prospect is gloomy.
   When one side is in any degree agitated, and the other remains
motionless, we predict paralysis of the latter.  If the pulse sink,
the respiration becomes louder, with puffing of the  cheeks, and
relaxation of the sphincters occur, we expect a promptly fatal
termination.
   Autopsy.—The appearances vary somewhat, but in a vast ma-
jority of cases betoken  impediment to the performance  of the
functions  of the brain, or actual lesion  of cerebral  structure.
1. Hemorrhage is of frequent occurrence.   Blood may be poured
out upon the surface of the membranes, or within the ventricles,
or in the very substance of the brain, with laceration.  2.  Serum
or sero-purulent fluid may be found in  the ventricles or upon the
membranes.  3. Turgescence  of the  cerebral vessels  is rarely
wanting in greater or less  degree.  Exceptions are  however re-
corded, on good authority, in which none of the above  marks of
disease within the head were discovered.
   Pathology.—Apoplexy is properly the abolition or suspension
of the sensorial functions, occasioned  by pressure on the brain.
Mechanical pressure, as by fracture  and depression of  the skull,
gives  rise to  a train  of symptoms precisely the  same.  This
pressure may be—1. Extravascular, i. e. from fluids poured out,
blood, serum, &c.;  or  it may be—2.  Intravascular, from mere
fullness or turgid state of the cerebral vessels; which latter con-
dition may disappear at the time of  death, leaving no trace. 
191
  Treatment.—This must vary with the condition  and circum-
stances of the patient, which in different cases will be  strongly
contrasted.  Apoplexy has, in relation  to these diversities, been
divided into two forms, sanguineous  and serous,  meningeal and
cerebral, entonic and atonic—phrases  significant,  and  applied
with  some  foundation  in propriety.  These modifications are
explained by the constitutional peculiarities of the subject, by
the nature of the cause which has affected him, by the degree of
lesion of the brain, and the particular locality of the lesion.
  1. A majority of the  cases present  the following symptoms.
The pulse is full and strong, though  slower than natural, the face
is flushed or turgid, the  eyes  prominent,  the  pupils somewhat
dilated, though not altogether insensible to the influence of light,
the respiration stertorous,  the surface is of  natural temperature,
the features flabby, and the  jaw somewhat fallen.   There have
been for the most part,  certain premonitory indications before
the  fit,  such as flashing of light before the eyes,  tinnitus and
other noises within the  ears,  fullness or throbbing, or pain in the
head and vertigo, with somnolency;  and sometimes a failure of
strength of  the arm and leg of one side, or  a sense of  numbness
in them or in the  tongue, for  paralysis  may precede as well as
follow apoplexy.
  In this state of  things,  the lancet  must be promptly used and
fearlessly,  and  blood drawn from a large vein  or veins,  to an
amount sufficient to make a definite impression upon the force of
the circulation.   Cold affusion on the  head is useful, the hair
being cut close or shaved.  Active cathartics and enemata must
be employed for their revulsive  effect;  the drastics will be chosen
on account of the  impaired susceptibility.  Counter-irritation by
sinapisms to the extremities, and epispastics, will be of service.
Emetics are equivocal remedies, and should not be  administered,
unless when the patient  has been  attacked immediately after a
full  meal.   The best means of promoting the certain recovery of
the patient, and of confirming  a cure thus begun, is to keep up a
regular and free determination  to the bowels, by the use of effi-
cient purgatives in repeated doses.
   2. The patient  is sometimes pale  or livid, with a cold  moist
 skin, and a pulse feeble and intermittent.  Here the lancet  is for- 
192
 bidden.   Cold water must be applied over the head, by affusion
 or with a sponge, and cups to the back of the neck and between
 the shoulders, or leeches  behind  the  ears or around the anus.
 Volatiles should be held occasionally to the nostrils, and mustard
 laid upon the extremities and epigastrium.  Stimulating enemata
 ought to be given without delay, and epispastics laid upon the
 spine and other parts of the surface.   If the pulse rise under this
 treatment, we may bleed  and administer purgatives.

                       PARALYSIS.

   Under this head I shall notice  several  diseases, usually recogr
 nized as distinct.  1. Hemiplegia, or palsy  of one side of the
 body, closely connected with our last subject, as  being an affec-
 tion of the brain, primarily, and always the result of pressure on
 some part of that organ.  2.  Paraplegia, palsy of the lower part
 of the body, transversely divided;  the  result in a vast majority
 of cases of lesion in  the spinal cord,  though it has occurred inde-
 pendently of it.   3.  Paralysis agitans ; and 4.  Paralysis vacil-
 lans, or Chorea Sancti Viti.
   Apoplexy in its worst grade has  been considered a complete
 and total paralysis, but there are degrees even in apoplectic seiz-
 ure, and the various divisions above  stated, are  obviously  forms
 of partial paralysis.  We may have palsy of a single limb, nay,
 of a single muscle,  or  of a  few muscles.  In Colica pictonum,
 there is palsy of one or both hands.  The arm has been palsied,
 while the hand,  if supported, was capable of writing.  A palsy
 of one side  of the face is not very rare.  The tongue is some-
 times palsied.  In what I  have called  P. agitans,  there may be
 a constant trembling of the hand, or more frequently,  an  inces-
 sant shaking of the head.  This is common with the aged, but I
 have met with it also in the young and robust.   In apoplexy and
hemiplegia, the brain is evidently the seat of injury.   The  mind
is disturbed more  or  less, and both sensation and motion are im-
paired.  In the three  latter forms of paralysis, the mind usually
remains unaffected and the sensibility of the parts is not changed,
the nerves of motion having  suffered exclusively.  This  may
either result from  some cause  acting upon the nervous ramifica- 
193
 tions which supply the parts, or may depend upon lesion of the
 portion of spinal or cerebral  substance  from which these spring.
 Paraplegia, which in  a  great majority of instances arises from
 obvious injury or disease of the spine, has been ascribed in a few
 to cerebral derangement, and has occurred as a sympathetic effect
 of gastric and intestinal disorder, without any perceptible change
 in the condition either of the brain or spinal cord.  In Chorea
 Sancti Viti, Paralysis vacillans—styled by some P. agitans, incor-
 rectly—the tremor or agitation is not constant, but exhibits itself
 only at the moment when an effort is made at voluntary motion.
 The volition fails in part, and the muscles called upon act with
 vacillation and irregularity, but not feebly.   There can be little
 doubt, I think, that  the  cerebellum, the  organ of association of
 action, is here affected as well  as  the nerves, and when the case
 is severe and  protracted, the whole brain may become disordered,
 the patient becomes fatuous, and there is tendency to convulsions.
   1.  Hemiplegia is nearly allied to apoplexy, which it may either
 precede or follow.  As the consequence of the apoplectic seizure,
 it has already been  spoken of.  Its approach may often  be ob-
 served and foretold.  I have  more than once  marked  in  the
 apoplectic, the exact  moment of its occurrence, denoted by a
 slight quivering  of  the  muscles of the face, trunk  and limbs,
 which in  an instant relax and subside into a passive condition.
  It often invades gradually.   The patient first complains of a
 numbness and tingling of one arm  and  leg, is apt to trip or stum-
ble, and to let fall what he attempts to hold ; there is noise in  the
 ears,  and the eye of one side  cannot be closely shut;  there is
 some distortion of the mouth, and articulation is impeded.  The
 mind is usually somewhat disturbed; the memory generally fails,
 though not invariably, and some terror attends the feeling of so
 great a calamity.  When fully developed, hemiplegia implies an
 incapacity to  stand or walk, or close or raise the hand;  but the
 power of  sensation and  voluntary  motion in the side  affected,
 though greatly impaired, is  seldom, if ever, totally lost, and in
numerous  cases the sensibility has remained, or been morbidly
enhanced, while  motion was impossible, and vice versa;  in one
remarkable  instance, there was loss of power on one side while
the feeling of that side continued, and  loss of sensibility on  the
                            25 
194
other, the voluntary movements  of which were  not impaired.
These facts are easily explained, since the discovery made by
Sir C. Bell, of the independent origin of the two sets of nerves.
   Sometimes  the case runs rapidly on  into apoplexy, occupying
from  a  few hours to a few  days, the prostration of muscular
power increasing,  and the mind becoming more and more dis-
turbed, until insensibility and coma supervene.
   Many patients,  however,  drag out  a  miserable,  protracted
existence of months  and years of unabated  suffering.   The
nutritive action of  the vessels of the affected limbs is imperfect,
they shrink and are emaciated, their natural heat being lessened—
harshness  and  dryness of the surface ensues, the ordinary trans-
piration  ceasing—the fingers are pale and waxen, and sometimes
contracted;  the countenance is distorted by the traction of the
mouth to the  sound  side, the saliva escapes over the chin, the
tongue is thick,  and when protruded turns to the paralytic side,
and  the speech is confused and indistinct.   There is sometimes
severe pain, and sometimes spasmodic  muscular contractions on
the affected side.   Amnesia is usually present in various degrees.
The memory  of words is oftener  lost than the  remembrance of
things or facts.  The  names of familiar objects are sought for in
vain,  or incorrect  names  obstinately applied,  and  words  pro-
nounced by the tongue which the will had not  contemplated.
The emaciation and  debility increase, until the patient sinks,
worn out and  exhausted by a long train of evils, in which every
function has successively suffered.
   In  a  few cases  a  gradual  improvement  takes place,  and a
restoration of  some of the capacities for action and enjoyment,
but such recoveries are rare.   They are attended with formica-
tion  and tingling of the limb, and sometimes painful swelling,
while the power of motion increases slowly and the mind gains
strength.  According  to  my own observation, this  recovery of
motive power  scarcely ever takes place except in the lower limb;
the paralytic hand  is very seldom restored in hemiplegia.
   The  causes of  hemiplegia are those  of apoplexy,  already
enumerated—plethora frorii luxury and excess  among the rich,
and the apparently contrasted though closely analogous condition
arising from imperfect supply of food in the poor, insolation, and
intemperance in drinking. 
195
  The prognosis is unfavorable.   It is proved  that absorption of
extravasated  blood, which by its  presence in the brain has pro-
duced  hemiplegia, may take place; but the  process is slow and
uncertain,  and the constitution in the  mean while sinks under
the general impairment of function.  Laceration and disorganiza-
tion of the cerebral tissue hardly admit of restoration.
  Autopsy.—The most common circumstance noted in the exam-
ination of hemiplegics, is the presence of a clot of blood in some
part of the brain.  It is usually, perhaps always, enveloped in a
cyst, and has undergone more or less  change from absorption.
The process  is slow;  the clot has been found undiminished  in
size, and filling the cyst, two years after the attack.   Sometimes
the cyst is  found empty, with  its sides collapsed—at others, it
contains serum.  Tokens of  inflammation of a portion of brain
are found; there is  induration of substance, ramollissement or
softening, a change the nature of which is not well understood.
Abscess or effusion of pus, of serum—various morbid  growths,
tumors  and  tubercular  deposits, have been seen connected with
the membranes.
  The pathology of hemiplegia is readily deducible from what
has been stated above.  It is the result of  pressure upon some
part of the brain, and  the degree and kind of effect are in relation
to the locality and extent of the lesion which interrupts the sen-
sorial function.   The  pressure  on which it depends  may be,
though rarely, intravascular.
  The treatment must be varied, as in apoplexy, to suit the con-
dition of the  patient.  If he be young and robust, the pulse full
and strong, the face flushed, with pain and throbbing of the head,
he  must be  bled largely, and cold water poured  upon the head
from a height.  Purgatives of active  and irritating character
must be promptly administered, and  their effect hastened by the
aid of enemata.
  In  the opposite state of the system, when the  countenance is
pale, the pulse feeble, the skin cold and moist, volatiles must be
applied to the nostrils, sinapisms and epispastics to the limbs and
trunk,  and the head sponged with vinegar and water.   Enemata
may be given, and leeches or cups put to the temples and back
of the neck. If reaction  ensues, we should deplete,  but with
caution. 
196
  In  the protracted state of hemiplegia, the persevering employ-
ment of purgatives has done service, and some of the cathartic
mineral springs are celebrated for cures effected.   Determination
to the head  must be combated by keeping the head shaved, and
occasionally applying a few leeches behind the ears, or blistering
the back of the neck or  between the shoulders,  or inserting an
issue  or a  seton  in  the  neighborhood.   Farther  revulsion is
attempted by frictions with turpentine, mustard,  &c. which are
supposed to  excite locally the enfeebled muscles  and nerves.
With the same view,  the skin of the  limbs affected is irritated
with  tartar  emetic, rubbed with  rough  tow and hard brushes,
stung with nettles, and burnt with  moxa.  Both the  cold and
hot baths are much eulogized.   But the most useful means, in
my hands, have been galvanism and electricity.  The tonics
are much employed, especially the metallic—the nitrate of silver,
bismuth, zinc,  arsenic.  Strychnine has been of late highly re-
commended, and is supposed to possess specific and peculiar
properties, which adapt it to the relief of the hemiplegic.  I  have
also seen some advantage gained by the careful use of veratrine,
both  externally and  internally  employed.   The  difficulty of
deglutition, which so much distresses some paralytics, was much
relieved after friction with the ungt. veratri about the jaws and
throat.
  2. Paraplegia is one of the most obstinate and hopeless of
human maladies.   The spine should be carefully  examined, and
at any point exhibiting fullness or tenderness on pressure, leeches
or cups should  be  repeatedly applied.  The use of purgatives,
and the employment of electricity and galvanism, furnish perhaps
our most reasonable hopes of improvement.
  3. Paralysis  agitans,  if in  the old,  is  incurable.   In the
young, it is connected with various other derangements of health,
and will  require  the treatment to be accordingly modified.  In
females,  it seems dependent  upon  habitual  constipation, and
sometimes  upon irregularity of  the catamenia.  Under both cir-
cumstances,  I have succeeded  in  removing it by employing a
combination of some resinous purgative with the rust of iron.
  4.  Paralysis vacillans, Chorea Sancti Viti, belongs generally to
childhood and early life.   It is produced sometimes by the irrita- 
197
tion of worms.  I have seen it arise during convalescence from
other maladies, as scarlatina,  catarrhal fever, &c.   I  knew it
supervene upon the introduction of a  needle into a part of the
body, and after a duration of some months, suddenly cease on the
needle finding its way out  of a distant part.  It often  invades,
however, without obvious cause.   I have seldom failed to relieve
it by the exhibition of iron, with an occasional purgative.  Other
tonics  are  used,  as bark, sulph.  quinine, and the cold bath.   I
have prescribed camphor and opium, in minute doses, with great
advantage.  In obstinate cases, I  have seen the best effects follow
from galvanism and electricity.

                         EPILEPSY.

   This terrible disease is of paroxysmal and recurrent character,
the  patient usually enjoying  good health in the  interval,  but
liable  to an  occasional attack upon  the application of exciting
causes of  great  number  and variety,  and in bad  cases sponta-
neously, or without  the influence of any obvious cause.  The
paroxysm  consists  in a sudden loss of  consciousness and sensi-
bility, attended,  when fully developed, by convulsive  agitation
of the  body and limbs.  Convulsion described as an  alternate
and rapid  contraction and relaxation of the muscles of voluntary
motion.    There is much  irregularity, both  as to  the  muscles
affected, and the force and quickness of their contraction.
   In a fit or  paroxysm  of  epilepsy, as ordinarily occurring,  the
patient falls, and is agitated with convulsions.  The countenance
is flushed or livid and horribly distorted, the head drawn forcibly
backward, the eyes  turned upward and  inward, and  the  lids
incessantly in motion.  The mouth is rapidly opened and shut,
with inarticulate sounds and moaning,  expressive of great suffer-
ing ; the tongue is mangled by the gnashing of the teeth, and the
lips are covered with foam.  The limbs are tossed violently or
drawn  together, with the  hands  tightly closed;  the trunk  is
twisted  to and  fro,  and the resistance of the  sphincters being
overcome by  the contraction of the abdominal muscles, the con-
tents of the  bladder and  rectum  are evacuated.   After a time
these convulsions  subside,  and  the patient lies passive, languid 
198
 and soporose;  his  intelligence gradually returns,  or  is at once
 recovered, after waking from this slumber, but there is no mem-
 ory or  consciousness of what has happened;  great debility, and
 usually some headache, remain for a few hours.
   Epileptics often  receive a species of warning, which admon-
 ishes them of the approach of a fit.  In some,  this consists in the
 throbbing of the head, tinnitus, &c. which precede apoplexy.  In
 others,  there is an indescribable  affection of one or more of the
 organs  of sense, either smell, taste, or sight; to perceive a partic-
 ular odor is not uncommon, and a patient of my own was always
 aware of what she denoted " a green taste" just before an attack.
 Others  feel in some part of the body, a sensation usually spoken
 of as "cold creeping vapor," which originating there,  moves up-
 ward towards the head.  This is  known  as " the epileptic aura;"
 but the accounts given of it by different  patients are  dissimilar.
 Some speak of it as a titillation, others as severely painful, others
 as indifferent or but slightly uncomfortable.
   The  paroxysm of  epilepsy is not  always fully developed,  as
 above described, the sensorial and muscular system being affected
 in various modes and degrees.  There may be for a moment, or
 a  very few moments, total  unconsciousness—a mist, as it were,
 coming  over  the mind, while the muscles remain  undisturbed.
 On the  other hand,  the intellect may be  clear while the aura is
 felt,  and  the muscles,  if not agitated, refuse  to obey the  will.
 One class of muscles may be exclusively and strongly contracted
 which is spoken of as the tetanoid form of epilepsy; or the whole
 muscular system may become at once rigid and fixed in the mode
 and degree or state of  action existing at  the precise moment of
 seizure—a state well known as Catalepsy, and of which I have
 met with  two well marked instances.  All these varieties may,
 at different periods,  exhibit  themselves in the same individual
 case.
   The autopsy of epileptics,  discloses no  uniform lesion or de-
 rangement.  Many affections of the encephalon and spinal cord
 have been noted, but they are found  in comparatively few sub-
jects; and on  the other hand, are often  observed unconnected
 with epilepsy.   Among them may be mentioned, ossific and other
 tumors attached to the inner table  of the skull,  and to the mem- 
199
branes of the brain, and purulent and other effusions upon the
surface of these membranes, and in the vertebral canal.
  The pathology of epilepsy is extremely obscure and ill-under-
stood.   The nature of the intermittent disturbance of the senso-
rial system and function,  upon which it depends, is absolutely
unknown.
  The causes of epilepsy are varied and numerous.  The predis-
position is transmitted hereditarily, and in certain families many
of the members become its subjects.   In persons thus predisposed,
almost every derangement of any organ or function may become
an efficient exciting cause.  I  would distinguish epilepsy, in ref-
erence to the first notable link in the chain of circumstances which
give rise to it, into Idiopathic and Sympathic.
  It is idiopathic when it occurs without  obvious derangement
of any other function than the sensorial, and when we can rea-
sonbly refer it to some known  agent, capable of directly impress-
ing the sensorial system, as for example, mental emotion of many
kinds, and the strong  principle of imitation.
  It is sympathic when, on the other hand, we trace the senso-
rial disorder to an  indirect or  secondary influence exerted upon
the brain and nerves, through the diseased condition of some of
the other organs or systems.
  1. The digestive.   Dentition and worms produce, by their irri-
tation, many attacks  of epileptic convulsion in  young children.
Intemperance is a frequent cause among adults, though it may be
questioned whether,  in this example,  the primary impression  be
made upon the stomach or the brain.  Hepatic disorder has been
accused of bringing on epilepsy.
  2. The genital.  In women, epilepsy is often connected with
derangement of sexual health.  Masturbation will give rise to it,
in both males and females.  Venereal excesses have proved fatal
by inducing epilepsy.
  3. Metastatic epilepsies.  Under this head I would include
such as precede and follow the exanthemata—such as supervene
upon the sudden disappearance of inflammations and the removal
of tumors.   I have more than  once seen such convulsions follow
the sudden disappearance of dropsical  swellings. 
200
   4. Epilepsies connected with " the aura."   This strange sen-
sation  has sometimes an obvious cause,  in the condition of the
part where it  commences.  The part is sometimes  tender on
pressure,  and sometimes it invites pressure.   Where no disease
can be traced on examination, I am still disposed to believe there
is a morbid local affection of the nerve distributed there.
   The prognosis, in the first species, or idiopathic epilepsy, is un-
favorable, except where it is clearly owing to some transient ex-
citement of the feelings, or when it is founded on the instinct of
imitation.  In the sympathic,  we distinguish  the several  forms.
Attacks occasioned  by the irritation of worms,  or dentition,  or
even by intemperance, are for the most part readily curable, upon
the removal of these transient causes.  So also of those which I
have termed metastatic,  which are  not  usually obstinate.  But
epilepsies, arising from genital derangements,  take promptly  a te-
nacious character, and are difficult to expel; and in the modifica-
tion specified under the fourth head, we have little room for hope,
unless we can appreciate and remedy the disorder of the part pri-
marily affected with the aura, or can detect and remove with the
knife the diseased portion of the nerve—means of relief very rarely
within our reach.  In general,  all the forms of epilepsy are diffi-
cult of cure,  in proportion to their duration.  Spontaneous cures
of epilepsy occur now and then, but are not well understood.  In
almost all cases, it is in our power to render  the paroxysms less
frequent, and perhaps to diminish their violence.   But few die in
the paroxysm.   It is affirmed to have brought on hemiplegia and
apoplexy, and by repetition, to tend  to reduce the patient into a
state of idiocy and fatuity.  Many epileptics,  however, live  long
and enjoy unabated vigor and clearness of intellect.
   Treatment.—During a fit,  loosen all clothing about the neck
and body—elevate  the  head,  and sponge or wash it with  cold
water—place a soft bit of  stick, or roll of cotton, between the
teeth, to preserve the tongue  from injury, and give the patient
fresh air.   The lancet may be of use, but is not often required.
I would bleed if the patient was young and robust, of apoplectic
make, with face flushed and turgid, and laboring under some
strong excitement of transient nature. 
201
  Owing  to the extreme obscurity of the pathology of epilepsy,
and our total ignorance of the conditions upon which it immedi-
ately depends, our efforts  for its removal, it must be confessed,
are rather  tentative than directed by scientific or definite indica-
tions.  The  practice  in  the case may therefore be considered,
without  impropriety,  under the heads of the Palliative  and
Empirical.
  The  palliative  management  of  the  epileptic,  is sometimes
successful  beyond our hopes; not only lessening the number of
the attacks of convulsion,  and subduing its violence, but even in
some happy instances arresting the disease altogether.  The diet
should be strictly regulated—temperate though not abstemious,
nourishing but  not  stimulating.  The hair should be cut close,
or even shaved off.  If at any time the head  throb or ache, or the
face be flushed, venesection should be resorted to, or cups and
leeches applied.  Vigorous and constant  exercise should be
enjoined—studious and sedentary habits abandoned.  The ad-
ministration of cathartics is often beneficial;  the most remarkable
cure which I have ever seen, was  effected by perseverance for
years in the habitual employment of gentle purgatives.   In  sym-
pathetic epilepsies, besides this general palliative course, we must
endeavor to eradicate or remove  the primary affection, wherever
seated.   A careful examination of the source of the aura should
be instituted, with the view to the counteraction of its influence,
in whatever method might be practicable.
  The empirical treatment of this justly dreaded malady, consists
in the administration of certain remedies, whose modus operandi
in the case is totally unknown, but whose reputation is the result
of tradition and experience simply.   I have not succeeded  with
any of these anti-epileptics, though  some of  them are in high
repute,  and have been favorably reported  of by physicians of
name and authority.  They are the nitrate of silver, the salts of
zinc, of copper,  and of arsenic, digitalis, and the mistletoe of the
oak.  Successful experiments have been also made with galvan-
ism  and  electricity.   These powerful  agents, especially the
former,  would  seem  capable of advantageous  application  here,
and deserve repeated trial from the profession.
                            26 
202
                      NEURALGIA.

  The physiology of the nervous system is too obscure to admit
of a clear  understanding  of its morbid  conditions.  The very
language which we use in treating of its pathology, is vague and
indefinite.   Thus Neuralgia is the term chosen to denote a pain-
ful  affection of certain nerves, as if all pain were not  essentially
nervous ;  it is intended here,  however, to exclude  the idea of
inflammation or structural lesion  of the  parts supplied by the
diseased  nerve or its  ultimate expansion.  Under this  head, I
propose to consider, briefly, three varieties of morbid affection,
closely allied in nature, and analogous in symptoms and results.
1. Spinal irritation.  2. Tic douleureux.  3. Visceral neuralgia.
  1. Spinal irritation must not be confounded with true Spinitis,
to which  however it may give  rise.   It has been accused as the
obscure source of a long list of maladies, even intermittent fever
having  been ascribed  to it.  In ordinary cases, which are much
more common  in females than males, and in youth than advanced
life, the patient complains at first of occasional uneasiness in the
back and loins, is easily fatigued, indolent, and unwilling to walk,
or stand, or sit erect.   Then come on aching along the course of
the  crural and sciatic  nerves,  and a feeling of weariness in the
lower  limbs.   The  general  health yields under the influence of
this constant uneasiness, want of exercise and disturbed rest; and
a long  series  of  sympathetic affections ensue, terminating  in
hectic  and atrophy, the  digestive and genital systems suffering
prominently.
  2. Tic douleureux is a painful affection of the extreme expan-
sion of some external nerve.  Good makes three species—Faciei,
Pedis,  Mamme—the  first being  most common.   I have seen
two instances  of  the  second.   The third is happily rare.  Tic
douleureux is paroxysmal,  spontaneously recurrent—observing,
though not very exactly,  the law of periodicity;  the pangs suf-
fered during an attack  are intense, and of singularly depressing
character.
  3. Visceral  neuralgia.—This is also a paroxysmal  and recur-
rent affection.   The ganglionic system of nerves is the principal 
203
(though perhaps not the exclusive) seat of suffering here, and the
anguish of  the wretched patient is indescribable.  One of its
most common forms is known as " nephritic colic;"  the kidney,
lower  intestines, and testes, being assailed with  pains of most
" atrocious"  intensity.  All the viscera  may be thus attacked.
Gastralgia is probably often a gastric neuralgia.  Dysmenorrhea,
usually a  uterine neuralgia.   Some of the varieties of headache
are doubtless of the  same  character, and perhaps  some of the
cardiac and  diaphragmatic  affections, so obscure, and so full of
pain and danger.
   The causes of neuralgia are not clearly made out.  Macculloch
and others after him attribute it to malaria, but it is not more fre-
quent in malarious districts than elsewhere.   It is more plausibly
alleged to be connected with previous dyspepsia, and sometimes
with gout.
   Treatment.—All forms of this disease are  intractable and te-
nacious.   We may generally relieve a paroxysm with the prompt
and unhesitating administration of opium, or some of its prepara-
tions.  The  doses should be as large as the stomach will bear,
and for quickness of effect, I prefer the solution, either of the
drug entire, or of some of the salts of morphine.  The warm bath
will aid their  action, and so it is asserted will  the combination
with them of camphor, musk, and assafetida.   In the intervals,
guaiacum and colchicum  are advised by some, while others rely
upon  the  tonics, selecting arsenic and iron.   While  there is any
tenderness upon pressure locally, either of  any portion  of the
spine  (which we should never omit to examine carefully) or any
other part of the body, cups or leeches should be applied there,
and counter-irritation assiduously attempted by sinapisms, blisters,
and by the ammoniated lotion of Granville. 
204
       DISEASES OF  THE MOTORY  SYSTEM.

                           GOUT.

   Podagra—Arthritis.—We have to consider gout,  like scrof-
ula, in a twofold point of view.  It constitutes or depends upon
a peculiar  diathesis, of which its several  local developments are
the  external manifestations.  Regular attacks of gout, however,
affect the  joints exclusively, whence the propriety of the term
Arthritis, and the arrangement of it here.
   The gouty diathesis or constitution  may be transmitted hered-
itarily, determining a predisposition  to its local manifestations so
strong that they cannot be escaped,  the subject being attacked
in childhood or  early youth.  In the generation of the diathesis,
full or luxurious living is the most influential agent;  this is much
aided by habits of indolence and refinement.   Climate has proba-
bly  an  effect in inducing this state of the system, as in Great
Britain, where  gout  prevails as extensively among  the  upper
classes of society, as scrofula among the lower.
   The nature of this  predisposition is  not at all understood.  It
is usually connected with a state of plethora,  and attended by a
proverbial exemption from  other forms of disease.
   The exciting  causes which tend to develope it and give rise to
an arthritic paroxysm, are numerous and diversified.   Intemper-
ance—nay, a temperate use of stimulants, even a single glass of
wine, will occasion it in the predisposed—so will any indigestible
or stimulating food,  fatigue, loss of sleep.   Local injury of a
joint, as a twist  or strain of the  ankle, is sometimes  followed by
a fit of gout.
   Gout is divided into entonic and  atonic—into regular, mis-
placed, and retrocedent.  It is entonic when the local  inflamma-
tion is attended  with  febrile excitement and  increased force of
vascular action.   It is atonic when  the pulse and strength are be-
low the usual standard—when instead of febrile  excitement and
local pain, we have general uneasiness and disturbance, with little
inflammation  of a joint or limb.  Regular gout  attacks a joint 
205
and is there fixed, the constitutional disorder being proportioned
to the local affection, and disappearing as it abates.   Retrocedent
gout consists in a metastasis of such local affection from the joint
first  attacked to  some one of the internal organs.   Misplaced
gout is said to occur, when, at or about  the usual period  of the
recurrence of a paroxysm, or under the influence of the  causes
which tend  to produce it, an arthritic subject  becomes affected
with much internal disorder.
  The pathology of gout is confessedly obscure  and uncertain.
The prevailing opinion  of  the day,  refers  the symptoms in all
their variety to disorder of the digestive system.   In this  view I
do not  concur.   The nature of the diathesis, especially when
hereditarily derived, is utterly unknown.   The local inflamma-
tion  is of peculiar character, and terminates only in resolution or
deposition of earthy matter, never in effusion of pus  or serum, or
in gangrene.
   The diagnosis of gout is easy in cases of long standing.   A
first  fit may be mistaken for rheumatism.   It is distinguished by
its intensity, and its exclusive invasion of the smaller joints, very
generally the ball of  the great toe.
   The prognosis in regular entonic gout  is decidedly favorable.
In atonic irregular attacks it is the reverse;  these are often sud-
denly fatal,  whether the stomach, the heart, or the  brain  be the
part  affected.
  A paroxysm of regular gout begins with a swelling of the ball
of the great  toe,  which  is extremely tender to the touch, with
great tension  and redness  of the  skin, the veins being full and
the arteries throbbing.   The pain, which  is insupportably  severe,
extends  upward  towards the ankle and  calf of the leg,  and is
much increased on letting the foot hang.   Motion is impossible.
There is fever, with headache  and uneasiness of stomach;  the
pain is described as very distinct and peculiar, and attended with
a sense of numbness and paralysis of the part.  The inflammation
occasionally changes from one foot to the  other, or extends to the
knee.   After a duration  of  a few days,  these symptoms subside,
leaving the  patient in good health.  At  first  the intervals  are
long, and the paroxysms do not  recur for a year or six months,
but by repetition their duration is lengthened and their frequency 
206
increased, until the local inflammation becomes almost permanent,
when we may have the deposition of urate and phosphate of lime,
so characteristic of gout.
   The symptoms of retrocedent and misplaced gout depend upon
the organ  attacked.   When the viscera of the thorax and abdo-
men are affected,  there appear the usual signs of gastritis, enteri-
tis, pneumonia, &c.  When the brain is the seat of the evil, it
assumes rather the  form of apoplexy than phrenitis;  and when
the heart is assailed, the case is angina pectoris, or perhaps more
correctly a cardiac neuralgia.
   When with these arthritic affections there  co-exists an infirm,
debilitated condition of the patient—atonic  gout—the  pulse is
feeble and wavering, the skin  cold  and clammy, the pain intol-
erably oppressive, and described as spasmodic, with constriction
of the chest or stomach.   When these pains are transitory though
severe, and shift from place to place, now assailing the trunk and
now the limbs, now one organ or part, and now another, it is the
"flying gout" of  the books.
   Treatment.—During  the paroxysm.   In  young and robust
subjects, and in the earlier  attacks, it will  be proper to resort to
venesection;  but  not in the opposite class of cases.  Purgatives
are almost always useful and necessary,  ^prefer the combina-
tion of a resinous  with a saline, adding some aromatic.  Emetics
are very seldom  indicated;  I would employ them  when  the
stomach was loaded with a recent full meal,  at the commence-
ment of a fit.  Opiates are much objected to by some, but in all
prolonged paroxysms I am in the habit of prescribing the Dover's
powder freely at night, and with excellent benefit.
   The tincture of colchicum and Eau medicinale, maintained by
many to be the same, are on the  one hand  highly eulogized, as
not only safe, but  admirably successful; while on the other, they
are accused of fatal tendency.  I have seen them both employed;
there was some advantage gained, yet not much, and no evil re-
sulted.  Wilson's tincture, a celebrated secret remedy, perhaps a
compound of colchicum and veratrum, is  certainly possessed of
remarkable power, and will often control and arrest the invading
fit of gout. 
207
  Local management.—Leeches are generally serviceable ;  they
diminish the pain, if they do not shorten the paroxysm.  Some
patients are relieved by a soft tepid poultice, while  others derive
comfort from cold astringent applications, as the solution of ace-
tate of lead, sulph. zinci, &c.   I have not  seen the good effects
promised  from opiate frictions and  blistering.   Percussion and
bandaging are recommended by Balfour and others,  but my pa-
tients cannot bear the part thus handled.  With regard to the
cold bath, so much a subject of dispute, I would resort to it  if, in
a young and robust patient, after proper depletion, the pain and
inflammation were obstinately prolonged.   Under other circum-
stances I  would  consider it unsafe, and dread its  giving rise to
retrocedent or metastatic gout.
   During the interval.—Temperance and exercise are the best
prophylactics.  The diet should be nourishing, but unstimulating.
A threatened attack  should be opposed by the use of laxatives
and tonics.  The tinct. guaiac. combines these properties; I have
 seen it often serviceable.  The alkalies and bitters have enjoyed
 a high repute,  but since the Portland powder lost  its reputation,
are not so much  used as formerly.
   The irregular forms of gout, the misplaced and retrocedent,
 must be treated on general principles.  If etonic, the local  affec-
 tions will be highly  inflammatory, and will require the prompt
and free  employment of the lancet,  leeches or cups, purgatives.
and blisters to or near the  part assailed.   If atonic, on the  other
hand,  an immediate  resort to opium  and stimulants is necessary.
 The tinct. opii may be given in large doses, with ether and  other
 diffusible  stimuli, while we apply the  quickest revulsives  to re-
 lieve the affected organ—mustard, hot turpentine, moxa, &c.

                       RHEUMATISM.

    This disease is especially interesting to the physician, from the
 frequency of its  occurrence, the  intensity of suffering which it
 often  causes, and the readiness with which, in the majority of
 cases, these sufferings are  relieved by proper management.
    The division  of rheumatism into  acute and chronic, is famil-
 iarly and universally recognized; yet it is not easy to describe 
208
clearly the distinctions which separate these varieties, nor even the
points of  similarity which  connect them.  In the first, the local
affection is always painful and inflammatory, and is attended, for
the most  part, with  fever of high excitement.   In the second,
the local affection is, generally, less intensely painful, and some-
times productive of no pain—the derangement consisting merely
in the impairment of the capacity of moving or being moved, and
the part thus affected often exhibits no external  mark of inflam-
mation, except a degree of  swelling and consequent deformity in
the first instance, with ultimate atrophy and entire paralysis.  If
fever be present, which is not usually the case in any obvious de-
gree,  it is of a low irritative type.   There are, however, cases of
chronic rheumatism, in which great pain is suffered by the patient,
especially on motion  of the diseased  part;  and others in which
fever, although not constantly present, comes on with much gen-
eral and vascular disturbance from time to lime.   Rheumatic in-
flammation chiefly  attacks the larger joints, but may affect  the
smaller articulations also, and the fibrous  tissue every where, and
perhaps the cellular.
   The predisposing causes are not well known, although it is evi-
dent  that certain  persons are much more susceptible of seizure
than others.   One attack renders the subject more liable to a sec-
ond.
   The exciting or occasional  causes  are more obvious; sudden
alternations  of temperature, and exposure to cold and  moisture,
are the chief.  So clear is this connection, that a partial exposure
will produce  a local  rheumatism,  as  in  the  familiar instance of
stiff-neck, from sitting near a partially opened window or door.
   The diagnosis of rheumatism is usually easy.   It is not liable
to be  mistaken for any other disease than  gout, the characteristics
of which  are well marked.
   The prognosis in acute rheumatism is favorable ;  very few  die
of it,  although fatal terminations have been met  with, where  the
attack was specially violent in a feeble constitution, or the febrile
excitement was protracted into the typhous state.   The principal
danger perhaps is found in the tendency to metastasis, the inflam-
mation leaving the joint or other external part, and invading some
of the internal organs, as the heart, the lungs, the diaphragm, &c. 
209
 The symptoms thus arising are urgent, and  the  patient, if not
 promptly relieved, sinks under his severe sufferings.
   In chronic rheumatism the prospects are more gloomy.  It is
 an affection of proverbial obstinacy, and in a large proportion of
 instances, adheres tenaciously.
   Symptoms.—Acute rheumatism comes  on with stiffness and
 pain in some one or more of the joints, or  in some  muscular part,
 soon attended with fever.   The pain is severe, especially on mo-
 tion, and the part  becomes  swollen and red, and tender on pres-
 sure ;  the pulse is full, hard, and  frequent; the skin harsh, hot
 and dry; the tongue lightly furred.  A nocturnal exacerbation  of
 pain and general disorder occurs regularly, and in the morning an
 uncertain degree of remission.  After a duration of  10 or 12 days,
 the pain and inflammation subside, and the fever disappears, the
 part affected remaining  for some time after weak and easily hurt.
 Rheumatic inflammation seldom  runs into suppuration ;  in the
 joints it produces an effusion of synovia, which is afterwards ab-
 sorbed readily.  It is much disposed to shift its place, changing
 from one  joint or muscle to another, and sometimes assailing the
 internal organs.  I have seen it twice attack the heart.  In one
 instance,  an acute carditis was excited, which proved rapidly fa-
 tal ; in the other, it gave rise  to  palpitations  and hypertrophy,
 with dyspnea, under which the patient finally sunk.  The symp-
 toms which are exhibited in these metastases, are usually such as
 appear in other acute inflammations of the organs invaded.  Acute
 rheumatism chiefly affects young adults and middle aged persons.
 I have seen it,  however, exquisitely developed in a child of three
 years, and in old people.  Both sexes seem equally liable to it.
   Treatment.—In the robust and strong it is well  to employ the
 lancet, but this instrument has been used with great imprudence
 by many, in the hope to extinguish the disease at  once.  A cer-
 tain degree of caution is required, or injury  will ensue ; and al-
 though it is undoubtedly proper to relieve hyperemia (if it exist)
 in the plethoric, and to reduce the vascular excitement which pre-
vails by blood-letting ; yet it should be remembered, that there  is
something peculiar  in the nature of the inflammatory affection,
which  refuses to yield to mere abstraction of blood; and that this
remedial measure, when carried too far, has changed a transient
                             27 
210
or acute, into an obstinate chronic or passive rheumatism.   Pur-
gatives are undoubtedly useful.  I employ the saline, in the first
stages alone; as the case progresses, in combination with diapho-
retics.
   Diaphoretics, indeed, have been regarded as specifically adapt-
ed to the management of rheumatism.   The antimonials are much
prescribed.  The colchicum is highly recommended here, as in
gout.  It is said to combine, when given in proper doses, a pur-
gative with a diaphoretic effect, and is much depended on by ma-
ny practitioners.  I make much use of serpentaria—at first, with
enough of the  Epsom salt in solution, to operate freely upon the
bowels—afterwards, with  some form  of  opiate.   The Dover's
powder is invaluably beneficial, when the earlier violence  of ex-
citement has been subdued by the lancet and cathartics,  and in
large  doses will often  remove promptly all traces  of  the disease.
In protracted cases, the acetate of ammonia,  with camphor and
opium, is highly efficacious; sulphur is  also well adapted to re-
lieve.  In combination with these, we may frequently administer
infus.  cinchone with  striking advantage.  The mercurials, so
warmly eulogized by some late writers, do not seem  to be requi-
red in simple rheumatism, but become necessary when there is
any complication with viscera] disorder, or with syphilis.
   The local management of rheumatism deserves attention.
Leeches or cups should be applied, and the flow of blood kept up
by warm fomentations or soft poultices, which will relax and re-
lieve  irritation and tension; at a later  stage of the attack, sina-
pisms may be applied, and embrocations of a volatile or stimulating
nature made use of.  The  vapor bath is serviceable.   1 mention,
only to disapprove of, cold applications.
   Chronic rheumatism is a state of disease, difficult  to describe.
It may be the result of an intractable attack of the acute variety.
There is  a subsidence  of fever, and of general  excitement; the
appetite and strength of the patient are in a great measure resto-
red ; and  the appearances of local  inflammation diminish  or dis-
appear, with the exception  of the swelling, which continues or
may increase, the joint being  incapable of motion.  In general,
there is no acuteness of pain, but the part is ill at ease, and some
cases  are  attended with excruciating  sufferings, which no lapse 
211
of time subdues, and in others, fever persists of the low irritative
type.   The muscles which move the affected limbs emaciate—
the joints become large, hard, stiff and misshapen, with a pale
and waxen hue of the skin covering them.   Chronic rheumatism,
when not the  consequence of the acute form,  is said to select
usually women and feeble men; but the most remarkable instance
of it ^ich I have ever met with, was in a stout  and robust man,
a physician, in  the prime of life, healthy and athletic.   The case
is worthy of description, as exhibiting very strongly the charac-
teristic  peculiarities of chronic rheumatism.  The subject  of it
was sent for on a warm  night in autumn, to see  a patient some
miles from home  ; he rode hastily thither, prescribed, and then,
bathed  in perspiration, lay down to sleep under a window in a
strong current of  air.   On awaking, he found himself incapable
of moving without  severe distress, every limb  and joint  being
stiff and sore.  A brother practitioner being called, bled him 40
ounces, from which time he  had no pain.  He was  still unable
to move, and in a few hours after was bled 20 ounces  more.  He
never recovered the use of his hands, but was able to  walk slow-
ly and feebly.  His joints were swollen, pale and stiff—he ema-
ciated gradually—his fingers  were slightly bent, and had the ap-
pearance of waxen preparations.  His appetite and digestion were
good, and he  had  no  obvious febrile  exacerbations,  though his
nights were often restless and  uncomfortable.   In this state of
helplessness he remained some years, with a clear intellect and
cheerful spirit.  Having  removed to a distance, I know not the
manner of his  death.
   Lumbago and  Sciatica are two forms of chronic rheumatism,
well known and of frequent occurrence in the aged.   In  these
affections of the  hip and  loins, there is usually much pain and
incapacity for  motion, but with little  fever or  general disorder.
Some  have doubted whether they are correctly to be considered
as rheumatic,  and  have regarded them as affections  of the large
nervous trunks; but it is difficult, if not impossible, to draw such
lines of distinction  as are here aimed at;  for many cases of pain-
ful affection of distant joints, with  swelling, readily recognized
as chronic rheumatism of ordinary character,  seem connected
with  or dependent  on affections of the  nervous trunks, and are 
212
relieved by cupping  or leeching the part of the spine whence
they arise.
   Treatment.—In chronic rheumatism I would advise an avoid-
ance of the  lancet.   The  stimulating diaphoretics are our best
remedies—guaiacum, camphor, ammonia and opium.   Stimulants
alone are much employed, and sometimes with good effect.   The
tinct. cantharid., turpentine,  savin,  and  balsam copaj^a,  are
strongly  eulogized.  Sulphur is often  beneficial, and  in feeble
subjects may be well combined with infus. cinchon. and serpen-
taria.  The Colchicum autumnale is supposed to be well adapted
here also.   The Phytolacca decandra is thought to be similarly
useful.  The Lisbon diet drink is a formula much employed* and
combines some of our best diaphoretics.   Experiments have been
successfully made with  the prussic acid,  in very obstinate cases.
Endermic medication, by vapor baths, fumigations of sulphurous
acid, chlorine, phosphorus, ether, has been much in vogue.   The
natural hot  baths have effected  numerous cures  in our own
country; the springs of mountainous Virginia, and of Buncombe,
in North Carolina, are much resorted to, and hot and sulphurous
waters are  drunk with remarkable benefit.
   Local  applications have not been neglected, and the number
and variety of those recommended at different  times, and  by
different persons, for the cure of this very obstinate disease,  are
great.  Leeches and cups are used occasionally with great advan-
tage.  To  Dr. Mitchell,  of Philadelphia, we owe the suggestion
of the preference due to the spine, as the place of application—at
the  part whence arise the  nerves supplying the joint  affected.
Epispastics, the pustular irritation of tart, antimon., moxibustion,
the  persevering employment of strong friction over, and forcible
motion of  the stiff articulation, have all restored patients.   Acu-
puncture has often  given  striking relief, and so have electricity
and galvanism.
   The diet, during the protracted existence of chronic rheuma-
tism, should be nourishing and generous.   Motion of the stiffened
limb should be resolutely and frequently  attempted.  If there be
any obvious susceptibility  to cold, it will be a useful precaution
to envelope  the  trunk and limbs in flannel, or even to apply to
the latter the flannel roller-bandage. 
213
    DISEASES  OF THE  EXCERNENT  SYSTEM.

  Of all the classes of the physiological nosologists, this has been
found most difficult to delineate and circumscribe.  The business
of excretion  seems  to be divided among many of the organs,
which assist incidentally in its  performance, while engaged in
their peculiar function.   Thus the lungs, the liver, and the intes-
tines throw off  much effete matter, while busied in  digestion,
absorption, and assimilation.   The kidneys are, perhaps, the  only
organs exclusively excretory; we know of no other function in
which they are employed than mere elimination.   Next to them,
the  skin perhaps deserves to be considered in this  point of view.
   Excretion  is the most  important office of the cutaneous integ-
ument, although by no means the only one.
   The diseases which affect this  extended surface  are numerous,
diversified, and often highly severe  ; they are of frequent occur-
rence, and in every respect deserve our particular attention.
   Among the chief of the maladies in which the skin is especially
implicated, are  the Exanthemata or eruptive fevers—a group of
diseases so called, from the fact,  that a cutaneous  eruption,  pre-
ceded or  attended by fever, forms  the prominent point in  their
history.   Under this head are included Variola, Rubeola, Scarla-
tina, Dengue, Varicella and Vaccine.
   The first  four combine many circumstances of close analogy.
A certain febrile disorder with notable gastric derangement pre-
cedes, by a pretty regular interval, a specific cutaneous eruption
of  definite character.  The period  at which this characteristic
eruption makes its appearance, though subject to  occasional and
slight modifications, is well known ;  it is transient in its duration,
running a limited course,  and then declining and passing away.
Small pox throws  forth its eruption on the third day from the
invasion of the disease—arrives  at  its height on the  tenth, and
then declines.   The rubeolous eruption  appears on the  fourth,
and declines after the  seventh.  Scarlatina shows itself on the
surface on the  second,  and fades from the fifth.  Dengue pro-
duces its eruption on the  third, and disappears after  the sixth. 
214
They are contagious always,  and often become epidemic also.
They affect  the human constitution  but  once—a rule which,
however, is proved to be subject to occasional exceptions.
  In the instances of small pox, measles and dengue, the gastric
disorder is notably diminished as soon as the eruption has appeared
upon the skin ;  in scarlatina this relief is less observable.
  The pathology of the exanthemata is specially obscure, although
there  is no want of  theory or hypothesis on the  subject.   The
nature of the connection, so uniform and essential,  between irri-
tation of the  mucous membrane of the respiratory and digestive
apparatus, and inflammation of the skin of varied appearance and
character, is entirely unknown.   It  is very common to represent
the cutaneous affection as a metastasis of  diseased  action from
the mucous  tissue, which is assumed  to be the seat of primary
irritation, and first  assailed, but this is incorrect.    The mucous
surface  is not always, if ever, restored to a healthy condition at
the time of the eruption ; but the nature of the diseased action is
altered.   It is now affected similarly with the skin, and continues
to be so until the latter is restored to health.  In small pox, pus-
tules form upon it; in measles, the red patches are  first seen on
the palate ; in  scarlatina, the tongue, throat and gastric surface,
are  last to lose their extreme susceptibility to painful impressions,
their heightened color and obvious inflammatory condition.
  The whole mass of fluids seems to be, in some manner, vitiated
in  these eruptive fevers, of which the best proof is found  in the
fact that they  are  conveyed to  the fetus in  utero, when the
pregnant mother is attacked.  Such instances happen not  unfre-
quently in variola, and, although more rarely, in measles also.

                        VARIOLA.

  Small pox.—A well known contagious, eruptive, inflammatory
disease.   It has been supposed to be  indistinctly mentioned in
ancient writings, as prevailing among the Easterns,  but we have
no definite description of it until the 6th century.
  Small pox is  usually treated of under the separate heads of
Distinct and Confluent; which  terms, however, refer not to any,
specific  difference, but  merely  to the  degrees of violence of the
attack, with the amount and extent of the attendant eruption. 
215
  Variola commences, like  the inflammatory fevers, with a rigor
or shivering, followed by heat, pains in the head, back and limbs,
gastric oppression, nausea and often vomiting, restlessness, anxiety,
and muscular debility.   Sometimes there is soreness of the throat,
with pain in  the side and chest, cough and dyspnea.  In young
children the invasion is  not unfrequently marked by convulsions.
These symptoms continue for three days; on the fourth usually,
(it may be twenty-four hours  sooner or  later,) the skin of the
face  and breast exhibits an eruption, consisting of small papule,
slightly projecting and of red color, which afterwards spread over
the arms and the rest of the surface.  From the time of its ap-
pearance, the febrile  symptoms decline,  and in a great measure
subside.  These  pimples or papule assume in a day or two the
vesicular form, becoming distended with a thin serous fluid; they
increase in number and size, and on or about the seventh and
eighth are of a circular  shape, with a depression in the centre, of
the great majority.   On the ninth  and tenth, the contained fluid
is turbid and purulent.   In proportion as these pustules abound,
the case is distinct or confluent.  In the latter form of small pox,
they often  run together, so as to make a complete mask for the
faee,  and on  certain parts of the body, those for instance which
lie  always in contact with the bed, run into large patches and
crusts.   Where  they are not in contact,  the skin between and
around them  is inflamed, red, and elevated.   There is ophthalmia,
and the face  and eye-lids are swollen, the mouth and throat are
sore, and the patient spits largely a tenacious saliva.  About the
eleventh day, there is an abatement of the  inflammation,  both
pustular arid  cutaneous.   The pustules, or many of them, crack,
and  the contained fluid  oozes out; they flatten, and by the four-
teenth have begun to dry and condense into a hard crust.   From
the twentieth, these crusts fall off, leaving in a great majority of
cases, a permanent depression or pit in the skin.
  The case may  thus terminate without farther danger  or incon-
venience, and such is the history of a mild or distinct attack ; but
when the pustules are very numerous or confluent, we may have
them spreading over and destroying the eye,  extending into the
throat and trachea,  occasioning suffocation or severe pulmonary
inflammation, and in such instances a secondary fever arises, de- 
216
pending, probably, on the great degree of constitutional irritation,
occasioned by so extensive and  violent an inflammation of the
mucous and cutaneous surfaces.   This  secondary fever invades
at variable periods, from the  eighth to the eleventh day.  The
tongue and mouth become  dry; the pulse is very frequent and
rather tense, but often feeble; the breathing is difficult; drow-
siness comes on, increasing into coma, and the patient sinks ex-
hausted with intolerable sufferings.
  The prognosis is favorable in distinct small pox; in the con-
fluent form it is the reverse.   Bad cases may be known from the
first, by an imperfect  eruption, the vesicles rising very little, be-
ing rather livid than florid, and filling, or as the phrase is, matu-
rating badly.  If at any time the pustules flatten, and the skin
becomes pale or livid,  the danger is great,  especially if the pulse
and strength fail, and  the mind is observed to wander.  The oc-
currence of any urgent  internal  determination is  to be dreaded,
whether to the brain, as shown by delirium, coma, &c. or to the re-
spiratory organs, with pain in the side or chest, cough and dyspnea.
  The sequele of small pox are often very serious.  Deformity
and blindness, with sometimes a permanent ophthalmia, a chronic
diarrhea,  anasarca, occasionally follow it.   The voice is in some
permanently changed, and rendered disagreeable, by injury done
to the soft palate.   Scrofula  is said to be excited  to severe  and
rapid  development, and  the predisposition to  pulmonary  disease
generally, but  more especially tubercular or scrofulous phthisis.
  Autopsy.—The variolous eruption is found not only on the skin,
the vascular network of rete mucosum being the seat of the pus-
tules, but extends to the mucous tissue lining the  mouth, fauces,
pharynx, trachea, larynx, and rectum, and upon the conjunctiva.
The structure and formation  of  the pustule in these positions, is
not well made out.  In the cutaneous integument  it is multicel-
lular.  The pit is occasioned  by the  sloughing of a circular por-
tion of the cutis vera.
  In many subjects the brain and its membranes are found dark
with vascular congestion.  In others  the lungs are engorged  and
hepatized, and the pleura inflamed.
   Treatment.—During  the  eruptive fever of small pox, if we
are aware of the nature of the case,  there is little temptation to 
217
interfere, when the attack is mild.   I know not that there is any
risk or evil, in the  ordinary management of fever of equal inten-
sity applied here.   If at the time of access there are exhibited de-
terminations to the head, lungs, stomach, &c, violent and severe,
the lancet may be used, and its effect aided by mild purgatives.
The mercurials are supposed to exert here a peculiar efficacy, but
of this  I  am  not  satisfied.   Great  gastric oppression, with foul
tongue and fetid breath, require an emetic, especially if the retch-
ing be insufficient, and fail to empty the stomach of its  crude
contents and  morbid secretions. Mild emesis can  scarcely  do
harm, and is serviceable  besides, by favoring a centrifugal deter-
mination of the fluids.   It often relieves the infantile convulsions
which precede the eruption.
   The purgatives  which I have advised to be used with  modera-
tion during the eruptive fever, must be abstained from when the
papule are forming upon the skin;  after this,  the bowels should
be kept free by laxative enemata.
   The use of the  warm bath, should be one of our earliest mea-
sures in the management of negroes and of whites of the  lower
class.  It is beneficial to children attacked with convulsions, who
may be relieved with the lancet cautiously employed, if the pulse
be full and hard and the face flushed; and on the other hand, if
pale and feeble, may be tranquillized with small doses of the tinct.
op. camph.   The  apartment of the sick should be well aired, and
perfectly clean.  He  should lie on  a firm mattrass, and if able,
sit up occasionally.  The  cool  regimen, so vastly preferable to
the heating system, anciently in vogue,  must  not, however, be
carried to an extreme.   It will, if urged, do harm, when  the pul-
monary symptoms are prominent.  Nor do  our negroes,  in gene-
ral, bear it well, unless much modified.
   Light mucilaginous  drinks should form the only nourishment.
The sore-throat should be gargled often with tepid water, and the
inflamed eyes washed from  time to time  with milk and  other
mild collyria, and carefully protected from light and other irritants.
   To prevent the pitting, so much feared, many  expedients are
proposed.  I  have  not  confidence in any one of them.   The re-
sort to them in confluent and really severe cases is trifling, and in
distinct small  pox  there is little deformity left.
                             28 
218
  In the secondary fever, most  advantage is  derived  from the
mildly stimulating diaphoretics, as the infus. rad. serp., with slight
additions of ether, camphor, or ammonia.   I employ opium un-
hesitatingly and freely, when it is required to relieve the cough,
dyspnea, restlessness, and other sufferings of the patient.  It does
not seem contra-indicated by any circumstances but those which
show a tendency to coma.  I prescribe the Dover's powder or the
camphorated tincture.
  In  protracted cases,  when the strength yields,  cinchona is of
much service.  The infusion may be combined with other rem-
edies.  Extensive crusts are rubbed off occasionally by the mo-
tions of the patient in  bed,  leaving painful sores.   These must
be dusted with cinchona or finely powdered chalk, the pressure
of the body frequently changed  by the attendants, and extreme
cleanliness inculcated.
  If the " striking  in" of the eruption, as the phrase  is, occur,
the pustules flatten and become indistinct, with failing pulse, and
cold and livid surface,  it is necessary to stimulate  promptly and
energetically, both by internal and external means.
  The treatment of the convalescent requires much attention.
He is covered with a new and highly susceptible integument, and
is specially liable to the  ill effects of  exposure and alternations,
from which he must be guarded strictly by proper clothing.   His
diet should, for a long  time, be plain and unstimulating, though
nutritious.
  Variolous contagion is both palpable and impalpable.   It may
be communicated palpably by contact  with the diseased person
or with fomites,  and by inoculation, or  the direct insertion of
small  pox matter into a wound.   It is also capable of diffusing
itself  impalpably  through the atmosphere.   At what stage of the
case a sick body becomes thus a focus of contagion, is not clearly
known—perhaps  from  the seventh day, when a peculiar odor or
effluvium begins to be  given off.
  The latent period, the interval  between infection and invasion,
is also doubtful; it is usually rated at from nine to fourteen days.
The effects of inoculation  show themselves earlier—about the
fourth day.
  Small pox attacks the same person but once—a rule clear and
positive, though not without exceptions.   This exemption gave 
219
great importance to the  practice  of inoculation, which enabled
the subject to select his own time and circumstances for suffering
the disease.   It is difficult to account for the immense difference
in violence and mortality between the casual and inoculated small
pox.
   Variola is liable to many  modifications in history and charac-
ter, some of which have  been pointed out and separated in com-
mon language by special denominations, while the strong simi-
larity which they present to  each other and to the common stock
of all, is indicated in the use of a word now become familiar eve-
ry where, varioloid.
   All the old writers speak of irregular forms  of small pox.  Syd-
enham is  particular in  detailing  the varieties which the disease
offered, in the several years  of its epidemic occurrence under his
own notice.  Lieutaud speaks of a " spurious  small pox," occa-
sionally taken for the legitimate.   Parr tells us that  " the varieties
of small  pox are numerous."   Others tell  us of water-pock, of
wind-pock, stone-pock, &c. in  almost unnumbered  diversity.  It
was only among the English, and not by them until the time of
Heberden, that varicella  (chicken pox) was distinguished from
small pox.*  Morton, of  the time of Sydenham, speaks of it as
mild small pox.   His cotemporary must so have regarded it, if he
met with  it at all.   And though Heberden, Willan, Rayer and
Mcintosh talk very positively of the distinctions between the
two, yet other writers have  not been able to mark them so clear-
ly.  Thomson, for  instance, maintains varicella, in all its varie-
ties, to be a modified small  pox, and while  Willan recognizes it
only as presented in the serous or vesiculous form, Rayer acknow-
ledges, that it occasionally assumes a pustulous condition.  With
regard to the grade, which is made the source of distinction be-
tween distinct and confluent small pox, it should be remembered,
that Ring has given  us a case of confluent chicken pox, and that
Mcintosh has recorded two  fatal cases, one in a child, the other
in an adult.  Heberden speaks of a malignant sort  of chicken
pox, in which " the continuance of the pain and fever, after the
  * That is, by the profession : nurses and common people had noted and named
these varieties at least half a century before. 
220
eruption, and the degree of both these, though there be not above
twenty pustules, are, as far as I have seen, what never happens
in the small pox."   Chicken pox has been known to pit the skin,
and distinct small pox  often fails to do this.  If we receive the
diagnosis of Mcintosh  and others, who discern chicken pox  by
the succession of crops and pustules, what shall we say to Heber-
den's acknowledgment of his having seen four cases of its une-
quivocal occurrence in small pox?   These are "the only instan-
ces," he says, and his language  is striking, " which have happen-
ed to me, something like what  is often talked of—a second crop.
  It seems to me that  the  above  observations, in making which
I have referred in preference  to the older writers, exhibit plainly
enough the difficulty of distinguishing small pox from its kindred
affections, if  their actual  identity be not established.  The term
varioloid is a new one, first used by Thomson, in his " Account
of the Varioloid epidemic," which prevailed at Edinburgh, in 1811.
Cross gives an excellent history of a similar epidemic, (which,
however, he  terms  small pox,) as occurring at  Norwich.  The
same pestilence, it is asserted, raged about the same time in France,
Italy, and Germany, from which last source it was brought into
America in 1818,  making  its first  invasion in  Baltimore, (Md.)
and Lancaster, (Penn.)   It was first noticed in Charleston in Jan-
uary, 1824.
   Varioloid has been  assumed to differ essentially from variola,
(small pox,)  because first—it affects persons known to have pre-
viously passed through attacks  of regular small  pox;  secondly, it
affects  persons previously  vaccinated; and thirdly, it presents
certain peculiarities of  history and character, which serve as dis-
tinguishing marks.
   The first of these alleged reasons is obviously of no force.   It
was long since observed, that  small pox sometimes failed to de-
stroy the liability to its own recurrence, and instances of its repe-
tition are to be found in all the old writers.   " Petrus Borellus,"
says Heberden, " records the case of a woman who had this dis-
temper seven times,  and  catching it again, died of the eighth
attack."  Dr. Oppert of Berlin, relates the case of a girl, who, at
six  years  of age,  had confluent  small  pox.   Seventeen  years
after, she was again attacked, and died of the disease.   A similar 
221
case is authentically stated to have occurred in this city.   If it is
replied that these cases are too few in number, to affect the gen-
eral rule, that small pox invades the constitution but once, we
readily acknowledge the correctness of the assertion,  and proceed
to apply  the inference to the case before us.  During the preva-
lence of  the epidemic of 1823-24, in Philadelphia, (call  it vario-
loid or small pox,) but sixteen persons are reported,  by Drs. Bell
and Mitchell, as attacked with it, who had previously small pox.
A similar list may be made out of cases of the same  kind occur-
ring here, while the pestilence prevailed  among us, so limited in
number however, as to prove most conclusively, that variola pro-
tects, at least in a certain degree, from varioloid disease.
   With  regard  to  the  second  point  mentioned above, it is only
necessary  to observe,  that no well  informed  physician of the
present day, retains any confidence  in  the absolute preventive
power of vaccine against  the  invasion  of small  pox, however
much he may be disposed  to confide  in  its unfailing modifying
influence.  But of  this, more hereafter.
   Thirdly, the principal peculiarities which are supposed to char-
acterize the varioloid, and to  offer specific marks by which we
may discern it, are,  so far as we have been able to   collect, the
following :
   First,  the eruption comes forth in successive crops.
   Secondly,  the pocks or pustules,  when formed, are conoidal,
without  a central depression.
   Thirdly, they are vesicular, and not multicellular, as small pox.
   Fourthly, they are smaller than the variolous.
   Fifthly, they contain lymph and not purulent matter.
   Sixthly, they dry and fall off without pitting.
   Seventhly,  their progress and  maturation are  unattended with
secondary fever.
   To all these we  would  rejoin, that the  circumstances  above
described are by no means  regular or connected in  their occur-
rence ; and that  if  they were, they would not imply sufficient
distinctness to constitute a separate form of disease.   For,
   First,  in the small pox, the eruption is sometimes incomplete
at first, the pustules appearing to thicken as the disease progresses;
and it is well  known to all nurses, to  be easy to increase, locally, 
222
 the number of pocks, by exposure of part of the body to long
 continued heat, as  by lying on it, wrapping it, or exposing it to
 the heat of a fire.
   Secondly, thirdly, and fourthly, the size and configuration of
 the pustules, vary much in the most clearly defined cases of small
 pox.  Upon the same individual, some will  be seen large, and
 others small—some conoidal, and  others depressed in the centre.
 The internal construction of the pustules,  will be  found to differ
 in  a corresponding  manner;  the  conoidal  are  vesicular—those
 which present the depression in the centre are,  like  the vaccine,
 multicellular, that is, divided  into  many separate cells or spaces.
 If we have not grossly deceived ourselves on many occasions, we
 have further noted that the pock changed  its appearance in this
 regard during its progress; at first vesicular and conoidal, it ex-
 hibited afterwards a depression at  the apex, becoming flattened
 and multicellular.   But upon this, as it is by no means important
 to the argument, we shall lay no further stress, content if we can
 draw the attention of the profession to it by our remark.
   Fifthly, as to the assertion, so often repeated, that it is charac-
 teristic of the varioloid vesicle  to contain lymph or  serum,  and
 not pus or  matter, as the common phrase  is, I affirm on the other
 hand, that  the small pox virus is limpid and colorless.   The most
 experienced inoculators, as for example, Parr and the two Suttons,
 always preferred clear transparent lymph.  It is in the latter stages
 of the  pock, after common  inflammation  supervened upon that
 which is specific and peculiar, that we find  purulent matter; and
 the few cases of varioloid or modified small pox, which  run on
 into this stage, exhibit just as distinctly the formation of pus.  If
 the inflammation of the skin be stopped at  an early stage, we
 prevent this;  and such, as I shall hereafter show, is the most
 important of the train of effects attributed to the vaccine.
  Sixthly,  John  Hunter has somewhere declared, that  in each
 pock of the variolous eruption, a slough of the  cutis  vera takes
 place, answering in  dimensions to the size and form  of the pus-
 tules.  This sloughing  forms the pit or depression left by small
pox, and the circumstance is assumed by him and others__Rin°-,
for example, and Dr.  Adams—to be peculiar to and diagnostic of
small pox, and to depend, not upon the intensity of the inflamma- 
223
tion,  but on its specific nature.   Thus they propose to separate
varicella or chicken pox, from variola or small  pox.   It is easy,
however, to demonstrate the fallaciousness of this test, supported
as it is by the authority of such high names.  A pit is not made
by every small pox pustule.*  In distinct small  pox, and in inoc-
ulated persons, there is frequently left no mark or trace of the
location  of a pock.  Nor can it be doubted, that the chicken pox
and the (so called) varioloid, occasionally, though seldom, produce
similar sloughs or depressions, and so leave marks on the faces of
those who have gone through an attack.
   Seventhly, secondary fever is often wanting  in the mild cases
of distinct small  pox, and very rarely occurs in the inoculated.
Dr. Parr indeed mentions the absence of  it as a peculiar charac-
ter of inoculated  small  pox.   It  is clear,  then,  that no inference
can be drawn  from its absence, of a nature favorable to our op-
ponents.  It arises like  the secretion of pus  from the irritation
of the cutaneous surface, and  is proportioned  in degree  to that
irritation.  It is, therefore, met with now and then, both in vari-
cella and varioloid.
   I believe varioloid to be identical in nature with small pox, be-
cause they are promiscuously capable of producing each other.
 The modifications which have been noted and discussed, I attrib-
ute  in a vast majority of the instances presenting themselves at
 the  present day, to the influence  of  vaccine,  of  which  I shall
speak presently.   In others,  (for they are confessedly irregular,)
 to certain indefinable and varied peculiarities of constitution, or
 habit, or condition of body in the affected subject.
   Under this  head of varioloid, I  unhesitatingly coincide with
 Dr. Thomson  in comprising varicella, (chicken  pox.)  This gen-
 tleman  entered upon the course  of observations, upon the Edin-
 burgh epidemic, made  by him with so much care and nicety, a
 thorough believer in the opinions of Heberden  and Willan, with
 regard to the  separate  and independent nature  of chicken pox.

   * Goethe, when a child, at Frankfort, was attacked by small pox there—long
 ill—but had the good fortune to escape without being disfigured.
   Mary, Q,ueen of Scots, so remarkable for her exquisitely fascinating beauty, had
 the small pox in her early childhood—but, says Bell, " It must have been of a par-
 ticular gentle kind, having left behind no visible trace." 
224
His candor, however, did not long permit him to remain the ad-
vocate of this view of the matter.  " During the epidemic, I had
occasion," he says, " to observe natural small pox, modified small
pox, and the disease which  I had been accustomed to regard as
chicken pox, co-existing in the same situations, and appearing in
their progress to produce one another.   In three families in  par-
ticular, situated at a considerable distance from one another,  and
between which, except through their medical attendants,  no sort
of intercourse had existed, my attention was strongly excited by
observing chicken pox arise in unvaccinated children, from the
contagion of malignant small pox.  The occurrence of this event,
in circumstances which left  no  room for doubt, because there ap-
peared to be no possible source of fallacy in the observation, led
me to conceive  that all the various appearances of the epidemic,
in the  different classes of persons whom it attacked, might be
produced by the operation of one and the same contagion."
   Phenomena precisely similar have occurred under my own ob-
servation, in the several invasions of this eruptive disease, call it
what you will.   Such of my patients as had not been previously
vaccinated, or had not had the small pox, exhibited for the most
part the regular symptoms of variola,  as it  is  found described in
the books and recognized by the best authorities.  Those, on the
other hand, who had been protected by either of the above means,
had the disease modified variously, and  in different  degrees of
mildness—some of them  scarcely, others not at all, distinguisha-
ble from varicella.  That the  same contagion is capable of pro-
ducing these several forms of variolous disease, whether  regular
or in any manner modified, is not only proved by their occurring
thus together spontaneously, or in the natural  way, but has been
definitely established by repeated inoculation with the  matter of
the modified vesicle,  varioloid  or varicelloid,  in which  regular
well-marked small pox was the result  of  the insertion of  the vi-
rus.  Among such examples, the case  of Dr.  Hennen's  son, of
Edinburgh,  is most worthy  of being detailed.  This  boy, from
whatever source infected, was  seized  with an eruptive disease,
concerning which Dr.  Thomson thus explicitly expresses himself:
   "If  I had been requested  to point out the case,  which seemed
to me  to correspond  most  accurately with the descriptions of 
225
chicken pox, I should certainly have fixed upon the eruption of
Dr. Hennen's boy."  It was the circumstance of Dr.  Hennen's
viewing  the disease in  his son, as a well marked example of
chicken pox, that led him to think of instituting the experiments
which produced such interesting results.   These results may be
stated  briefly, as follows:  In four children  inoculated from the
above  case, the disease was mild, and of short duration—vario-
loid or varicelloid;  in two, it exhibited  the appearance of small
pox.   In  three men, who caught the infection from sleeping in
the same rooms with these inoculated children, the disease was
" uncommonly severe"—not to be distinguished from small pox;
and in a fourth, under  the same circumstances,  " the mildest
variety ever described of chicken pox."
   Upon these grounds, then, I cannot help reprobating the intro-
duction of a new  term, the  application of which is not  only
unnecessary, but calculated to  confuse and lead into error.   The
modifications which have been assumed to constitute  a separate
disease, dignified with  the  specific  appellation of varioloid, are
each  and all of them  to be found described  by the old writers,
under  various names.  Thus  we have  from Dr. Huxham,  " an
Account of an anomalous  form of  Small Pox at Plymouth, in
1741."  Thus we meet among the old writers with the phrases,
horn pock, stone pock, water pock, wind pock,  crystalline pock,
swine  pock, sheep  pock, chicken pock, and numerous others, by
which they intended to point out the undefined, but not uncom-
mon varieties, which the variolous eruption occasionally assumed.
I have already remarked that  chicken pox was  familiarly recog-
nized  as one of  these varieties until the  time of Heberden,  who
separated  it under  the  name  of  Varicella or Variola  pusilla, in
which he was  followed by Willan.  I  now add, that Dr. Bate-
man, closely as he was attached to Dr. Willan's views in general,
found  reason to doubt their correctness in this  particular, as ap-
pears  from an extract of a letter, written by him to Dr. Howitz,
of Copenhagen, in which he says, " I am much inclined to concur
with you in the supposition, that chicken pox is, in fact, modified
small  pox."
   These varieties and irregularities formerly noted of variolous
disease arose from  peculiarities of constitution probably, in some
                             29 
226
instances;  in others,  from local or general condition of atmos-
phere, habits,  manners,  &c, and perhaps in most,  from causes
entirely unknown and unassignable.
  To  all these is  now added, a more general and an  uniform
disturbing  cause—the influence,  namely,  of the  vaccine; and
hence, at the present  day,  these variations and modifications are
more regular,  and better defined than they were  of old, as well
as infinitely more frequent.
   Vaccinia, the vaccine,  derives its origin  from the cow, (vacca.)
It was first made  known  to the medical  profession in 1798, by
the justly celebrated Dr.  Jenner, whom we rank, unhesitatingly,
among the greatest benefactors of the human race.  The history
of vaccine is an exemplification of the acuteness of the remark of
Southey, in his Omniana,  " that most things are known before
they  are discovered." Prela,  physician  to  the  Pope in  1825,
contends, plausibly, from passages in Pliny and Celsus,  that the
vaccine was  known to the ancients, under the name of boa.  It
had been long observed,  in Gloucestershire and Dorsetshire, two
of the dairy counties of England, that their cows were occasion-
ally affected with a species of ulceration about the udder, which
communicated to the hands of the milkers a pustular eruption.*
The  occurrence of this  eruption was  noticed to have conferred
upon  such  persons a security against the casual infection of small
pox, and such was the " general opinion," says Parr, " that the
inoculator, who attempted to convey the small pox to one who
had been  thus previously affected with vaccine, was ridiculed."
There was no difficulty  in following up so plain a hint, and the
artificial communication of this disease, as  a preventive of variola,
  * It has been attempted to trace this affection of the udder of the cow to the
grease, a disease familiar to grooms, as attacking the heels of horses—the same
hands being employed, as is affirmed, in the stable and the dairy.  Both are again
derived from the small pox itself, the matter of which is argued to undergo, when
brought into contact with these surfaces in the lower animals, the changes observ-
ed.  I am not satisfied, however, either with the facts or the reasoning adduced
on this head.  I also regard as unworthy of notice, the assertions of Ozanam and
others, concerning the conversion  of variolous into vaccine matter, by simple mix-
ture of milk from the cow.  But I should  be  glad to have made,  in our own
country, some decisive experiments in respect to the transmission of small pox
through the cow, by inoculation of the udder. 
227
was tried first by a farmer of that country, and  afterwards by
Dr. Jenner, with the most satisfactory results.  The early wri-
tings of the latter on this subject were received with scorn, and
his papers refused publication among the Philosophical Transac-
tions.  It however forced its way into notice; the value of the
discovery was, after vehement and angry debate, established on
the most authentic basis, and the  zeal of its  promulgator amply
rewarded by the British parliament.   Since that time the vaccine
has been extended all over the globe,  and all  nations of mankind
have exulted  in the benefits thus bestowed upon  them.  It was
first introduced into this city by our highly esteemed historian
and practitioner, Dr. David Ramsay.  To the present time it has
enjoyed the undoubting confidence of the profession, with scarcely
a solitary exception,  and at once superseded, and almost entirely
suppressed, the practice of inoculation.
   Vaccination  is performed by introducing, under the cuticle, a
small portion  of lymph, taken from a vesicle about  the eighth,
ninth or tenth  day,  while yet the fluid distending the vesicle is
transparent and colorless.  The .puncture remains  unchanged
until the  third or fourth day, when slight elevation  and inflam-
mation are perceptible, which increase slowly.   About the sixth,
it assumes a regular circular form, with a depression in the centre.
The vesicle is completely developed on the eighth or ninth day,
and attains  the average diameter  of one-third of an inch.  An
areola now surrounds it of an intensely florid red color, and some
febrile excitement of the system is perceptible, with stiffness, pain,
and slight swelling under the arm,  if the vaccination  be perform-
ed  about the usual spot, above the, elbow.  The diameter of the
areola  differs  from  one  to two inches.  It  is attended with a
degree of roughness, hardness and  intumescence of the skin over
which it spreads—circumstances which denote its existence and
extent in the black.   The vesicle  is  multicellular, that is, com-
posed internally of numerous spaces or little cells, which commu-
nicate freely with each other.  The fluid  within  these cells
begins to dry away on the eleventh or twelfth day, having pre-
viously lost its transparency, and become milk or straw colored;
the  areola at  the same time  declines, and gradually disappears.
About the  twenty-sixth day, a hard  round  scab of mahogany 
228
color, smooth  on the outside  and remarkably hollowed nn the
centre, falls off, leaving a permanent cicatrix or scar of peculiar
and characteristic aspect—its surface being marked with minute
pits or depressions, similar  to  those on  the head of a thimble,
"denoting," probably, " the  number of cells of which the vesicle
had  been composed."   It has been observed that,  in variolous
inoculation, the vesicle forming at the point of insertion has been
attended by the eruption of others in different parts of the body;
but as respects vaccine, it is a fact of very rare occurrence.   Two
such instances, however, have been communicated to me authen-
tically.
  I shall not attempt to describe any of the numerous deviations
from the above  history, which are to be met with in the irregu-
larly diversified  forms of what are called  " spurious vesicles."
Suffice it to say,  that any striking or obvious departure from the
ordinary phenomena, in the  progress of a vaccine pustule, should
make us cautious of confiding a patient to its protective influence.
Vaccine, like every other disease, may undergo certain modifica-
tions from the condition of the recipient, an infinite majority of
which  are  slight and unessential, not affecting its character and
influence, nor impairing its genuineness.   Others there are, how-
ever, though  few in number, which change the nature of the
specific action, either locally, or in its effect upon the  system, and
thus render it " spurious."  Of the  local modifying causes, the
principal and  most common is the mechanical irritation of the
vaccinated spot,  (as by rubbing,) by which a common inflamma-
tion is  substituted for the specific, and a eommon sore produced.
Erysipelatous  inflammation may also supervene,  and  interfere
with the formation of a regular vaccine pustule.   Vaccine may,
perhaps,  be affected by or combine  with some forms of constitu-
tional disease, and thus take on a hybrid state.  All  cutaneous
affections disturb  the  regularity of its  progress, if  they do not
hinder the success of the operation, and  no physician vaccinates
as willingly from a pustule  on  the arm of a patient  known to
labor under  scrofula,  herpes,  or lues venerea, &c.  as from a
healthy subject.   There is a lurking doubt, in the mind of every
one, however scornfully he may regard the humoral pathology, 
229
whether he may not,  by vaccinating from such a case, commu-
nicate a mongrel disease.
  I am disposed to lay some  stress  upon the progress of matura-
tion  of the vesicle,  although this  may be  slightly hastened or
impeded, without detracting from the value of the pustule.  Thus
the temperature of the season, if high, may occasion it to antici-
pate twenty-four or thirty-six hours perhaps ; and  severe cold on
the contrary,  by checking the cutaneous circulation,  may retard
it in an equal  degree.  The debility or robustness of the subject,
may give rise to like results.
   The pustule should  be prominent and  clearly defined, and the
areola distinct and vivid.   There should attend, some febrile dis-
turbance of the general system.   The appearance of  the scar, as
above described, I consider as of much importance.   We should
re-vaccinate when this peculiar appearance is wanting, and when
the scar is smooth and resembles that of a burn.
   I do not  find the  observation made  by any writer, but I  have
certainly noticed the occurrence of a doubtful or spurious vesicle,
to cause much difficulty in procuring,  subsequently, the satisfac-
tory results of vaccination in the production of a regular or genu-
ine pustule.
   Vaccination is, of course, best and most successfully performed
with fluid lymph, taken  immediately  from  the vesicle, but this
simple  mode  of communication is  not always possible.  When
required to be transported to a distance, or kept for any length of
time, it may  be preserved by  various  methods.   The fluid is
caught on a small plate of glass, which is pressed closely against
another of similar size and shape,  and the  edges  waxed, to pre-
vent the  access of  air.   We receive  it on  the points of quills,
likewise protected from  the  air  by envelopes.  Cotton thread is
dipped in it, and laid aside with equal care.  But in the scab we
have the most convenient means of preserving and transporting
this invaluable agent.   It has been kept for years, and found ca-
pable of communicating the  genuine disease, just as when recent.
It may be protected from the contact of air and moisture, by im-
mersion in softened wax and spermaceti.  It is scarcely necessary
 to remark  that the  first  scab  alone possesses the specific  vaccine 
230
character;  if this falls off, or is rubbed off too early, another may
succeed it,  but possesses none of its useful properties.*
   Some have strenuously argued the propriety of recurring occa-
sionally to  the udder of the cow, the  original source of vaccine,
to ensure its genuineness, and renew it from time to  time ; but it
may now be looked on as settled, that its primary and essential
characteristics are unchanged and unimpaired,  by any imagina-
ble number of transmissions.  Nay more, it is  obviously impro-
ved by thus passing through the human system; it is so modified
as to have  become a milder malady, though not less effectual in
its influence on the constitution.   A person inoculated directly
from the cow, always suffers more,  much more it is said, than one
who receives the infection from a human vesicle, and as far as has
been ascertained, with no corresponding advantage to compensate.
   Among  the animals which  have been found capable of receiv-
ing and  communicating the  vaccine,  are the horse,  the  ass, the
camel, the buffalo, the goat, the sheep, and the baboon.
   It has been doubted whether variola does not exert a reciprocal
influence  upon  the vaccine—whether it tends  to prevent  its in-
troduction  into the system, or in any  manner or degree modifies
it, and  disturbs its regularity when so received.  But the most
positive proof has been obtained, of the transmission of perfect
vaccine, through constitutions previously subjected  to the vario-
lous impression.   It has been in this way brought across the At-
lantic, by  the successive vaccination  of individuals, among the
passengers and crew of the vessel, many of whom  were known
to have had the small pox.
   Much has  been  said of the difficulty of communicating the
disease more than once to the same constitution.   Gregory, of the
small pox  hospital, declares that " it is impossible, or nearly so, to

  * It is difficult in this latitude, to preserve any form of vaccine matter, (even the
scab not excepted,) through  one of our summers.  The heat and moisture of our
climate, in the warm months, occasion it to undergo a deterioration or decomposi-
tion, which renders it unfit for use—at least, such  has been the uniform result of
numerous experiments, made with the greatest nicety and care.  If we fail in trans-
mitting the vaccine from one subject to another, in continuous succession, through
the summer  and autumn, we find ourselves under the necessity of obtaining a new
supply from  our more fortunate brethren elsewhere. 
231
reproduce the vaccine in any thing like its genuine form, where
the cicatrix left by a preceding pustule is perfect, and  the result
of a perfect vesicle."   Dr.  Darrach,  of Philadelphia, in experi-
menting on this subject, found  that the repeated insertion of the
matter in the arms of vaccinated children occasioned a local dis-
ease, exactly similar to that  produced  by the first operation, with
the exception that the pustule and scab were much diminished in
size.   In none of these cases could fever, or any other constitu-
tional  effect, be  discovered.  Unprotected children were, with
complete success, vaccinated from one of these scabs not larger
than a line, (one  twelfth of an inch in diameter,) which  was the
result of a fourth insertion of the virus.
   The duration of the  influence of the vaccine—the permanen-
cy rather of the effect which it has wrought upon the system—
has been denied by some who are staunch believers in its tempo-
rary power to destroy the susceptibility of the body to the inva-
sion of small pox. But the mass of facts collected under this
head, certainly goes to prove, that whatever may be the result of
the vaccine inoculation—whatever the impressions made by it up-
on the organism—this result, these impressions, are not likely to
be impaired or obliterated by any process of  time, or any chan-
ges in the state of the system from any cause.  Of two  hundred
and fifty cases collected by Dr. Gibson,  "in which small pox is
said to have occurred after vaccination, it appears that by far the
greater number had been vaccinated less than two years."   In
Dr. Thomson's account of similar eruptions, they occurred at va-
rious intervals after vaccination, from a few days to fifteen years,
not warranting, in any degree, the suspicion that the power of the
vaccine is weakened or exhausted by time.
   To ascertain the true influence of vaccine upon small pox, is
an object of the utmost importance.   I will, therefore, briefly and
formally recapitulate the points fairly established, by a due con-
sideration of the  facts collected on every side.
   First, Vaccination is no longer to be regarded as exhibiting the
 absolute power of preventing the access  of small pox.  In some
 persons it does  seem completely to  destroy the susceptibility to
 variolous contagion ; in all it diminishes notably,  though in dif-
 ferent  degrees, the liability to  be infected. 
232
   Second, The introduction of the vaccine virus into the system
in its genuine form, and in the proper manner, never fails to pro-
duce there such changes as to modify certainly the future influ-
ence of  the variolous poison,  if, under  any circumstances,  it
should affect the constitution.
   Thirdly,  The modification thus  asserted, does not appear to
consist essentially in a diminution of the violence or duration of
the first stage, the eruptive fever.  This, though  it is in general
very slight, may be as severe as in casual  small pox.
   Fourthly, Nor does it appear to imply essentially a diminution
of the quantity of eruption upon the skin, although the number
of pustules is usually very limited in small pox after vaccination.
   Fifthly, The great power of the  vaccine unquestionably con-
sists in modifying the progress of inflammation in the variolous
eruption.   Hence,  the slighter degree of cutaneous irritation,
which terminates in numerous instances without secretion of ei-
ther lymph or pus—the less amount of matter formed in the pus-
tules (when effusion does occur)—the sudden check given, in a
majority  of cases, to the suppurative process after it has commen-
ced—the early disposition to rapid drying.  Hence, the absence
or transient duration of ophthalmia, which, with ulceration of the
cornea and destruction of the eye, constitutes the worst and most
unmanageable sequela of unmodified small pox.  Hence, the rare
occurrence of sloughing of the cutis, and consequent pitting,
seaming and scarring  of the skin.   It has  now become,  happily,
as unusual as it once was common, to see a person deformed with
these marks of small pox.  Hence, lastly, the infrequency of what
is termed secondary fever, and its mildness when it does show it-
self.   This is well known to be the most dangerous of the  seve-
ral stages of unmitigated small pox;  it is tedious in duration, and
leaves  scarce one constitution in a thousand, without inflicting
severe injury and  permanent deterioration.  The  convalescence
from small pox is, on this account, in the unprotected, notorious-
ly slow.   On the other hand, there is no convalescence more rap-
id or more perfect, than that of  a patient who has been assailed
after vaccination.   He recovers both perfectly and promptly.
   "Observe," says Dr. Gregory, "how strikingly opposed to (con-
trasted with) each other in this respect, are the influences of in- 
233
oculation and  vaccination.  Inoculation lessens the quantity of
eruption, but does not alter in the slightest degree the progress of
inflammation in that which is thrown out.  Vaccination on  the
other hand, while it does not  (necessarily) affect the quantity of
eruption, always influences  more or less the progress of inflam-
mation in it."
   Sixthly, Nor can it be denied, that as far as we have a right to
draw our  conclusions from the tables of mortality, published in
reference  to this question, vaccination  tends much more surely
and effectually to the prevention of fatal results, than inoculation.
Thus among the cases stated to us by Doctors Bell and  Mitchell,
as occurring in Philadelphia in 1823-24, out of 248, 64 had been
previously vaccinated, 1 only died; 7 had natural small pox pre-
viously, three  of these died;  9 had been  inoculated, 3 of these
died;  13 unknown, no deaths.   Of those entirely  unprotected,
(155 in  number,) there died 85, more than  one  half—a dreadful
mortality.
   It is surely impossible to set in  a stronger light the advantages
of vaccination, than is done  in the above  paragraph.   Results
similar to  these are given in the annual reports  of the  National
Institution of Great Britain, and in every other  authentic docu-
ment, without exception, to which we have access.
   In our own  community, variolous and varioloid  diseases have
prevailed repeatedly.  I give a list of the deaths, extracted from
our annual bills of  mortality, as follows:
   1824,     small pox,  1       swine pox, 1
   1825,        "    "   49
   1826,        "    "   29
   1827,                         swine pox, 1

   1 82q'  C   no aeatns recorded.
   1830,     small pox, 17       varioloid,   4.—Total,  102.*
Of whom, as far as I could ascertain, on the most diligent inqui-
ry, but one was known to have been previously  vaccinated.

  * The greatest number of cases occurred in 1829-30.  Vaccination had then been
uried extensively. The city and suburbs contain a population of 40,343.  During
the whole of the above period, cases of small pox were occasionally brought into
the harbor by vessels from infected ports.
                              30 
234
  If we ask, how has this ancient and justly dreaded pestilence
been deprived of its terrors, and shorn of its fatal energies, what
shall be the impartial answer ?   Not by any change in the nature
of the case, not by any loss of its inherent power over the human
constitution, for the mortality among the unprotected is most ap-
palling—greater than  that of yellow fever, or perhaps even the
plague,  amounting every where, it would seem,  to fully one half.
Nor is it owing to such  protection as inoculation affords,  for that
practice has been obsolete among  us for the last  quarter of a cen-
tury.   But it is clearly attributable,.and we do not hesitate to as-
cribe it, to the kindly influence of the vaccine—the most valua-
ble among the generous benefits conferred upon  their fellow men,
by the cultivators of the divine art of healing.

                        MEASLES.

  Morbilli—Rubeola.—A specific form of fever, eruptive, con-
tagious, inflammatory.   It is often epidemic as well as contagious.
It is difficult to communicate by inoculation, but Home and Spe-
ranza affirm their success—employing blood taken from the vivid
patches of eruption.
  Symptoms.—Rubeola makes its appearance with the ordinary
tokens of catarrh.  There is rigor often, followed by heat  of skin,
headache, hard and frequent pulse, soreness of throat,  watery red-
ness of the  eyes, sneezing, a hard and dry cough,  nausea and
retching.  In  children,  convulsions  occasionally  attend.   This
state of things may continue for many days, but usually on the
fourth  the eruption  breaks forth,  at first  visible on the face and
arms, gradually spreading over the body.  It is in patches of small
red spots, rough and  a little elevated.  The fever generally abates,
but not  always on its coming out.  The eyes suffer  much,from
it, the adnata being covered and  the lids swollen.  It begins to
fade on the seventh, and  soon dies away, the cuticle  desqua-
mating  in minute branny  scales.  In the progress  of measles,
or at the  subsidence of the eruption,  pneumonia is  very apt to
develope  itself.   At this latter period,  diarrhea of  very obsti-
nate character  often arises.  Rubeolous ophthalmia is apt to be
persistent. 
235
   The prognosis in measles is generally favorable, and the  dan-
ger is fairly  proportioned to the attendant  maladies above men-
tioned, the pulmonary  inflammation especially.   In children the
convulsions are occasionally, though not often, fatal.   It some-
times  happens that the fever  is of low typhous type, which
is unfavorable.  The "striking in,"  or sudden  disappearance of
the eruption, is also unpropitious,  and  excites well grounded
alarm.
   The diagnosis does not seem to me difficult; yet it  was not
until nearly the end of the  17th century, that measles were sep-
arated from small pox, a confusion  which we should now regard
as impossible.
   It may be  confounded with scarlatina, which  has indeed been
called confluent measles.  This very phrase  suggests a distinc-
tion, for the  patches of rubeolous eruption  are usually separated
by notable intervals.  In 1829, however, I saw some cases in
which they were nearly confluent.  In scarlatina the deep diffu-
sed redness of the tongue and mouth is diagnostic.  The catar-
rhal affections are  prominent in measles—the sneezing, cough-
ing, &c, and the ophthalmia, which is often absent and very sel-
dom severe in scarlatina.
   Pathology.—One might  almost venture to  declare that  rube-
ola consists in the combination of some peculiar exanthema with
catarrhal fever.  This affects the human constitution but once, a
rule presenting very few exceptions.  The eruption may occur
alone, a circumstance not unfrequently met  with  in  rubeolous
epidemics—the Rubeola incocta of Good, R. sine catarrho of Wil-
lan, the bastard measles of common people.   Now  by  this form
the susceptibility to a second attack is not destroyed nor even im-
paired.  Other varieties of measles are noticed by writers—R.
nigra, R. maligna,  R. variolosa.   I have met with none of these.
The concurrence of measles with typhous fever, presents a livid
eruption, with great danger, a compound of nigra and maligna.
   Treatment.—It  often  happens that  the  catarrhal symptoms
which precede the eruption, are not sufficiently severe  to call for
any remedial management,  and the  nature of  the  case is first
shown by the appearance of the red patches  on the surface.   Un-
der such circumstances it is best not to interfere, farther than to 
236
keep the patient at rest in bed, and on low diet, regulating prop-
erly the temperature of his  apartment, which should be  mode-
rately but not unpleasantly warm.   But  in a proportion  of the
cases, something more will be required.   If there are tokens of
pulmonary inflammation, and the pulse will bear it, venesection
should be freely resorted to, and the use  of the lancet followed
by the administration of  cathartics,  combined with  diaphoretics,
as the solution of Epsom salt in the infus. rad. serp.  The vas-
cular excitement being thus reduced, the diaphoretics should be
continued, with  some demulcent and anodyne preparation, to re-
lieve cough and procure  rest.  Cups or leeches to the  chest may
be demanded, and the thorax enveloped in warm poultices, if the
dyspnea be severe.   In children affected  with much gastric dis-
order and convulsions, the emetic is useful—given perhaps while
the  subject is in the warm bath, and followed by a mercurial
cathartic.   The  eyes should be kept clean with  tepid water at
first, and  afterwards washed with mild  astringent  collyria.  If
diarrhea  comes on upon the  subsidence of the eruption, small
doses of opium will restrain it,  aided by  the cretaceous mixture
with kino, or by small doses of acet. plumb.
  The pectoral uneasiness  remaining after measles,  is best re-
moved by the persevering application of successive blisters to the
chest, or  the irritation of the  tartar emetic ointment, while we
administer full doses of Dover's powder nightly.
  The sudden disappearance—" striking in"—of the eruption, is
always  alarming, and apt  to be attended with  convulsions in
children;  and in adults, with dyspnea and  abdominal distress.
If the pulse be full and hard, we must bleed freely ;  but if on the
other hand, as is more common,  the  patient has sunk into a sort
of collapse, we must resort  to  the  highest order of stimulants.
The hot bath, of 100° Fah. at least, must be made  ready, while
we  apply sinapisms  to the  cold and pale, or livid  surface; the
camphorated  tincture of opium, with the  volatile alkali, and  hot
wine or brandy,  must be  given  boldly and in  abundance, until
the skin becomes warm and the pulse rises.
  When rubeola is accompanied with fever of typhous character,
it is proper to premise a mild emetic, after which a mercurial ca-
thartic will be  of service, followed promptly by the stimulating 
237
diaphoretics, which should be persevered in, adapting  the doses
to the condition of the patient and the effect produced.
   The convalescent from measles requires to be treated with cau-
tion.  His diet must be mild and unstimulating, though nutritious,
and he must be clad warmly, and guarded from all exposure.

                      SCARLATINA.

   Scarlet  fever.—A contagious,  eruptive, pyrectic  disease,
characterized by a peculiar efflorescence of a very florid red hue,
whence the name designating it.   First described about the mid-
dle of  the 17th century.   It  is often epidemic, as well as conta-
gious.   It has been communicated  by inoculation, and  as has
been asserted, with the same effect as in small pox,  of procuring
a milder disease.   As a general rule,  it attacks but once the same
subject.
   Scarlatina is divided by writers, commonly, into three varie-
ties—S. simplex, S. anginosa,  S.  maligna.   I regard these as
mere differences in degree of violence and intensity.  The attack
is ushered in with irregular shiverings, attended by oppression at
stomach,  and  nausea, with  occasional  vomiting; then succeed
heat of skin, thirst, frequent pulse, and headache, with sometimes
delirium.   The eruption appears generally on the second day, but
may postpone until the 3d or 4th,  showing itself first on the face
and neck, and gradually  spreading over the trunk and limbs, un-
til it almost covers their surface.   On the succeeding day, the li-
ning membrane of the mouth, fauces and pharynx becomes infla-
med, with ulceration of the tonsils and uvula, in the anginose
form.  The tongue  throws off its fur and assumes a deeply red
color, the surface being at first smooth, but soon shining with el-
evated and projecting papille ; it is acutely sensible to the touch,
or to the application of temperature either above or below its own.
The efflorescence, which in many  cases is almost confluent, is
bright  red, hot, dry, little elevated or rough, indistinctly papular.
The skin seems thickened.   On the 5th and 6th days it begins
to fade, and desquamates gradually in minute branny flakes.  At
this time the hands and feet are swollen, and for some short  peri-
od the new surface remains morbidly sensible, especially that of 
238
the mouth.  The  inflammation in the anginose form, is not al-
ways attended with ulceration, but  sometimes the tonsils, &c.
are covered with flakes of lymph or false membrane.
  In bad cases the eruption comes out irregularly, and is ready to
recede.   When this occurs, congestion or inflammation of some
internal organ  is prompt to follow, and we have either dyspnea
with thoracic pain, or vomiting and purging, or convulsions.   If
the patient be  not quickly relieved, the pulse sinks, the counte-
nance becomes ghastly, the complexion pale  or livid, the skin
cold, and death rapidly haptens on.
  By the term Scarlatina maligna, I would designate those cases
in which the fever assumes the typhous type.  This is common
in some localities,  where  of course the epidemic  visitations of
scarlet fever are highly dreaded.   The eruption in  these attacks
may be  early or otherwise.  The throat is affected with ulcera-
tion, which has a tendency  to slough, is of ash color, and gives
out a fetid odor, and an acrid discharge, excoriating the nostrils,
offending the stomach and intestines, and producing vomiting and
purging.  The internal  organs are often attacked at the  onset;
there may be delirium, often quiet and playful—dyspnea with
mucous rale, and intestinal or peritoneal inflammation.   The ter-
mination of  this variety is often  fearfully  hurried, taking place
from the 3d  to the 5th day.  Recovery is very slow  and for a
long time doubtful.
  The convalescence from scarlatina is attended in many cases
with anasarca, and in some with general dropsy.  It is not so  apt
as measles or small pox to leave permanent sequele, affecting  the
thoracic or abdominal viscera.
  Autopsy.—The appearances  on examination after death, vary.
In some, there is engorgement of the brain, and  vascularity of
the membranes, with effusion.  In others, the lungs are congest-
ed and hepatized;  in others still, there is injection of the mucous
surface of the stomach and intestines.  I have had  no  opportuni-
ties of personal observation, having lost but a single case of scar-
latina, which I was not permitted to inspect.
   Diagnosis.—I have not found it difficult to distinguish  scarlet
fever from measles, which it most resembles, by the want of  ca-
tarrhal symptoms in the fever  of  incubation—by the confluent 
239
extension and peculiar appearance of the eruption, which in mea-
sles is in patches, more distinctly papular and more prominent.
The scarlet tongue, with elevated and swollen papille, is also
characteristic.   They differ much in the sequele to which they
subject the patient.   The books make a confusion between Scar-
latina and Cynanche maligna.   In the instances of the latter for-
midable pestilence which I have met with, the eruption was not
general or much diffused, and the tongue continued furred thick-
ly to the end.
   Prognosis.—Scarlet fever, as it prevails in this city, (and it is
of frequent  occurrence,) assumes usually  a mild form, and  the
proportion of deaths is small.   The  type of fever in the first
place, and in the second the degree in which the internal organs
suffer, would indicate  the force of the attack.  Thus, if there
were delirium or convulsions, or the ulcers of the throat assumed
a  gangrenous aspect, or  dyspnea  supervened, and especially if
with any or all these there were combined a disappearance of the
rash or efflorescence, we should know the patient to be in serious
danger.
   Treatment.—In general, it will be sufficient to commence the
management of the case with a mild cathartic.   For children, I
prefer the castor oil;  in adult cases, a combination of Epsom salts
with magnesia, or rhubarb, and some aromatic.  In the great ma-
jority, no farther interference will be necessary.  Small doses of
tinct.  op. camph. are useful to tranquillize  the restlessness of the
patient, and determine to the surface.   Attacks of more than or-
dinary violence however occur, in which we are called on for far-
ther aid.   If the vascular excitement be  specially high, it may
be reduced by the lancet.  The throat being much inflamed, we
may apply leeches at the angle of the jaw or on the neck.   An
emetic will  relieve  occasionally the oppressed  stomach, if it be
not emptied by spontaneous vomiting.   After the eruption is fair-
ly out, the cathartic should be  abandoned, and the case trusted to
diaphoretics.
   Currie, Gregory, and other high authorities, advise strongly the
cold affusion in scarlet fever, and attribute to it  the best results;
while, on the other hand, those who consider the cutaneous erup-
tion in the exanthemata  as a metastasis from the mucous  mem- 
                            240

branes, which they regard as the seat of primary irritation, dep-
recate  the application of cold  water,  as  extremely dangerous.
Truth lies between them—but in general we may decide that
the remedy, though safe, is not necessary, nor capable of the stri-
king good effects which some would teach us to expect from it.
Should any form of visceral inflammation arise in the progress of
the case, it must be combated with the usual remedial measures.
I am not aware that the connection  with scarlatina, modifies the
necessary treatment.
  In Scarlatina maligna, it  is prudent  to begin with a prompt
emetic, followed by a mild dose of calomel.   The cordial diapho-
retics are early  required, and may be combined with other stim-
ulants in requisite amount.  Cinchona, the  volatile alkali, and the
tinct. op. camph.  are among our best remedies.  The hot bath
should be used, if the surface is cold and pale or livid, and sina-
pisms extensively applied.  If the bowels are not moved by the
mercurial, enemata should be administered.   The throat should
be washed with tepid water and steamed, and if there be from
the ulcers much fetid discharge, which may irritate the stomach,
the emetic may require to be repeated.
  Great confidence is  placed by many practitioners, in the  exhi-
bition of the infusion of Cayenne pepper, both as a local correc-
tor of the morbid condition of the gangrenous ulcer, and as the
stimulant best adapted to the exigencies of the case.
  The dropsical affections which supervene so often during con-
valescence from scarlatina, must be  treated as formerly advised,
under the head of Hydrops,  with this modification, that they al-
low and require an early and free use of tonic and aromatic for-
mule, as the infus. cinchon. with rad. serp. and camphor, in small
doses, with nitrat. potass, and nitrous ether.
  I ought not perhaps  to omit, that  the German  homeopathists
propose the use of belladonna as  a preventive of  scarlatina in all
its forms.   They imagine it to excite a state of disease similar
to, or identical  with scarlatina.   The speculation  is ingenious,
but it is not sufficiently confirmed.   My own experiments with
the belladonna have been altogether unsatisfactory. 
 
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