DUE TWO WEEKS FROM LAST DATE £» LDEC 2 o 1949 J ESSA.YS >sc.-£JL5 PATHOLOGY AND THERAPEUTICS, BEING THE SUBSTANCE OP THE COURSE OF LECTURES DELIVERED BY SAM'L HENRY DICKSON, M. D., PROFESSOR OP THE INSTITUTES AND PRACTICE OF MEDICINE, IN THE MEDICAL COLLEGE OF THE STATE OF SOUTH-CAROLINA. VOL. I CHARLESTON: McCARTER & ALLEN, CORNER OP MEETING AND PINCKNEY STREETS. 1845. ANNEX • • • WB 3)S54e. Y. I Entered according to the Act of Congress, in the year 1845, by SAM'L HENRY DICKSON, M. D., In the Clerk's Office of the District of South-Carolina. BURGES & JAMES, PRINTERS, No, 6 Broad-st., Charleston. TO N. CHAPMAN, 1L I). PROFESSOR OF THE INSTITUTES AND PRACTICE OF PHYSIC AND CLINICAL- PKACTICE IN THE UNIVERSITY OF PENNSYLVANIA, In testimony of THE HIGH RE6ARD ENTERTAINED for HIM BY ONE WHO, WITH HUNDREDS OF OTHERS, RECEIVED THEIR FIRST AND MOST AGREEABLE LESSONS IN THE STUDY OF MEDICINE, FROM HIS PUBLIC LECTURES—A SERIES OF DISCOURSES DISTINGUISHED FOR THEIR INGENUITY, USEFULNESS ANB ELOftUENCE:— .8 THIS WORK IS RESPECTFULLY DEDICATED, BY THE AUTHOR, fc PREFACE, It had long been my intention, in compliance with a wish repeat- edly expressed by the classes in attendance at the Medical College of the State of South-Carolina, to publish, as soon as I could devote myself to the preparation of such a work, a complete and systematic Treatise on the Practice of Medicine. But, I have now, neither the ambition to attempt the task, nor do I imagine, that the advantage to be attained by its performance, would be, in any degree, commensu- rate with the sacrifice of time and labor which it would demand. The field is fully occupied, at least for the present; and the student or young practitioner, who has in his hands the volumes of Craigie, Copland, Dunglison, and Mackintosh, can require nothing more of that compendious and extensive character. Besides this, the real utility and success of a different class of writings, in style and manner less formal and more popular—Elliot- son's, Graves', Stokes', Chapman's, and Watson's Lectures, have decided me to give to the press, with little alteration, the substance of the Essays which constitute my College course of instruction. No one who will read them, can be more fully aware of their imperfections than I am; yet, I will venture to entertain the hope, that they may present some views worthy of consideration, more especially to the Southern student and practitioner, for whom they were originally written, and to whom, they are now, with all due deference, submitted. Charleston, Dec. 25th, 1844. 1* INDEI OF CHAPTERS. INTRODUCTORY REMARKS, Pathology Defined;—definitions of disease, various and unsatisfactory. Divi- sion of diseases into functional and organic—local and general. Inductive method of treating the subject, CHAPTER I. Causes of Disease;—divided into remote and proximate or efficient and consti- tuent causes. Remote or efficient sub-divided into predisposing and exciting; these not always distinguishable. Predisposing causes described as internal or external—original or accidental. Idiosyncrasies and temperaments spoken of; sex, age, color, climate, etc CHAPTER II. Exciting Causes;—alternations, abrupt changes of temperature, climate, etc.; manners, customs, occupations, dress, passions. Poisons considered in this relation; divided into vegetable, animal, mineral, aerial. CHAPTER III. Mal'aria—paludal miasm;—its history still vague; its source disputed • its na- ture undetected; its mode of action questioned. Proofs of its existence ; contingencies favoring its production and efficiency; imputed effects; inlet of its impression on the system. CHAPTER IV. Animal Putrefaction;—the gases evolved, kill promptly when concentrated; give rise, when diffused, to typhoid forms of pestilence. Putrescent food poisonous. Parasitic animals briefly spoken of; the animalcular theories of disease adverted to. Animal poisons; divided into two classes—1. Normal and natural secretions; 2. New and morbid productions. Viii. INDEX OF CHAPTERS. CHAPTER V. Contagion;—exclusively the result of diseased processes; assumes two forms- palpable and impalpable; its nature and qualities not clearly made out: counter-agents; effects independent of quantity. Modes of efficient applica- tion; latent period; specific history; results. Tests of the contagiousness of disease; quarantine regulations discussed. CHAPTER VI. Endemics, Epidemics—local and general;—terms carefully defined; causes and history considered. CHAPTER VII. Seats of Diseases;—humoralism, solidism, hoematology. Pathological anato- my ; its true value. Diagnosis treated of. CHAPTER VIII. Tendency of Disease. The dogma of a vis medicatrix naturae combated; dis- ease "a forced state." Death defined and described. Euthanasia; patholo- gical death: modes of—signs of; proper disposal of dead bodies. CHAPTER IX. Phenomena—signs and symptoms—of disease considered in detail;—rationale attempted. 1. The digestive system; morbid appearances of tongue and mouth; exploration of abdomen; gastric and intestinal derangements; mor- bid secretions and excretions described. 2. Circulatory system; syncope; palpitation. The pulse treated of; plethora; hypercemia; anoemia; hemorrh- age. 3. Respiratory system; exploration of the thorax; dyspnoea; orthop- ncea; cough; expectoration of mucus, pus, fibrine or lymph, tuberculous matter, etc. 4. Sensorial system; pain; excessive and deficient sensibility; depraved state of the organs of the senses; mental disturbances—fatuity, delirium, hallucination, mania, coma. 5. Motory system; relaxation of sphincters; prostration ; paralysis, partial and general; cramp ; spasm; con- vulsion. 6. Excernent system; morbid changes of cutaneous integument • complexion; temperature; eruptions—petechias, vibices; sweating. Urine- very various ; acid, alkaline, albuminous, saccharine; anuria. Alvine excre- tions indicative of the morbid conditions of the stomach, intestines liver etc. CHAPTER X. The Countenance often Diagnostic and Prognostic—Facies Hippocratica • risus sardonicus; decubitus. Periodicity treated of; diurnal and septenary revolutions; sources doubtful and disputed. Self-limiting maladies discussed • their history given, and their true characteristics suggested. The condition of convalescence briefly considered. INDEX OF CHAPTERS. IX. PRACTICE OF PHYSIC, OR THERAPEUTICS. CHAPTER I. Nosological Arrangement;—mere matter of expediency and convenience. Phy- siological system preferred and followed. CHAPTER II. Diseases of Circulatory System;—preliminary discussion of irritation, conges- tion and inflammation. Irritation; seat in the nervous tissue; nature various and complex; morbid consequences detailed. Congestion, a local hyperoemia, active and passive; spontaneous or derivative. Inflammation; definitions of; described; microscopical observations of; signs and symptoms; their ration- ale, and proximate cause. Effects of inflammation; modified by structure of tissue assailed, and nature of remote cause. Fever following inflammation; assumes two forms, continued and intermittent or hectic. Treatment. CHAPTER III. Idiopathic Fever;—general phenomena; proximate cause; primary seat; doc- trines, theories and definitions of fever; description; tendency; crisis; critical days; remote causes; results or effects. CHAPTER IV. Types of Fever;—Intermittent; Remittent; Continued. Intermittents subdivi- ded into Quotidian, Tertian, Quartan; these variously modified; Double and Triple Tertian, etc. Paroxysm of Intermittent; cause; history; effects. Treat- ment during paroxysm ; during apyrexia. ■ CHAPTER V. Remittents;—Bilious Remittent; history; cause; varieties; prognosis; conse- quences; autopsy; treatment. "Country Fever;" "Congestive Fever;" ileitis- mercurials; quinine. CHAPTER VI. Infantile Remittent;—Worm Fever; history; causes; diagnosis; prognosis- autopsy; treatment. CHAPTER VII. Continued Fevers;—Yellow Fever; names; history; causes and fostering con- tingencies ; acclimation; contagiousness discussed; second attacks; diagnosis- prognosis; autopsy; treatment adapted to stadia; cold bath; mercurials; quinine. X. INDEX OF CHAPTERS. CHAPTER VIII. Catarrhal Fever;—sporadic; epidemic; influenza; history; causes; prognosis •; treatment. CHAPTER IX. Typhus Fever;—includes Typhus and Typhoid; modifications discussed ; identity maintained, through many varieties; history; causes; prognosis; diagnosis proposed; autopsy -T "dothinenteria;" treatment. CHAPTER X. Pneumonia Typhoides ;—names; history; met with in England and Ireland, as- well as America; anomalies; causes; diagnosis,- prognosis ; autopsy ; treat- ment. CHAPTER XI. Symptomatic Fever;—Continued and Intermittent. 1. Inflammatory; connected with external wounds and injuries ; closely analogous with the attendant fever of the phlegmasia?; developed promptly. 2. Hectic; of quotidian or double quotidian type; connected with chronic inflammations and internal disorgani- zation, slowly progressive ; developed after protracted existence of its cause ; history; treatment. CHAPTER XII. Syncope;—Leipothymia; nature; seat; history; causes; diagnosis; prognosis;. effects; treatment. CHAPTER XIII. Angina Pectoris;—Sternalgia ; probable seat and proximate cause; history j remote causes; diagnosis ; prognosis; autopsy ; treatment during paroxysm ; during interval. CHAPTER XIV. Hemorrhagej—general history; causes; plethora discussed; seat and nature various; entonic and atonic, or active and passive; modes of occurrence - periodical; vicarious. CHAPTER XV Particular Hemorrhages;—Epistaxis; history; causes; treatment. Hemorrhage from gums, fauces, etc.; does not often occur without previous injury or dis- ease. Hemoptysis; sometimes idiopathic; modified by cause; by morbid condition of subject; diagnosis; prognosis; history ; causes ; autopsy; treat- ment. Hoematemesis; description; diagnosis; history; causes; treatment. INDEX OF CHAPTERS. XI. Hoematuria; rarely idiopathic; produced by violence, or connected with renal disorder or cystic; history; treatment. Hemorrhagia Proctica; gene- erally symptomatic; history; causes; treatment. CHAPTER XVI. Hydrops;—general history; diversity of seats and modes; sthenic and asthenic, or entonic and atonic ; constitutes a diathesis, occurring idiopathically; often consecutive, the result of previous disease; causes discussed; prognosis; autopsy. CHAPTER XVII. Particular Dropsies;—Anasarca;—Hydrops Cellularis; history; modifications; causes; effects; prognosis j autopsy; treatment. CHAPTER XVIII. Ascites;—Hydrops Abdominis; history; causes ; diagnosis ; prognosis; results ; autopsy; treatment. CHAPTER XIX. Hydropleura;—Hydrops Thoracis; occurs not often alone, as idiopathic; diag* nosis ; history; causes; autopsy; treatment. CHAPTER XX. Hydrocephalus;—Hydrops Capitis; seldom connected like the other forms, with dropsical diathesis ; seats; nature ; history; diagnosis ; prognosis ; causes ; autopsy; protraction and effeets; treatment. CHAPTER XXI. Scrofula;—universal diathesis; nature and proximate cause; generation; pro- pagation ; seats of strumous lesion ; history; remote causes; degeneracies of structure; autopsy; treatment; prophylaxis. Marasmus, Atrophia Ablacto- rum; period of life; history; causes; treatment. LECTURES ON PATHOLOGY AND THERAPEUTICS. PATHOLOGY. INTRODUCTION. It is of great importance, that in entering upon- the long series of investigations which are to engage us during our present and future meetings, we should select and pursue a natural and inductive method. The " Institutes and Practice of Medicine" include all that belongs to the origin, history, effects, cure, and prevention of diseases. These subjects must be considered in the order in which they present the most obvious relations. We must pre-suppose an extensive acquaintance with the facts and doctrines of physiology as of necessity preliminary to our present course. Pathology—a knowledge of the condition of the functions of the human body in the states of disease and death, is a theme entirely comparative; involving, and founded upon a knowledge of the condition of the same functions in their natural and healthy state. It is difficult to define disease with such precise fidelity that no exception shall be taken to the accuracy of our definition; and this difficulty seems to be insurmountable, as inherent in the very nature of the case. The presence of disease always implies some aberration or irregularity in the performance of vol. i.—2 14 INTRODUCTION. one or more of the functions; but such aberration, it must be admitted, is in itself a mere symptom, an effect—resulting from a cause; the effect external and cognizable—the cause internal and occult; and as we know in very few instances, the intimate na- ture and mode of action of this cause, we can know very little of the indispensable condition upon which disease depends, and which indeed forms an essential part of the meaning of the term; nay, although as I have said above, a cognizable irregularity is so uniformly implied in the state of disease, the doctrine is not without apparent exceptions; as for example when an exposed subject has become infected by contagion or malaria. During the latent period that ensues, as also in the apyrexia of some in- termittent fevers, and in the intervals of certain recurrent affec- tions, gout, epilepsy, neuralgia, he seems to enjoy his usual health, without any sensations of discomfort or disturbance of function that can be detected or described ; but in this state of inevitable predisposition to some impending malady, it would be absurd indeed to regard him as in a sound or physiological condition of body. As then we always comprise in our consideration of dis- ease not only the aberration of function in which it might at first view be supposed to consist, but also some reference to the source or origin of the disturbance, the first step to the proper understanding of our subject must be an inquiry into the Causes of disease. This will suggest and lead on to a careful observa- tion of the parts upon which these causes act, and whose move- ments they disorder, and thus we shall find ourselves engaged in the question as to the Seats of diseases. The Phenomena or symp- toms which result from the efficient impression of the various causes of disease upon the parts which they affect, will of neces- sity engage our notice in this connection; and here we shall de- rive much advantage from the investigations and discoveries of pathological anatomy, a department of our science hitherto too little cultivated in our schools, but now fast attaining its proper standard of estimation. Hence we shall proceed to the consideration of the Effects of disease, or the changes wrought upon the system by its presence, its characteristic influences or its protraction. Thus we shall learn the modes and circumstan- ces of death, that event which is destined to terminate all orga- nic existence, but which assumes so awful an aspect in its rela- INTRODUCTION. 15 tion to our moral and intellectual being. Lastly, under the head of therapeutics, which regards properly the cure of diseases only; I prefer to treat incidentally of hygiene, the highly valuable science of prevention—the noblest office as it is the most urgent duty of our profession; because the rules which require to be laid down are comparatively specific and adapted to separate instances rather than of wide or universal application. Disease it has been said exhibits itself in some aberration or irregularity in the actions or movements of the body. This dis turbance may be unconnected, especially in the first instance, with any structural change, any alteration of the anatomical con- dition of the organ concerned in the performance of the function. By its mere protraction, however, such change seems ultimately to be induced in numerous instances, and then the organic de- terioration increases or perpetuates the disorder to which it owes its rise. In other cases certain changes of structure obscurely and gradually take place, which after a time inevitably interfere with the normal performance of the functions of the part affect- ed. Hence the distinction of diseases into functional and orga- nic, and the importance of a close inspection of dead bodies; and hence the value of accurately described autopsies, and exten- sive and well preserved museums of pathological anatomy. A farther distinction of disease is recognized into local and general. A single part or organ may be exclusively affected, and the case will then be more or less important in proportion to the more or less direct influence of such organ upon the vital ac- tions of the constitution. General ensues upon local disease when the primary and original affection of a part, has been com- municated, whether by nervous sympathies or by radiation of morbid impulse and irritation to other and more remote portions of the system ; or when, as perhaps may occur, the whole of the organs, or several of them have been simultaneously impressed by a malignant influence. Each of these conditions, it is evident may occasion the other; general disease being most commonly, if not uniformly, the extension of some local affection, sympa- thetically or otherwise—as in tetanus, in the phlegmasia, etc.; and local derangements being frequent results of the disturbed sensations and actions of particular organs, occurring in the pro- gress of a general or constitutional disease, especially where this 16 INTRODUCTION. exhibits a tendency to determine to any particular organ, as in intermittent fevers, which by their repeated succussions give rise to enlargements and indurations of the spleen and liver. It may indeed be argued with much plausibility that all diseases are originally local; for so far as we know the agency and adaptation of the causes which produce them, they seem limited in their application, and unlikely to affect in the first instance more than one tissue or structure. The human frame constituted and organized in the admirable manner, which it is the province of anatomy and physiology to develope and describe, when set in motion by the mysterious force of the vital principle, has an evident tendency to pursue in a definite method the performance of the numerous functions peculiar to the living body. It would continue doubtless, if un- disturbed, to fulfil these offices, in this natural way, with undevi- ating perseverance, until the materials of which it is constructed were worn out, or the organs of supply failed to restore the waste incurred by action; and such indeed is the euthanasia of the poets, and speculative philosophers, so seldom (if ever) met with in fact. The circumstances of our varied states and conditions however, exhibit a perpetual tendency to derange the harmony of its actions and the regularity of their progression. Causes of disease present themselves on every side; they assail us from within as well as from without. The effort to elude them alto- gether is indeed hopeless; but they can to a certain extent be avoided, if detected and pointed out, and their influences may be much modified and diminished by proper attention. Without a thorough knowledge of their sources, their history, the ordinary modes of their invasion of and action upon the human constitu- tion, the physician, whatever degree of skill he may empirically obtain in the cure of diseases, will of necessity remain unquali- fied for what I have already designated as the nobler and more benificent department of his profession, the art of preventing them, and obviating their recurrence. CAUSES OF DISEASE. 17 CHAPTER I. CAUSES OF DISEASE. Causes of disease are formally distinguished by the books into the remote or proximate, or to substitute other words which may convey some meaning—the efficient and constituent. The prox- imate cause is almost universally regarded indeed, as in the words of old Gaubius "morbus ipse" the very disease itself; it will therefore be more properly considered when we come to treat of diseases, individually and specifically. Let me observe, however, that the use of terms in this manner is not only vague and uninstructive, but that it involves a contradiction and a great absurdity. Can any thing be the cause of itself—in any sense its own cause? We had better at once resort to the ludicrous definition of the doggrel poet, and denote the proximate cause as "That without which a thing is not— The causa sine qua non." Perhaps it would be well to define the proximate cause as the first essential link in the chain of morbid actions, whose results become obvious in the symptoms of disease. This is the con- stituent condition, upon which depend all the subsequent cir- cumstances that give diseases their characteristic and peculiar form. Our acknowledged ignorance on this very obscure sub- ject, ought to teach us much caution in the promulgation of what are called "Theories of Disease." Remote causes are more within the reach of our investigations, and have received from the earliest times, as they deserve, a large share of the attention of pathologists. They are variously divided and subdivided, as to their nature and modes of action. Some of them are specifically hostile to the constitution, un- friendly to health, and exert of themselves a morbid and malig- nant influence upon the organism, or some of the structures of which it is composed. Others again are only incidentally inju- rious,—as by excess, or by alternations of action too hasty for the powers of accommodation, or too strongly contrasted for the habitual conditions of the recipient tissues. 2* 18 CAUSES OF DISEASE. They are farther divided in reference to their modes of action, into the predisposing and exciting—a distinction which although artificial and by no means uniformly preserved, may be recog- nized with advantage and utility. The terms are happily chosen as significant in a good degree of their actual purport. Few human constitutions are so perfectly formed or arranged as not to betray on occasion, evident tendency to certain modes of irregular and morbid action. Such tendency or predisposition may be dependent upon, and produced and modified by circum- stances both internal and external to the subject: these circun> stances may have acted with efficient influence even before birth and during the conformation and contraction of the parts of the body, and thus deserve to be denominated original—or they may be applied at any period of life accidentally or incidentally. Exciting causes may be briefly characterized as the several agents which when operating upon the subject, have the prompt and definite effect of developing some form of morbid action. I have said that these causes are not uniformly separable or distin- guishable from each other in their influences. Some of the most obscure predispositions are strong enough to urge on the occur- rence of manifest or open disease^ without the intervention of any known or obvious mode of excitement—nay this spontaneous de- velopment of disease, is often inevitable and irresistible; and on the other hand, we find the invasion of numerous maladies, utterly independent of all supposable predisposition, coming on at once upon exposure to their source. It is on this account that I am disposed to substitute the distinction formerly instituted, of causes of disease into the specific and incidental. The specific poisons, malaria, contagions, endemic and epidemic vitiations of the atmosphere, are all of them (with many others that might be enumerated,) both predisposing and exciting; or rather they are indifferent to all previous states of the constitution and capa- ble of immediately impressing it with a malignant impulse. The modus operandi of these several causes is as obscure as the intimate nature of disease itself. In regard to a very large class of disorders we may safely affirm, that the production of morbid action or disease in the abstract, is to be attributed to the influ- ence of exciting causes, properly so called—occasional or inci- dental agencies—while the nature and form of the train of effects CAUSES OF DISEASE. 19 produced are mainly determined by the predispositions existing already in the constitution, or in the parts of it which may have been affected. Two persons being alike exposed to sudden change of temperature, one of them whose respiratory organs are unsound or irritable shall be attacked with bronchitis or pleurisy, while the other whose digestive system is more liable to disorder, shall suffer from colic or dysentery. Parry, Broussais and others have taught, that the effect of these causes is only an increased intensity or enhancement of the natu- ral actions of the parts affected; in other words, that morbid ac- tion differs from that which is healthy simply in force or degree. Their reasonings upon the subject are, however, entirely unsatis- factory, and their theories altogether unfounded. They have lost sight absolutely of the specific nature of some of the causes of disease, dwelling only in the argument upon such as I have called incidental; and here lies the source of their error. Where we attribute disease merely to excess, it is evidently difficult to draw the line either in regard to the application of the cause, or the production of the consequences. It is logically clear that an effect must have a definite relation to its cause; hence it follows that the contagions, malaria, arsenic and nux vomica, as they specifically differ each from all the others in nature and proper- ties, must produce maladies specifically different in character. Accordingly we find a most obvious and striking variety in the results of the disordered action by which they manifest them- selves ; we find new secretions gifted with strange properties, possessing unaccustomed chemical qualities—and as in small pox, endued with wonderful powers of extension and reproduction; in other instances, as in cancer and fungus hematodes, we are annoyed with irrepressible growths of new and malignant for- mations. That such remarkable differences in the results imply similar and essential differences in kind, not merely in de- gree—in the nature, not merely in the intensity of the actions by which they are brought about, is a plain and obvious conclu- sion, which the ingenious writers above mentioned have entirely failed to set aside. Predisposing causes may be either internal or external, origi- nal or accidental. All individual peculiarities of form or struc- ture, all irregularities or departures from the ordinary configura- 20 CAUSES OF DISEASE. tion of the body and its several parts, must necessarily lay the foundation for the ready occurrence of some functional disorder, or by the impediment thus offered to the proper development of some one or more of the organs, give rise to maladies connected with such defect. Thus congenital shortness of the neck gives, in advancing life, a notable liability to apoplexy, by allowing the blood a more prompt and forcible propulsion into the cerebral vessels, than they will bear with impunity, even under mode- rately increased excitement of the circulatory system. A con- tracted or misshapen thorax is the obvious origin of well known tendencies to disorders of the respiratory functions. The defi- ciency of the pigmentum nigrum in the eyes of the albino, is a miserable peculiarity, by which he is rendered morbidly sensible to the universally delightful stimulus of light, and subject to opthalmia, from the admission of very small quantities of it to the irritable organs of vision. It is here that I would arrange also the various Temperaments, as they are denominated by physiological writers. The signs or circumstances by which they are denoted and described, seem to me clearly indicative of a disproportionate development of, and de- termination to some particular system of parts, or apparatus, or set of tissues, and a correlative or contrasted imperfection of certain other tissues, apparatus or system, rendering both these structures so defectively constituted liable to correlative or contrasted forms of disease. The history of temperaments, therefore, belongs not to physiology, but consists of a detail of morbid and pathological phenomena. Thus in the sanguineous temperament we have depicted a notable pre-eminence of circulating power, with pecu- liar facility in the process of sanguification; hence arises a pecu- liar tendency to the phlegmasia and other maladies, of which hypercemia is a part, or which depend upon the force or momen- tum with which the blood is propelled—as hemorrhage, apoplexy, etc. In the phlegmatic we have a condition of the vascular sys- tem directly contrasted with the above. There is imperfect assimilation with consequent torpor and sluggishness of the nutritive and secretory functions. There is liability to glandu- lar obstructions, to deterioration of structure, to imperfectly or- ganized or inorganic depositions, etc., as in tubercle; or transu- dation from the atonic capillaries, as in dropsy. The nervous CAUSES OF DISEASE. 21 temperament, which is also sometimes entitled the poetic and the melancholic, is characterized as these phrases ijnport—by inordinate susceptibility of the sensorial system. The senses are acute, the faculties of the mind active and keen; the imagi- nation is especially lively. These qualities imply great mobility and irritability—physical, intellectual and moral. The spirits are easily elated and depressed—the functional movements of all the organs readily modified and disturbed. Spasmodic and con- vulsive affections promptly follow any mode of irritation. Hal- lucinations eagerly admitted and warmly entertained, run into many varieties of insanity, while the restless and anxious desire of excitement soon brings fatigue, satiety, ennui and despair in its train. It is almost exclusively from this temperament that the unblest grave of the suicide is filled. We should observe that these several temperaments—the constitutional peculiarities referred to under that comprehensive word—run into and min- gle with each other, so as to be found usually combined and complicated, seldom absolutely simple and unmodified. In like manner the individual peculiarities and those of the class, will be multiplied, varied, and complicated in a definite relation with the variations of structure and conformation with which they are indissolubly connected. From all this it is evident that a man whose frame is so organ- ized as best to promise the enjoyment of health, and to endure unimpaired throughout the longest protracted life, should be of no marked or notable temperament. All the original tissues should be proportionally developed; the several systems of parts, should be so equal in power, and their energy of action so nice- ly balanced, as to render it impossible to determine or point out the preponderance of any. I need not remark that such a state is exceedingly rare—nay—I might perhaps safely go so far as to aflirm that the production of so perfect a constitution is beyond nature and without example. It is important to keep in view throughout our discussions, that law of organic life which ensures the hereditary transmis- sion of individual peculiarities, both of structure and function. Thus we have races built up, sectarian and national physiogno- mies indelibly stamped, and inevitable tendencies to disease en- gendered. Deviations from the more perfect conditions of the 22 CAUSES OF DISEASE. bodily frame, from whatever circumstances they may have deri- ved their origin, may often be thus delivered down through suc- cessive generations. We may trace them indefinitely in a single family, in a tribe, in a community; and the instances on record have already accumulated to such a mass, and are offered with such a weight of evidence—are so easily recognized by obser- vation, and so clearly established by experience, as to leave no room for the smallest doubt. There is perhaps no mode of pre- disposition so strong or so difficult to be evaded, and the term hereditary is applied as well by the learned as the vulgar, to dis- eases themselves. A certain number only are designated by the employment of this strong, yet not inappropriate phrase; but should I go about to enumerate to you all the maladies which are indeed capable of such transmission, there are few upon the long catalogue of the Nosologist that I should venture to leave out. And how can it be otherwise ! The parent communicates to his offspring in the mysterious process of generation, his features, his figure and stature—his complexion and the color of his hair; nay, his very voice, the glance of his eye, and the expression of his countenance. Can we doubt that a similar and equally close resemblance in minute internal structure and modes of action, must be occasioned by the like agency ? Some of the most familiar and prominent examples of hereditary trans- mission of inevitable tendency to disease, are to be found among the various forms of scrofula, and particularly in tubercular phthisis. Descendants of a stock thus tainted, often exhibit the lamentable union of obvious physical deterioration, with the highest intellectual and moral excellence. Their mental preco- city, frequent proofs of genius, and readily acquired habits of assiduous industry, command from childhood our respect or admi- ration, while their soft gentleness of temper, and almost univer- sal amenity of disposition, attract irresistibly our best affections. Alas! these early honors are almost surely doomed to be buried in an early grave. How touching the biographies of the ill-fated youth, whose sun of hope and high aspiration has thus suddenly gone down in premature darkness. Such instances abound in all our schools and colleges, where the very progress of the most zealous favorites of science and literature, seems to tend inevita- bly to their destruction. It cannot, I fear, be denied, that this CAUSES OF DISEASE. 23 great evil is perceptibly on the increase, and the victims of pul- monary consumption are annually becoming more numerous; nor have our most strenuous efforts yet availed to arrest this downward current. I call your attention particularly to this point. When it is in order for me to treat of this terrible disease, and instruct you in the remedial means to be pursued, after it is de- veloped and detected, I shall in candor, be obliged to make a reluctant and melancholy confession of the almost uniform in- efficiency of these means, however skilfully applied. I cannot therefore too often or too forcibly impress upon you the necessity of watching with peculiar jealousy this ancestral predisposition ; there is none stronger or more fatal. The most sanguine and gifted practitioner regards with sad despondency a case of here- ditary scrofulous phthisis, even in its earliest stages. Wilson Philip has in one of his ingenious treatises, the follow- ing remark: " Much has been said of the nature of hereditary disease; all that is necessary for us to know is the fact that can- not be disputed, that those parts which were most liable to disease in the parent, are likewise found so in the children." The cor- rectness of this cautious statement will hardly be impugned, but we may go much farther without any departure from truth and nature. The morbid conformation of minute structure upon which such predisposition depends, is sometimes communicated so fully and in so exquisite a degree, that the disease itself is de- veloped immediately after or even at and before birth. I shall have occasion to mention to you in detail by and bye, the actual occurrence of scrofulous disorganization in the lungs of embryos, resembling or identical with, the morbid appearances of these viscera in their respective parents. What are we to say of such cases as these? Is the original germ deposited in a defective or diseased state ? Or is it rather impressed with morbid change during the gradual evolution of foetal life, by sympathy, or nu- tritive communication with the mother, as we see embryos at- tacked with small pox or syphilis during the pregnancy of a con- taminated parent. It is indeed matter of familiar remark that hereditary peculiarities of whatever kind—whether physiogno- mical, or morbid, or merely eccentric, are more apt to follow the female than the male line of descent—so that we may make it a physiological as well as a legal maxim, "Partus^ sequitur ven- 24 CAUSES OF DISEASE. trem." Yet we must not offer the rule as either universal or ex- clusive. The communication of male peculiarities (though if possible it is more mysterious and inexplicable) is also matter of every day's occurrence. Nothing is better known than the trans- mission of gout, to the third and fourth generation, from a lux- urious ancestor, through both males and females, often alluded to as a strong exemplification of the fulfilment of the threat or prophecy that if " the fathers have eaten sour grapes, the chil- dren's teeth shall be set on edge." Among the most singular of the hereditary affections of which I have met with any authentic record, is the account communi- cated to the Massachusetts Medical Society, by Dr. Hay of Read- ing, of a family subject in a peculiar degree to hemorrhage from trivial causes. He commences his history of the predisposition a century back, during which period he enumerates five deaths in the family from hemorrhage, and frequent instances in which the slightest braises and scratches brought on bleeding so seri- ous, as to threaten a fatal termination. He observes that "the children of bleeders, as they are familiarly called in the neighbor- hood, are not subject to this disposition, but their grand-sons by their daughters. The bleeders are distinguished with no great difficulty from the other children of the family, by their com- plexion and other external marks." A history of similar hem- orrhagic disposition transmitted from a negro woman to her descendants, somewhat less striking in degree than the above, was sent me by Dr. DeRosset, of Wilmington, North-Carolina. Insanity in all its forms, that most awful dispensation of an angry Heaven, thus descends as an infernal legacy from miserable parents to their unhappy progeny. "Of all diseases," says Esquirol, "insanity is most eminently hereditary;" an appalling sentiment coming to us with the force and weight of the highest authority of the age. So strong is the feeling upon this subject, that it has been repeatedly a matter of discussion among political econo- mists, whether it would not be right and proper that these heirs of lunacy should be prohibited by law from marriage__with the view to prevent thus the propagation of so wretched a race of beings. Such legislation, however, although it might offer some slight and partial benefit, would most assuredly fail in the end of its proposed effect. Descendants of insane families often pos- CAUSES OF DISEASE. 25 sess in early life the finest minds, the fairest forms and most engaging manners: thus highly adapted to feel and to create strong attachments, affection would soon teach their lovers to scorn the fetters which the laws would not suffer them to wear, and their illegitimate offspring would find in the contempt and obloquy to which they would be exposed, new and powerful means of exciting into action the^ir unfortunate constitutional predispositions. None will deny that the human animal, as the noblest of creatures, is worthy of all care and attention, though every scheme which has for its object the improvement of his attributes and condition, physical and intellectual, is invariably sneered at, and its proposer regarded as a ridiculous visionary. In defiance of "the world's dread laugh," however, I will avow that I do not despair of the arrival of a period when more ra- tional and enlightened considerations of these subjects shall pre- vail, and the breed of men shall be thought worthy of at least as much foresight as the breed of cattle and horses. When that day comes, parents will not sacrifice their daughters to the here- ditary lunatic, nor to the worn out debauchee; nor will it be looked upon as improper, or indelicate, or unreasonable to sub- stitute for the present inquiries as to estate, dowry, and means of living, such questions as shall inform them concerning the moral and physical soundness of those to whom they are to commit, not only the immediate happiness of their offspring, but the hopes and prospects of their posterity to all future time. We may next refer to those predispositions which result from the sex of the individual. Man with greater physical and men- tal energy, is more liable to sthenic and inflammatory diseases, while the delicate and mobile frame of woman yields with pliancy to slight impressions, being easily excited to all irrita- tive affections, exhibiting at the same time, as much or even greater tenacity of life. It is not, I think, unfrequent, in stories of " moving accidents by flood and field," to find woman surviving her more robust partner. Less able to struggle with calamity, a wise and bountiful Providence has endowed her with superior power to endure it. Age has also its special tendencies to disease, so numerous and so familiar that it would be a useless waste of time to set about to enumerate them. Not only does a transient influence of this nature perpetually act and subside, even in VOL I.—3 26 CAUSES OF DISEASE. the soundest constitutions, as at dentition and puberty, but a modifying, controlling and suppressive power is exerted in the most tainted constitutions. Thus gout rarely appears before the period of ripe manhood; and in the descendant of strumous parents, the time of development is found to determine the mode and location of the scrofulous disease—in infancy the skin and eyes, next the joints and glands, and after puberty the respira- tory organs will show successive deterioration. Infancy has limited Susceptibilities. It may be said to be free or nearly so, from the invasion of idiopathic fevers, and is gifted with notable powers of resistance to all forms of contagious disease, the ex- anthemata excepted, and pertussis. As we grow older a wider range of impressions is admitted. At and near puberty, changes occur in the determinations to the several systems of organs, giving new liabilities and diminishing the old. To both sexes this is a period of some risk, but the female is most apt to suffer. She suffers exclusively from correlative changes of constitution at "the turn of life," as it is called among women; that point at which the prime of existence being past, we begin to feel the evils of decay. Women always regard this epoch, and justly, as a critical one, from the disturbances which attend the cessa- tion of the uterine and ovarian functions. Old age brings with it a long train of maladies, grouped together and graphically described by Sir Henry Halford, under the title of "Climacteric Disease," from the date at which they commence. They are readily traced, however, as separate effects of the impairment and decrepitude of the several organs and their functions. Color is in this relation, a topic of especial interest to us. We have been long accumulating histories of the maladies of the white race, but our records are meagre in regard to any of the other varie- ties of men. We know literally nothing, speaking professionally, of the constitutional peculiarities of the red man, so long our reluctant, and so often our hostile neighbor. Of the black, we have been forced to learn something, from interest and from humanity. We have found him singularly insusceptible to some of our diseases, as for example, those which owe their origin to malaria. Spasmodic affections readily assail him, although such susceptibility seems unaccountable when we reflect on the obtuseness of his senses, and the want of CAUSES OF DISEASE. 27 development of his nervous system generally. He sinks prompt- ly under the violence of inflammatory disorders, and does not bear well energetic measures of positive depletion. He falls readily into the typhoid affections; beneath the attack of cholera his vital forces subside with scarcely an effort; and from his Very birth he is peculiarly liable to trismus and tetanus. The recuperative forces of the negro, indeed, seem in a general way less elastic, and exhibit less activity. He is incapable of endu- ring cold, and requires for his comfort and the development of his powers, high degrees of heat and other modes of excitement. While reasoning thus, however, concerning the black, it must not be forgotten, that even in regard to those immediately about and among us, we have not taken care to separate properly in the consideration of their characteristic peculiarities, the influ- ence of the various agencies of habit, occupation, mode of life, etc., from the inevitable and original predispositions arising from color and constitution. On the whole, we ought to confess that there is a wide field here, yet unexplored, and that much re- mains yet to be learned by our profession concerning this class of our patients. Under this head of original predispositions, we next class Idiosyncrasies, as they are technically termed. Some of these strange and unaccountable peculiarities are clearly connected with individual structure and conformation, while others would seem to be obviously of accidental origin, and therefore more properly to be arranged among the sympathies and antipathies. As examples of the first kind we may notice the liability, some- times common to a whole family, to be affected in an unpleasant manner by flavors and odors not generally disagreeable, such as the smell of an apple and other fruits, and of various flowers; though the poet has thought fit to satyrize as affectation the ex- quisite sensibility which "dies of a rose! in aromatic pain." Several instances are recorded in which the smell of ipecacuanha regularly brought on a paroxysm of asthma. In the case of a lady whom I knew familiarly, there was ahvays a notable de- gree of general distress, accompanied with dispncea, occasioned by the flavor of an egg, whether raw or prepared, whether alone or mingled in any mode of cookery. When the smallest quan- tity of any such preparation was inadvertently taken into the 23 CAUSES OF DISEASE. stomach, the uneasiness produced by the perception of its pre- sence, was aggravated into intense sickness and vomiting. Whether in all these instances the origin of the morbid influ- ence may not be ascribed to some actual injury inflicted, or former deep disgust excited by the specified agent, continued or repeated by those associations which both mind and body form so quickly, and which adhere to them with such tenacity, is, as I have said, doubtful. But even if it be so, must we not acknowledge the whole train of results to be laid in some original peculiarity of .constitution ? Thus we find individuals and whole families on whom antimonials act poisonously, occasioning painful and dangerous spasms of the stomach and of the muscles of volun- tary motion; and others who cannot take opiates without great suffering—delirium, head-ache, nausea and prostration. Such cases might be multiplied indefinitely, and should be kept in mind as forming subjects for unremitting and careful inquiry in your future practice. That these idiosyncracies impede and limit the remedial effects of medicaments in numerous instances in which their influence has not been suspected, is highly pro- bable, and even food and drinks in particular forms, may exert an agency upon the stomach and general system, more or less prejudicial to invalids and convalescents. Of accidental or acquired predispositions the number is so great, and the sources so widely distributed, that any attempt to detail them would be entirely futile. Striking examples may be addu- ced in the recurrent and paroxysmal class of diseases; all indeed of which periodicity is an attribute; asthma, epilepsy, hysteria, furnish us with melancholy instances in which a single attack seems but the first of an interminable series. The repetition of the paroxysms of intermittents at regular intervals; the associa- tion of certain morbid movements in the system, with the revo- lution of noted periods of time, is one of the most familiar phe- nomena of pathology. Sometimes we ascribe this periodical disposition to the peculiar influence of a morbid poison, as in the case last adverted to, and in the other malaria fevers: but all fe- vers, the hectic or secondary as surely as the idiopathic, observe this precise regularity of movement. There must be something inherent in the very nature of things, something belonging to the essential history of the animal constitution, which gives founda- CAUSES OF DISEASE. 29 tion for this law of the economy. I shall hereafter speak of the suggestion that it is owing to planetary influences. Whatever may be its origin, its effect we know to be much aided by the force of habit—a power which sways all the actions of all our organs, and often in a singularly uncontrollable manner; deserv- ing sometimes indeed to be regarded as among the most formida- ble causes of disease. Nothing can be more obscure than the nature of these periodical changes in the condition of a tissue or part, so transient yet so vehement, often leaving as in epilepsy, no trace whatever of anatomical change, yet producing, while it lasts, such intense sympathetic disorder of the system. In another class of cases we account for the liability to future anal- ogous attacks, by observing some alteration in the part affected, as in rheumatism, mania, pulmonary inflammation, and gastro- enterites generally. There may be a permanent enlargement of the smaller vessels, giving occasion to a degree of hypersemia, an element in almost all inflammatory affections. This is percepti- ble in persons of weak eyes, as the phrase is, and those subject to frequent sorethroat, in whom the vessels of the conjunctiva and mucous membrane, may be traced, of inordinate size and fulness ; or there may be the opposite condition of consolidation, or closure or obstruction of vessels from effusion or deposition. This will of course impair the integrity of a tissue or organ, and even when its common actions are not impeded, offer a degree of diffi- culty in the occasional excitement of any increased action, or any accidental demand for increased secretion. But diseases not only pave the way for their own recurrence, but they also develope, or give rise to predisposition to other dis- eases. The sequelae of measles and of variola, are often more to be dreaded than the original attacks; diarrhoea, opthalmia, inflammatory and convulsive coughs, remain long after the fever and cutaneous eruption have subsided, and are ever after more readily brought on. They are said also to aid the develop- ment of scrofula. Vaccine is accused, not without some plausi- bility, of generating a troublesome series of cuticular affections. Nor must we omit to notice the contrasted fact, that one class of maladies at least, the exanthemata, and perhaps the contagious fevers also, destroy or vastly diminish the liability of a constitu- tion, once affected by them, to be attacked a second time. The 3* 30 CAUSES OF DISEASE. modus operandi exerted here, is totally unintelligible: so also where one seems to prevent or greatly modify the future inva- sion of another, as in the influence of vaccine on small pox. We proceed next to the consideration of the external sources of predisposition, and under this extensive head we shall find ourselves obliged to refer to almost every class of circumstan- ces, surrounding and acting upon us. Climate is perhaps the principal and most important of these means of modifying the condition of the system. In conjunction with original diffe- rences of stock, and variety of tribal descent, it is the source of what may without impropriety be termed national temperaments. The swarthy Spaniard and the Italian, with black eye and hair, may be placed in contrast with the blue-eyed and fair-haired Ger- man and Scotchman, as presenting diversities of climatic suscep- tibility to different forms of disease, not less notable than their opposite conditions of physiology and constitutional tempera- ment. The foggy Hollander is proverbially of phlegmatic habit and disposition; while the Englishman and the Turk, are even less contrasted in complexion, than in the nature and rapidity of the maladies which affect them. Individual exceptions to the rules thus proposed to be laid down may, without doubt be met with, and perhaps not rarely, but their truth and force are clearly exhibited in the mass. Indeed, so striking is the power of cli- mate in modifying the external signs of the internal constitution, that some philosophers have been led to believe it adequate to account satisfactorily for the variety of races of men, all the diversities of which, they attribute to the agency of the sun which beams upon them, and the soil which they inhabit, aided' perhaps in some measure by the influence of manners and habits, themselves the products of the sun and soil. The nature of the surface, the geological as well as the geo- graphical locality, is deserving of attention. In low, flat, allu- vial regions, the inhabitants are subject to known forms of dis- ease, varying less in their character than their intensity and violence, according to the degree of solar heat, to which they may be subjected. In northern latitudes these maladies assume the chronic and intermitting types ; within the tropics they are generally prompt and rapid, often extinguishing life as malig- nant remittents, and in the continued fevers, within a few hours. CAUSES OF DISEASE. 31 It is not easy to say why this combination of heat and moisture, with the products of organic decay, so vivifying to the vegetable kingdom—so genial to the inferior animals of all kinds, from the elephant to the lowest reptile, and so infinitely productive of insect millions, should be thus unfriendly to the health, and even to the existence of the higher races of men. The arid deserts of Arabia, on the other hand, are said to present frequent in- stances of wonderful longevity; and if we may believe travellers, sickness is scarcely known among the wandering hordes that traverse them, finding at various points an uncertain home, though their supplies of food and drink are both scanty and un- wholesome. Even in hilly countries we find the fertile meadows and low grounds fringing the margins of .the rivers and smaller streams, the frequent seats of disease; whether from the pre- sence of mere moisture or the evolution of a specific poison is a question to be hereafter discussed. Mountainous regions seem, on the whole, most favorable to health and longevity, provided the cultivation of the soil, which in these elevated positions, is usually comparatively infertile, be sufficiently productive to ob- viate the risk of actual suffering from defect of nourishment. The imperfectly ventilated vallies among the ranges of moun- tains, however, are found in every part of the world, to be sub- ject to some special forms of disease. Bronchocele or goitre is one of these. It is so often met among the alpine glens, that it was long attributed to snow water, the only or chief supply ob- tained there. But in the coves of the Alleghany it occurs fre- quently, where men drink of the purest springs. In the same districts is generated also the terrible poison which produces milk-sickness, afflicting not only man, but many of the lower animals. These local endemics are in certain instances extremely obscure, and the closest examination does not detect any apparent source to which they may reasonably be^attributed—as the frequency of tetanus in the West Indies, Santa Cruz especially—the Barbadoes leg and the pellagra of Lombardy. Perhaps the best test of the salubrity of any region of country may be found, not in the en- joyment of pleasant temperature, the luxuries it offers, nor the selected instances of longevity which may be met with, but in the fruitfulness of its women and the rapidity of increase of its 32 CAUSES OF DISEASE. inhabitants. In these respects it cannot be doubted that the colder climates have the advantage, not only of tropical but even of the temperate latitudes. The progress of large masses of men has uniformly been from north to south. Thus Europe has been re- peatedly overrun by hordes of hyperborean barbarians, such as the Huns and Goths and Vandals—and seems doomed, heaven avert it! to be again reduced to slavery and wretchedness by a hardly less savage tide from Muscovy and the banks of the Don. Why this should be so, and how an iron soil and an inclement sky should give life and vigor to a greater number of human be- ings than can find room and obtain subsistence where they are bora, are questions as embarrassing to the naturalist and physio- logist as they are to the political economist. The state of society is a topic which should by no means be omitted, in treating of the causes which originate predispositions to disease. Man in his primal condition, it may be supposed, was subject to few and simple maladies, and old age, with its gradual decay, was probably the principal outlet of human life. But it is also reasonable to conclude that this decay must have supervened earlier, the constitution must have been worn out sooner, under the violent exertions, the alternate excessive fatigue, and indolent repose, and the frequent and severe sufferings from the difficulty of procuring subsistence in the state of savagism, than under the contrasted advantages of civilization. It is owing to these circumstances that wherever they come in contact with each other, the tribes of savages melt away before the face of civ- ilized man. The latter increases more rapidly; his women are more fruitful; his descendants, as a mass, possess greater strength and agility. We are apt to be deceived by fixing our attention upon the strange stories occasionally told, of Indian activity and energy. Individuals among them may from continual training, arrive at the possession of great physical power ; but as a body, they are far inferior in muscular capacity to our mechanics and laborers, and will not compare with our equestrians and pugilists in either strength or activity. To praise them for their endurance of hunger is indeed to "make a virtue of necessity;" their lazy improvidence inures them against their will, to long fasts, which after all, there is no proof that they bear better than other men. Nor can the Indian sustain greater or more prolonged fatigue CAUSES OF DISEASE. 33 than the hardy seaman, the enthusiastic hunter, or the post-boy and courier of civilized life. The idle dreams of certain half lunatic philosophers, such as J. J. Rousseau, would exalt the sav- age to the station of a demigod. But be not misled by these ab- surd speculations; examine for yourselves, and you will soon cease to doubt that, setting aside all the moral and intellectual improvements which civilization brings in its train, the physical man in cultivated society, is infinitely superior to the barbarian. It is nevertheless true, that the refinements of life have been the occasion of much suffering from disease; indeed it ought to be acknowledged, that many of our present list of diseases arise, or derive force from the circumstances of civilization. Yet there are few or none of these which when introduced, have not been accompanied or soon followed by their appropriate remedies, or at least such compensation, that the balance is left decidedly in our favor. Civilized man not only lives happier but longer than his savage ancestor; and the prospect before us is farther bright- ened by a knowledge of the fact, that the evils of refinement are by no means multiplied with the same rapidity as formerly, while the increasing industry and skill of medical philosophers, aided by the philanthropic exertions of enlightened legislators, are daily diminishing the number and intensity of the sources of disease, and gradually narrowing the widest outlets of human life. In proof that these views are not merely pleasant imaginations, I would point you to the comparatively limited ravages of the plague, the terror of our ancestors, both of France and England; to the scarcely less than total extirpation of the small pox ; and to the triumphant operations daily proposed in modern surgery, many of them almost miraculously successful in preserving life, and restoring the capacity for action and for enjoyment. On the other hand, it must not be denied that the cultivation of feeling and taste in refined society, has substituted for the moral indiffer- ence and stoicism of the savage, a dangerous, perhaps a morbid degree of mobility and sensibility, to which we must attribute in some measure, the greater frequency of insanity. This result is furthered by the fluctuations of commerce and politics, and the excitement of the distracting passions of fear and avarice. Of late too, we over stimulate the young intellect, by an anxious, 34 CAUSES OF DISEASE. busy and precocious education, which occasioning too urgent de- termination to a delicate organ by nature and necessity of slow development, originates a predisposition to all the forms of cere- bral disorder. This evil is however perceptibly on the decline, and common sense will soon rescue our infants from the hand of the too zealous pedagogue, and turn them loose from the confine- ment of the school-room into the fields and gardens. It is plea- sant to reflect also, that if there is more lunacy, there is less idiocy than among the various tribes of savages ; and an additional con- solation remains yet in the fact, that obvious improvements are every day made in the treatment of insanity, by which the con- dition of its unhappy subjects is not only rendered far less terri- ble, but the proportional number of cures is becoming vastly augmented. The influence of the various conditions of the several classes of men, is next to be noticed, though in this place in a very brief and general way, as they not only give rise to definite predisposi- tion, but rank among the most forcible of the exciting causes of disease, and are hereafter to be frequently referred to. Agricul- ture offers us, doubtless, the most healthful of all occupations. The labors of the farmer, though unremitting, are not burden- some ; though regular, are free from monotony, and varying with the seasons, give pleasant excitement to the mind. It is not easy to point out any predispositions as liable to arise from this primi- tive and tonic mode of life. Physically speaking, it is the most enviable lot of humanity. The citizen, on the other hand, de- prived to a greater or less extent of the luxury and stimulus of fresh air and free exercise,, languishes under a deficiency of mus- cular strength and digestive power. The sedentary artizan and the manufacturer, like plants shut out from the influence of light, possess and transmit to their descendants, a sort of imperfect vitality. Of all the dwellers in cities, the mechanic suffers least, provided his occupation gives him free muscular motion, and shelter from special or undue exposures. Lastly, we mention the student, who can scarcely avoid deterioration of health from his pursuits. His frame is attenuated by defective nutrition and imperfect muscular developement; his thorax contracted and de- formed by the bent posture which brings his dim eyes nearer his books and papers, and allows him to support his feeble body EXCITING CAUSES. 35 against his desk or table. Incessant mental labor determines dis- proportionately to his brain, he becomes the ready victim of the various types of cerebral disease, and the long list of maladies which ensue from deficient development of other organs, and he lives a martyr to dyspepsia, or dies prematurely under the gradual wasting and sure decay of pulmonary consumption. CHAPTER II. EXCITING CAUSES. It is common to speak of the various agents, which effect, by a prompt and obvious impression on the living system, the de- velopment of some mode of diseased action, under the general head of exciting causes. I am inclined to attribute disease in the abstract indeed, to the forcible impulsion of some such agent, endowed with a morbid force, either by virtue of its inherent qualities, or by the contingency of its being discordant, at the time, and under the circumstances, with the condition of the vital susceptibilities. The particular form which the attack so produced will assume, will generally be determined by the special predispositions of the subject affected. The rule thus laid down, is, however, liable to so many exceptions, that their number may seem to impair the precision and value of the defi- nitions given by authors. It is indeed very often difficult to distinguish between these two classes of causes. The very terms, predisposing and exciting, are occasionally applicable equally and alike to the same morbid agency; and there are many circumstances which give rise to disease, which it would be difficult if not impossible to arrange exclusively with clear- ness or confidence under either head. Thus, for example—that state of the atmosphere which we vaguely denominate an epi- demic constitution of the air, may both predispose to and excite a given form of disease; so may marsh miasms and all the poi- sonous exhalations comprehended in the phrase malaria; and 36 EXCITING CAUSES. so in an especial manner may the virus of any spreading con- tagion. All these determine definitely and with remarkable uniformity, the nature and course of the results of whatever influences they exert upon the animal constitution. On the other hand, there are some predispositions of the most obscure and untraceable character, which nevertheless exhibit an uncontrol- lable power of developing special maladies, without the aid of any occasional mode of excitement whatever. In a gouty sys- tem, for instance, the hereditary tendency may be so strong that no evasion shall avail—no human prudence or foresight prevent the occurrence of paroxysms and attacks both functional and organic, such as are usually and justly attributed to excess or intemperate indulgence. Podagra is affirmed occasionally to show itself in youths, and even children, absolutely excluded from all the contingencies adapted to give it existence. The same thing is perhaps even more strikingly true of scrofula, which, as I have had occasion to mention to you, has been known to exhibit itself in its open forms in the infant at birth. There is nothing in the history of the human constitution, perhaps, more remarkable than the readiness with which it accommodates itself to all possible diversities of situation, cus- tom and habit. In all his external relations, indeed, man is the creature of habit; nay, his very instincts would seem to under- go some modification from its proverbial influence. Yet with this slow and permanent pliability, there is connected a corres- ponding susceptibility of disturbance from the impression of sudden alternations; and hence it arises, that among the princi- pal in importance, the most general in extent, and the most fre- quent in occurrence of all exciting causes, we must enumerate these alternations; changes of temperature; of all the other atmospheric conditions doubtless though less appreciable, as of its electric and magnetic states, its moisture and dryness, etc.; of local position; of occupation; of enjoyment; or of suffering. In all these respects, any notable and abrupt departure from the usual train of contingencies by which he is surrounded, cannot be borne without injury and disorder, proportioned chiefly to the force of contrast to which he is subjected, and modified by the varying capacity of accommodation inherent in each in- dividual. EXCITING CAUSES. 37 The most superficial observer cannot be ignorant of the effects of change of climate, which this day of emigration affords us innumerable opportunities of witnessing. Vegetables removed from their native soil, and from the region of country particu- larly adapted by nature to their growth, are apt, unless guarded with special care, to wither and die at once, or to degenerate more slowly and finally decay. Animals are somewhat less limited to local position, although subject to the same law. The camel may live, but cannot keep up his number any where else than in the sandy deserts of Asia and Africa. The lion, the tiger and the elephant may procreate but cannot multiply—perhaps cannot exist permanently as a race except in the torrid zone ; the lama is found only in a narrow region of South America. Those creatures which man has domesticated are aided by our care to withstand the shock of transportation, and the horse and dog accompany their master all over the globe. Those wild beasts which we find in contrasted and distant climates, do not fail to exhibit obvious modifications of external appearance, tending to fit them for the opposite circumstances in which they are placed. Bears, hares, foxes and wolves, in extreme northern latitudes, have their fur thick, fine and long, and of a snowy whiteness— by these qualities of their covering being protected from cold. In an analogous way, too, their very instincts as we call them, are modified, so as to preserve them from collision, if I may so express myself, with external nature. The tribes of the human family exhibit, as we should anticipate, still more extensive powers of accommodation, without which, indeed, the divine gift of the whole earth as their domain would have been at least partially nugatory. Endowed as he is with wonderful powers of observation and reflection, man is capable of preparing for and guarding against all the modes of impression to which he subjects himself by change of place, and may thus accommo- date himself to every new condition of climate, and repel or evade the influence of the most opposite extremes of tempera- ture and other circumstances. I say he may; for with all his boasted reason he frequently commits in this regard errors the most stupid and wilful, and runs headlong into the very dangers he is warned most loudly to shun. Under the burning rays of the bright sun of Hindostan, and in the pestiferous islands of vol. i.—4 38 EXCITING CAUSES the Caribbean sea, the English army and naval officer wears his thick broadcloth uniform, and instead of the vegetable ali- ment, subacid fruits and cool sherbet of the native, feeds high the fevers which consume him, by the hot wines, fermented liquors and stimulating meats and sauces of his native home. Commerce as well as conquest has been hitherto m the hands of northern nations, who are by both these means introduced in vast numbers every day into regions the very antipodes of the lands which gave them birth. The British troops who lately, in the prosecution of the most unjust war by which the annals of our race are stained, took possession of the island of Chusan, paid an immediate penalty by the almost universal sickness which seized them, and their absolute decimation. We ourselves are so situated, unfortunately, as to have before our eyes a perpetual succession of examples of the evils of which I am speaking. Europeans emigrating to the countries between the tropics are not more notoriously liable to be assailed by dis- eases peculiar to their new position, than are our northern breth- ren who come to reside in the low, fertile, alluvial districts of the south and west. So surely and uniformly is this the fact, that it is expected among us, almost as invariable matter of course, that every such individual shall undergo a seasoning, as it is commonly termed, that is, an attack more or less severe of some form of endemic disease peculiar to the warm months, before he is acclimated, that is, assimilated in constitution and habit of body to the condition of a native or old resident. And the anticipation is surely not unreasonable. We know the fact that all abrupt and violent transitions tend to produce vehement and morbid impressions, unless measures be taken to prevent or modify the results of their specific influences. With this view a newly arrived emigrant from more northern regions should avoid the heat of our noon-day sun and the chill dampness of our abundant night dews; he should yield in some measure to the warning langour which will oppress him, especially in the hot afternoons of summer and autumn; he must guard against every mode of excess, physical or moral, and shun fatigue, indul- gence of passion, and all degrees of intemperance in the use of food and drinks. Heat, when intense or protracted in its application, we know EXCITING CAUSES. 39 to be, alone and of itself, capable of producing many and fatal diseases; inflammatory fevers, coup de soleil, apoplexy, these are the direct consequences of its agency. But the morbid effects of high temperature which are most common in hot climates, are somewhat indirect, and are not satisfactorily accounted for like the above named affections, by its merely stimulating power, or its property of expanding the vital fluids. A large class of disorders of the digestive system, the stomach, intestines and liver are arranged under this head. They are ascribed by James Johnson, with much ingenious reasoning, to the action of heat upon the surface of the body. With this surface he supposes the liver to be connected in a peculiarly close and collateral harmony of actions, which he terms "the principle of hepatico— cutaneous sympathy," by virtue of which an inordinate action of that great and important organ necessarily follows the excite- ment of the skin under the influence of heat. How far these speculations may suffice to explain the origin of the maladies peculiar to southern countries, it is not easy to say; proofs are not wanting, however, of the concurrence of cutaneous and hepatic derangement in tropical countries and low latitudes. The skin is covered with prickly heat, an annoying and well named eruption, and becomes yellowish or sallow; there is im- pairment of the appetite and digestive powers; diarrhoea often occurs, exhibiting an increased and vitiated secretion of bile; dysentery or fever with the same complication present them- selves ; or cholera, or true hepatitis, acute and chronic, and jaun- dice ; with all these, or it may be, independently of them, the subject is conscious of a marked and universal depression of both mental and bodily energy. It must not be imagined that in pointing out the stranger as the victim of these deplorable influences, I mean to imply his exclusive liability to suffer under them; far from it. The native tribes of these torrid regions derive many or most of their idiosyncracies of habit and consti- tution from the same influences, so far at least, as they are un- protected by a modified organization, internal or external. Hence their langour, their comparative imbecility, their defect of elastic force and want of vital tenacity, so terribly demonstrated by the mortality of pestilential visitations among them. The opposite climatic condition of cold, severe and long con- 40 EXCITING CAUSES. tinued, is also a very powerful exciting cause of disease. The extreme parts of the body when subjected for a time to a tem- perature impressively low, readily lose their vitality; the circu- lation in their small vessels becomes weaker and weaker, until it stagnates and they are said to be frost bitten. In a less degree, the same causes produce a well known and troublesome affec- tion termed pernio or chillblain. The influence of cold being extended and still farther protracted, there is great drowsiness, with lassitude and extreme dislike to muscular exertion. A deep sleep comes upon the unhappy patient, who is doomed, if he lies down to indulge himself, never to rise again. The long winters of high latitudes produce a permanent constriction and harshness of the cutaneous surface with a coincident and obvious diminution of all the secretions and excretions, the urine ex- cepted. Hence constipation, colic, glandular affections, rheuma- tism, catarrh, and a variety of pulmonary disorders which, acting promptly upon tubercular predispositions, give rise to frequent phthisis. It is scarcely necessary to say that the southerner is more liable to these evils than the natives of these northern climates, though the latter do not fail to exhibit forcibly enough their unequivocal tokens. Nothing can be more obvious than the danger of great and abrupt alternations of temperature. They are indeed familiarly remarked to be among the most efficient and certain of the long catalogue of exciting causes of disease. No one can fail to perceive the probability of a severe shock to the system, when exposed to the sudden contact of a current of cold damp air, while heated by unaccustomed exercise or confine- ment in a warm room and bathed in a relaxing perspiration. The sensation of chilliness or the actual rigor which is the almost inevitable result, is of course attended with an imme- diate constriction of the skin, the fluid expelled from whose vessels must be determined with an irregular force and velo- city upon the internal organs and surfaces. Thus commences a train of morbid actions, which can scarce fail to result in the production of some one of the phlegmasia?, rheumatism, or catarrhal fever. Nor must we overlook the danger of the appli- cation of heat after cold, which though seldom thought of or provi- ded against, seems to me at least as full of risk as that of cold EXCITING CAUSE?. 41 after heat. In this case we have the vessels of the cutis while braced to their highest degree of tone, hastily and unduly stimu- lated, and their fluid contents expanded and augmented in volume. Unable to yield with sufficient promptness to this dilatation, or to relax into the state proper for their normal offices of excretion and transpiration, they are affected with a morbid excitement; the surface becomes hot, dry and harsh; the great organ of circulation sympathizes with the irritation thus produced, and fever is aroused, whose type, force and future history must depend for the most part on the existing predispo- sitions of the subject affected. We next proceed to consider the agency of food as an exciting cause of disease. Man is an omnivorous animal, and among the infinitely varied articles of diet which he employs either to sus- tain life, or to add to his list of luxuries, we shall find many things possessed of qualities injurious or dangerous, and many which from changes of the condition of the stomach may become deleterious. The experiments of Magendie prove that animal life cannot be supported by an exclusive use of any of the nu- tritious principles found in food. For the production of healthy and well assimilated chyle, neither gum nor oil nor sugar alone will suffice. 'The scurvy which affects sailors during long voy- ages and which is probably destined to disappear before the im- provements in navigation and in the modes of preparing ship's stores, is occasioned by their confinement to a diet of salted meats and fish without due intermixture of fresh vegetables or fresh meats. It always subsides when variety is offered—though the articles resorted to, as in the instance of the acids so highly eulo- gized, may add little or nothing to the actual amount of converti- ble aliment taken. Similar diet on shore does not produce similar effects, simply because it is never quite as exclusive; yet though it does not give rise to scurvy, we see it originate many other cu- taneous and gastric disorders. I cannot go into detail on this very extensive subject—but shall leave it with one farther remark which deserves to be recollected by all of you—that as almost every production of nature and art may be taken with impunity when sanctioned by habit, so the most nutritious and digestible substances may act as dangerous irritants to those unaccustomed to their use. Hence we find that all sudden and notable changes 4* 42 EXCITING CAUSES. of diet are apt to occasion greater or less disturbance of the diges- tive organs. The same observation is equally correct as to our habitual drinks. Water itself varies so much in the several soils from which it bursts forth in springs or in which it is collected in wells, bearing in solution so many ingredients of widely differ- ent chemical and specific qualities that it may become an excit- ing cause of disease. Diarrhoea is familiarly known to be brought on in strangers by the water of the Mississippi, and of the lime- stone districts of the west, and even of the impure wells of our own alluvial country. In certain regions, nephritic disorders are frequent and calculus is common; and I am inclined to concur in the popular opinion, which ascribes these facts to the quali- ties of the water drunk there. Malt liquors are accused of giv- ing rise to similar affections, and wine used largely, produces a very peculiar tendency to inflammation and calcareous deposi- tions in the smaller joints. Writers on Hygiene often stigmatize, among a great number of articles of common consumption at our tables, the infusions of tea and of coffee as injurious to the tone of the stomach, and in various modes deleterious to the general health. It is difficult to refute the allegations thus urged ; it would be uncourteous to refuse at least a partial faith in the statements brought forward to sustain them. It is altogether probable that idiosyncracies exist, which entirely forbid the use of these cordial and delightful aromatics. Yet for myself, I must say that I have seldom or never had occasion to observe the ill effects attributed to these beverages. On the contrary, I regard them not only as grateful and pleasantly stimulating, but in the manner generally employed, as perfectly innocent drinks. As modified by sugar and diluted with milk, there surely can be hardly the least risk in taking them, in all ordinary circumstances of common health. Condiments, so necessary to the perfection of modern cookery, have been much discussed. In the moderate amount usually mingled with our food, they can do no harm. I am disposed, however, to object decidedly to the free use of acids to which some persons are inclined. Whether in sauces, or in the more objectionable solid form as pickles, they are I think injurious both to the teeth and to the stomach. EXCITING CAUSES. 43 I have thus spoken cautiously and briefly of the qualities of our food and drinks, as capable of exciting disease; but they do this, it is probable, far more frequently by the amount or quantity taken, whether considered absolutely or relatively to the condition of the subject. What then shall I say of in- temperance, whether in eating or drinking—of gluttony or of sottishness ! The voice of an angel could not entice the drunk- ard from his cups, or the glutton from the gratification of his gross and beastly appetite; though both the reason and the sad experience of each, has left him no doubt as to the fatal effi- ciency of these most fruitful of all the exciting causes of disease. Our professional duty, in regard to these subjects, is at once clear and imperative; as imperative as any of the commands of God and our conscience—as clear as the evil influences of intemperate habits. We must not omit to warn, with freedom and boldness, though with proper caution and delicacy, all such of our patients as shall have begun to tread this downward path—leading, as surely as the inevitable decrees of fate, to suffering, ruin and in- famy. While exulting in the enjoyment of health, and absorbed in the pursuit of pleasure, they would not hear, "though one rose from the dead ;" but in the hour of sickness and on the bed of languishing, when oppressed by the distresses which they have brought upon themselves, and borne down by the terrors of im- pending death, the still small voice of conscience and the earnest and disinterested reproof of their physician, will be listened to and heard attentively. Circumstances like these, afford us op- portunities for impressing deeply the minds of those under our care, which no other classes of men enjoy, and they must not be lost! Paint the immediate and direct consequences of their fatal in- fatuation upon both mind and body, and you cannot paint them too strongly; the physical torments resulting from excess are not to be described, and the horrors of approaching madness far greater than the efforts of the most vivid imagination can con- ceive. Detail to them the more protracted and indirect effects of this lingering suicide; the paralytic trembling, the steadily pro- gressive and premature decay, and the early and unhonored old age that await them. It is possible—though I fear I ought not to express any strong hope of such success—it is possible that 44 EXCITING CAUSES. you may enjoy the delightful gratification of thus saving some fellow-creature from a terrible self-destruction; by making the attempt you will at any rate secure to yourselves your own ap- probation and the esteem of all the good and intelligent. We may next remark, that irregularities in dress are entitled to rank high among exciting causes of disease. Dress should be properly adapted to climate, to season and to changes in the state of the atmosphere, either of temperature, moisture or electrical and other influences, when they can be known. Civilized man lives a life almost altogether artificial. Our infants, warmly wrap- ped up from the moment of their birth, acquire or retain a sensi- bility of the cutaneous integument, which in advancing years, will readily receive any form of morbid impression, unless due protection be regularly afforded it. To such impressions the lower extremities seem very specially liable, perhaps from the comparative want of force in the vascular circulation. There is no error therefore, in the common notions as to the danger of sitting or standing with cold and wet feet: and we are but too familiar with the effects to be anticipated from the exposure of the frail form of delicate beauty, unless mantled in furs and thick soft woollen envelopes, to the rough keen winds of the winter night. Much has been written on the choice of materials for our clothing, and especially for the garment to be worn next the skin. Those who regard chiefly the varying electrical conditions of the atmosphere, urge upon us silk as deserving a preference, and there are great numbers who advocate its claims very strongly. Flan- nel seems to answer every purpose, defending us well against the cold and moisture of the air. When it proves warm and irrita- ting in summer as some complain of it, we may substitute cotton in some tissue or other. Nor can I help adding another to the frequent but unheeded warnings, as to the injudiciousness of em- ploying linen for the inner dress. It is quite unfit for this pur- pose ; being a ready conductor of caloric it renders the surface ea- sily accessible to all changes of temperature, and as it absorbs moisture slowly, the perspiration thrown out from the body is al- lowed to remain in contact with it, chilling or irritating it accord- ing to the heat of the seasons and the condition of the subject. Frequent changes of the interior garment, let it be made of what- ever material, are essentially necessary to health. Much of the EXCITING CAUSES. 45 predisposition to low fevers met with in our negro slaves, and in the destitute poor every where, seems to me to be owing to the retention, in contact with the skin, of the oily, saline, and other recrementitious substances which it is one of its peculiar functions to eliminate. We see its more direct effect too, in the frequent occurrence of cutaneous eruptions. In regard to dress, as indeed with respect to all our customs, manners, and social and personal habits, fashion lays upon her votaries certain heavy penalties, which they bear, especially the weaker portion—our women—with the contented spirit of cheer- ful martyrdom. The female corset, or stays, with their appen- dages, have been subjects of severe animadversion. They are however susceptible, I think, of a fair defence. They are not necessarily hurtful, but do injury by excess or want of adapta- tion. They give a graceful support to the form, which they unequivocally improve by imparting an air of firmness and neatness. If laced too tightly, however, they compress the thorax, impeding the respiration and rendering the motions of the body awkward and restrained. The steel-piece or whale- bone in front, if too broad may press upon one or both breasts so as to give rise to inflammation, schirrhus or abscess. The occupations followed by man in civilized society, and rendered necessary by his artificial wants and luxurious refine- ments, must not be omitted in our brief enumeration of the sources of disease. They have indeed been already alluded to among predisposing causes, but it is not in that way they chiefly exert their influence. It is almost inevitable that the special use of any one organ or set of organs of the body, shall unduly or disproportionately determine to, develope or excite the parts thus acted on. Hence arises a long train of evils. Even in the external configuration of the body there is a loss of symmetry. The oarsman has a full chest with muscular arms, but ill-shaped and unsightly lower limbs upon which he walks badly. The dancer on the other hand, exhibits large calves and buttocks, with a weak and slender arm. It is not to be forgotten that some modes of employment improve the condition of the organ while others deteriorate it. Thus the sailor accustomed to the spy-glass and always straining his vision to its utmost limit, enjoys a keen and good sight, while the gold-smith and watch- 46 EXCITING CAUSES. maker labor under various defects of the organ—near-sighted- ness, dimness of vision, and frequently opthalmia. Mechanical irritations are to be noticed, and the results of vehement muscu- lar action. In agricultural districts where it is customary to pare the soil, the laborers who work in this mode can scarce escape hernial protrusions from the nature and force of the awk- ward postures and movements of the pelvis and abdomen. The miller, the stone cutter, and the needle grinder, suffer bronchial and pulmonary inflammation brought on by the small particles of mineral, metallic and chaffy substances which they inhale mixed with the air they breathe. Ginning and picking cotton render our negroes liable in the same way to similar affections. Coal miners and heavers are said to exhibit after death, not rarely, masses of black dust impacted in the lungs. Still worse are the specific ill effects produced by the specific poisons used in the arts or applied incidentally to the surfaces of the body. Painters become subject to colica pictonum and paralysis, from handling and inhaling the salts of lead. Gilders are poisoned by the fumes of mercury; their gums are swollen and spongy, their teeth loosen and fall out, and a general trembling of the muscu- lar system supervenes. To obtain the same fluid metal from the earth, shortens so much the lives of the miners, that it is the almost exclusive employment of criminals and convicts. Bakers, by kneading the fermenting dough, bring on an obstinate cuta- neous inflammation of the hands and wrist. Chimney sweeps only by accident escape the foul and intractable cancer scroti, caused by the irritation of the soot lodged in the folds of the scrotum. In all manufactories, the confinement, bad air, con- strained postures, and though mentioned last, yet not least in importance, the wearisome monotony to which each individual is relentlessly condemned by the modern system of minute divi- sion of labor, are all calculated obviously to deteriorate the physi- cal condition, weaken the constitution, and depress intensely the powers of vitality. What spring of life can there be found in the bosom of him who knows that his whole earthly existence is to be spent in polishing a button, or sharpening the end of a pin? Hope never enters such establishments as these. Her cheering influences never lighten the dreary labors of the long day spent within their gloomy precincts. EXCITING CAUSES. 47 Few if any of the exciting causes of disease are more fre- quent or influential than the various emotions and passions of the mind. They are usually divided by physiologists and pa- thologists into two classes, the stimulant and sedative; but in this view of the diversity of their agency I cannot coincide. All emotion, every passion is in its own nature stimulant. This is their original and essential effect. They present, however, the obvious analogy with many physical stimulants, that in the more intense degrees they may overpower, and this instantly, the physical forces ; or the excitement to which they give rise, may be very transient and therefore not readily observable, while the consequent depression is fixed and permanent, and cannot there- fore escape our notice. Their direct and immediate operation seems determined upon the nervous centres, if I may so express myself—the brain, the spinal cord, and the ganglions of the great sympathetic. They affect the circulation indirectly, and in a very exact proportion to the sensibility and irritability of the temperament of the subject. They quicken the motions of the heart; they render tremulous and unsteady the contractions of the voluntary muscles, though they increase generally the force of the contractions. When intensely aroused and long protracted they strongly tend to overthrow the throne of reason, and produce some one of the forms of insanity. Anger occasions flushing of the face and redness of the eyes, and by determining the blood forcibly to the head directly en- dangers the integrity of the cerebral structure, and gives rise to epilepsy and other convulsions, to paralysis and apoplexy. Broussais tells us that this passion "when physiologically con- sidered, is primarily a simultaneous irritation of the brain and the epigastric centre. Hence the vital action of the brain is often changed in the most violent paroxysms of anger into hemorr- hages or inflammations which resist the best directed efforts of art." Nor do the other viscera escape unhurt in the concussions of rage. The same author declares that he has seen it "produc- tive of both hemoptysis and severe pneumonia." The effects of violent grief are very similar. I have myself seen apoplexy follow a paroxysm of this passion. Hysterical and epileptic convulsions are more common. There is less risk 48 EXCITING CAUSES. of injury, if abundant tears from the eyes of the mourner come to the relief of the cerebral oppression. Joy, when exquisitely developed, readily becomes a dangerous emotion, and by the same pathological influences. The door- keeper of congress fell apoplectic on hearing the news of the cap- ture of Cornwallis. "Prosperity," says an ancient proverb, "is harder to bear than adversity." It is proper to note, that during violent joy and profound grief, the subjects of these emotions re- fer much of their uneasiness to the region of the heart, which they speak of as "full," "oppressed," and "bursting." Of all the passions,/ear is the most annoying and deleterious. Tremor, spasms and convulsions are its frequent effects. It aug- ments, occasionally, certain of the excretions, and relaxes the sphincters, thus giving use to diarrhoea and micturition. It arouses the muscles of voluntary motion to forcible action, endows with immense strength, and "gives wings" for the flight which it prompts. There are numerous examples on record of its fatal influence, when intense in degree, frequently renewed or long continued. Anxiety, a state of mind of which fear is the predominating element, produces some of the most singular of those phenome- na, which are familiarly referred to as exhibiting the close con- nection between the moral and physical portions of our being. The beautiful hair of the high-born Marie Antoinette, became gray in a few hours from the excess of this emotion: and the whole frame has been known to assume, in a short period, all the appearances of sudden old age. Love, though last not least on this brief catalogue, is doubtless the most powerful of human passions, well deserving to rank among the most fruitful sources of disease, and this even, when successful and happy. It is at best but a stormy emotion, and knows no tranquillity; but when accompanied by jealousy, its ordinary attendant, nay its almost inseparable companion,"that mind must be singularly well poised, and that frame robust in- deed, which can withstand their concussions. Anger has been called by the Latin poet, a "brief madness"—love is more mad than anger, and unhappily is not so brief. EXCITING CAUSES. 49 The poisons, properly so called, deserve a prominent place in this enumeration of the exciting causes of disease. The word poison may be defined to mean a substance or agent whose spe- cific and peculiar efficiency is injurious to the health of the sub- ject on which it acts. The degree of injury which they are ca- pable of producing varies in each, from a transient disturbance of function to mortal prostration of vital power, or fatal organic le- sion. The force with which each shall act, is liable to be modifi- ed by several contingencies, as the condition of the recipient, the amount of dose, the repetition or duration of its action. But these circumstances do not change or modify in any notable or uniform manner, the nature or kind of influence to be expected. Our definition, it is obvious, will include the long catalogue of medicines, which all, if efficient in the production of any per- ceptible effect upon the body, derange some of its functions. As therefore all medicines are in this sense poisons, so some the- rapeutical experimenters, with Stoerk at their head, have been dis- posed to regard all poisons'as medicines : and the speculation has been fruitful of some valuable results in the addition to our appa- ratus medicaminum, of several important remedies, of which prassic acid and strychnine will serve as examples. But the rale thus proposed is liable, as you will soon observe, to a very wide range of exceptions. Poisons are usually divided according to the kingdoms of na- ture in which they have their origin, into vegetable, mineral, and animal;—to these I will add a fourth class—the serial, which comprehends several important and extensively influential agents not to be arranged with definiteness under either of the other heads. 1. The vegetable poisons are numerous. Some few of them, as the upas and mancinella, act by exhalation, and reach the sub- ject at some distance; applied to the skin they irritate severely. In this latter mode, though with very different degrees of violence, the horse radish, mustard, rhus radicans, rhus vernix, cashew nut, mannarilla, and cerbera ahovai, affect the surface with in- flammation. Some require to be introduced into the circulation through a wound or abrasion of the cuticle. It is in this way that the terrible effects of the woorara, ticunas and other South- American and Asiatic poisons are produced, and thus the weapons vol. i.—5 50 EXCITING CAUSES, of certain savage tribes are rendered deadly. But a still greater number of vegetable substances act upon and through the me- dium of the mucous membrane lining the digestive tube. These you are familiar with, under the names of emetics, purgatives, etc. titles only serving to point out the modes in which they disorder the system. The more indirect effects of the diuretics and nar- cotics, are supposed to be accounted for, partly by a sympathetic action extended from the nerves of the surface to which they are applied, aud partly also by their absorption into the mass of cir- culating fluid, and being carried to the organs upon which they are specifically adapted to act—the kidneys, namely, and the brain. 2. The list of mineral poisons is not very long, if we recount only those which nature offers us ; but the researches of chemis- try have added prodigiously to the extent of this class, by her combinations and decompositions.- The pure earths, as they are styled, and the alkalies, are caustie and corrosive ; so are the min- eral acids generally. The metals are inert or almost harmless, until by the action of the air or of some acid, they are converted into oxydes or salts, with the exception of mercury, which in its simple volatile form seems deleterious ; this is perhaps true also of arsenic. In the quicksilver mines, the workmen are consider- ed victims, whoses places almost annually rendered vacant by death must be filled by new victims. Criminals are employed in this way, and thus expiate the guilt of murder, treason and sa- crilege. The direct action of mercury is upon the salivary glands, and the neighboring tissues and the bones of the face, giv- ing rise to ulceration, gangrene, caries and necrosis. Arsenic, unhappily well suited to designs of evil from- the mi- nuteness of the fatal dose and the easy disguise of which it is susceptible, excites a dreadful and uncontrollable gastritis. Lead produces rachialgia and paralysis, and perhaps epilepsy. Cop- per is stimulant and corrosive. Antimony occasions vehement vomiting, cramps and spasms. 3. Reserving the animal poisons for future consideration, I proceed, 4. To speak of the aerial. Under this head, (which constitutes indeed a large class of agents deriving their origin promiscu- ously from all the sources above mentioned, the vegetable, animal and mineral kingdoms of nature,) I shall include, besides the gases, EXCITING CAUSES. 51 properly so called, all the impalpable contaminations of the atmos- phere, with the single exception of the contagions, which are hereafter to engage our special attention as obviously and exclu- sively of animal formation. Some of the asrial poisons we may denominate chemical, as •consisting or composed of elements which are known in the laboratories, and can be produced by the processes of art and detected by definite tests; others again are obscure in their na- ture and entirely beyond the skill of the chemist to create, detect, or destroy them, such as the various modes of miasm or malaria. From what you have learned on the subject of respi- ration, and the uses of atmospheric air in the animal economy, you are of course aware, that any change in the constituent principles of which this fluid is compounded, or even of their relative proportions, must be attended with dangerous conse- quences to those who breathe it so modified, whether the change consist in the subtraction of any of its essential ingredients, or in the addition of any new element. You will never meet, per- haps, with any accidental example of the deleterious effects of inhaling air rendered unfit for respiration by the mere supera- bundance of one of its own constituents, except in the instance of carbonic acid gas. Its proportion in the atmosphere is small but uniform, about one part in one hundred, but it is evolved largely from the lungs at every act of expiration. If, therefore, an animal is confined for any length of time within a limited amount of air, he will die. His death was formerly ascribed to the consumption of oxygen only, which was regarded as the vital element, but the experiments of Goodwyn prove that he will die from the directly poisonous influence of the carbonic acid, before the oxygen is so far consumed. Ordinary combus- tion, which you know presents many analogies with respiration, gives out also large volumes of this gas, and thus in close rooms many have died A young man of France, the son of a cele- brated chemist, chose, during the horrors of the revolution, this mode of suicide. Shutting himself up closely in his chamber, he inhaled the fumes from burning charcoal, and amused himself by writing down from time to time a record of his thoughts and sensations. Before the writing ceased to be legible, it was evi- dent from some of the expressions, that his mind had wandered 52 EXCITING CAUSES. Since then, this has become, on the European continent, a rather fashionable mode of voluntary death. Thus perished acciden- tally, in 1826, two young men on board a small vessel in the harbor of New-York. They warmed their little cabin with a pan or stove of lighted charcoal, and were found next morning quite dead. It would appear that nature in various modes, but especially by the action of plants upon the atmospheric air, evolves in her immense laboratories, considerable volumes of this gas, which by its specific gravity, is carried into mines, caverns, vaults and wells. These places thus become the scenes of fatal accidents, from the carelessness of miners and well-diggers. Certain spots have become notorious for the pouring forth of continual streams of carbonic acid, either in combination with water, as at Sara- toga and Seltz, or in its free state, as at the famous Grotto del Cane, near Naples. In this recess a dog being held for a short time becomes restless, languid, and at last falls senseless. After a brief convulsion he sinks into apparent death, but if promptly removed into the fresh air revives in a few minutes. The symptoms which affect men who descend hastily into vaults, wells, etc., resemble these. The patient falls asphyxiated, incapable of motion, insensible ; his face is livid or purple; ani- mation is entirely suspended. The best remedy seems to be the shock of cold affusion; a vein should be opened in the arm, and the blood if possible made to flow. The skin, nostrils and eyes should be stimulated by hot applications, by mustard and the vol. alkali. To guard against accidents of this kind, it cannot be too often repeated, that previously to the descent of a workman into any deep cavity, natural or artificial, a lighted candle should be let down. If this continues to burn brightly, the air is pure enough for the purposes of respiration; if it is extinguished or grows dim, we must infer the presence of a poisonous proportion of carbonic acid gas. Q.uick-lime should be thrown in, in sufficient quantity to absorb while slacking the surplus amount, and the test of the burning candle re-applied until that fact is proved. Our newspapers have lately contained the details of numerous fatal accidents from the escape of coal gas, carburetted hydrogen, into close apartments during the night, since the general substi- EXCITING CAUSES. 53 tution of this mode of producing artificial light. Chambers in which gas is burnt should be specially well ventilated. Very peculiar effects are observed to follow the inspiration of air in which there is an undue proportion of oxygen, which when undiluted is known to be a violent stimulant. The nitrous oxyde or exhilarating gas is the most familiar of these, and is very often experimented with both privately and publicly. Yet it is not always free from danger, though in the great majority pro- ductive only of a delightful and transient intoxication, during which the imagination is highly excited and the sensibilities of both mind and body rendered intensely acute. I have known it produce asphyxia with great muscular prostration, violent con- vulsions, spasm, irritation and inflammation of the respiratory organs. Subjects predisposed to pulmonary disease of any kind should never breathe it in the ordinary manner. History affords us a dreadful example of the effects of con- tinuing to respire a given volume of confined air, vitiated by successive subtractions of oxygen, and additions of carbonic acid gas, and loaded with the several effluvia given off from the sur- face of the body. Those of you who are not already familiar with it, will find both interest and instruction in the story as told by Smollett, or more recently by Macauley. The English forces of Calcutta being overpowered, and the city taken by the Suba of Bengal in 1756, the garrison, to the number of one hundred and forty-six persons were all driven into a prison of about eighteen feet square, walled up to the east and south, and open only to the west by two windows strongly barred with iron. In this miserable situation, many of them being wounded, and all fatigued with hard duty, they soon sunk into a state of distraction and despair. The heat was intense, they were covered with a profuse sweat, and the air soon became poisonously infected with the effluvia from their bodies and lungs; composed doubtless of carbonic acid and ammoniacal exhalations. In their fierce struggles to approach the windows, many were trampled down and the weaker were suffocated mise- rably or became asphyxiated. The terrible night at length passed away, day broke and an order was sent for their release; but of one hundred and forty-six who had entered this dungeon, 5* 54 mal'aria. so well known "as the black hole of Calcutta," no more than twenty-three survived. This recital, so shocking to every feeling of humanity, con- veys an impressive idea of the influence of extreme circum- stances ; but no one has hitherto taken proper pains to point out distinctly the agency of the same circumstances in a less degree and extent. Yet it is evident that they cannot be without their injurious effects upon the constitution, as found in crowded or ill ventilated apartments. Care should therefore be taken by all to avoid them, but especially by such as are predisposed to any of the numerous forms of pulmonary disease. CHAPTER III. mal'aria. I have already taken occasion to state that certain of the Eerial poisons are not, like those last spoken of, definitely cog- nizable by the chemist, nor capable of being produced in his laboratory by artificial combinations and decompositions. Under this head we treat of many of the miasmata of the writers of the last age—atmospheric pollutions, as they regarded them, mineral, vegetable and animal, for they considered them to derive their origin from all the kingdoms of nature. It is first in order to discuss the febrific miasms, with whose effects all the inhabitants of hot climates and alluvial soils, wherever situated geographically, are destined to become too familiar. In all allusions to the topic of endemic disease, medi- cal writers find themselves compelled to lay great stress upon the fact that there are large tracts of country in different sections of the world, observed from the earliest times to be subject to a particular class of maladies. The regular occurrence of such disorders at the annual return of the accustomed season, is mat- ter of universal expectation; and the uniformity of their history is equal to that of any of the periodical movements of nature. mal'aria. 05 From a similarity of effects—for these diseases are every where the same, or very nearly identical—we infer a similarity or iden- tity of cause; and in the inquiry as to the nature, origin and pro- perties of this cause, we are led to investigate the question, what circumstances are found to exist in common in the several seats occupied by the endemics alluded to. The result of this inquiry has been, an agreement of opinion almost universal, as to the existence of an aerial poison, whose nature and qualities are not clearly made out, but whose influences are very easily traceable in the production of certain definite effects, and whose sources are, at least, in the majority of instances, sufficiently well known. I proceed to examine as briefly as may be, into the correctness of the received doctrines on the subject. The term miasm (from the Greek puuvu—to pollute) has been long employed in medical writings to denote, generally, those contaminations of the atmosphere surrounding us, which do not immediately affect its respirability nor destroy its power of sup- porting life and combustion, but which introduce a new and poi- sonous agent, tending to excite disease in the human system. I see no objection to the use of this ancient phrase, but it is not sufficiently explicit for our present purpose; and as the repeti- tion of the compound terms intended to limit its meaning, idio miasma and paludal or marsh miasma, significant of certain notions relative to the source and nature of the agent now to be treated of, would be tedious and inconvenient, I shall prefer the modern word "Malaria"—an Italian expression compounded of a noun and its qualifying adjective, signifying literally "bad air." It is employed by MacCulloch in his learned and valuable trea- tise, and has been sanctioned by almost universal usage among recent writers in every modern language. The nature and qualities of this poisonous agent, have been of late the themes of much ingenious discussion and patient and per- severing investigation; but as yet, no test has been discovered by which we may detect its presence, previously to the produc- tion of its morbid influences upon the living body. Chemists have examined with the most minute care, the constituents of the morbid atmospheres in which it has been supposed to abound. Conjectures innumerable have been offered, as to its nature and constitution. The known products of vegetable decay have gg mal'aria, been again and again experimented with, but to no purpose. Nei- ther by eudiometrical applications, nor by the most perfect analy- sis can any additional ingredient of a gaseous nature, either in a state of mere mixture or chemical combination, be detected in such air; and we therefore infer that it is not carbonic acid, nor carburetted hydrogen, nor any other of the chemical compounds that conjecture has suggested. Its want of any notable degree of self repulsion, to be mentioned hereafter, is perhaps the strong- est ground for denying its gaseous nature; yet it seems reasona- ble to expect some further aid from chemistry in this matter, as all the irrespirable gases known to be produced in any consider- able abundance by natural processes, have been suspected pf constituting the characteristic ingredient in miasmatic exhalations, Both Volta and Orfila are favorable to this belief in its gaseous nature, and such is the prevailing opinion of our professional brethren of the great west, even at the present day. We must not pass altogether without notice, the animalcular theory of malaria. Among the ancients, Lucretius, Varro and Columella maintained that the poison of marshes consisted of animalculae invading the body through the lungs, and perhaps also through the stomach. In modern times, this hypothesis has found favor in the eyes of Leewenhoeck, Kircher, and other mi-' croscopists, and was received by Linnaeus; nor has it wanted defenders in our own day, of whom we may mention Holland, O'Neale and President Cooper. I have only to say concerning it, that all the facts, observations and arguments offered upon the subject, leave the evidence still deficient, and merely avail to show the possible truth of the speculation. While these authors as- cribe the influences of malaria to living animalcular irritation, the late Dr. Dwight suggests the probability, that this miasmatic exhalation arises from the death and putrefaction of the immense multitudes of these minute tribes. We shall refer to this however in another place. There may be mingled with the atmosphere many substances in a state of diffusion, which chemistry has at present no means of detecting. Such are the odoriferous particles of musk and camphor, and the delightful fragrance emitted by the gay flow- ers which scent the air of spring; such the minute particles of opaque matter, darkening in greater or less degree the light of mal'aria. 57 day, and tinging with peculiar hues the beams of the sun. A recent experimenter, it is affirmed, has at last succeeded in pro- curing a peculiar deposit from the dewy air of insalubrious places. Boussingault has exhibited a blackish matter in small quantity, which he collects by exposure of plates of glass, through the night, in atmospheres of known foulness. If this dark matter be the poison of malaria, this point should be tested if possible, pa- thologically, as also the chemical constitution of the deposit. When treating of its effects, it will be more in order than in the present relation, to speak of the inferred qualities of this poison- ous agent. I have already said that it is from the similarity of these effects that we deduce the presence and identity of a common cause efficient in their production. Peculiar forms of fever, for exam- ple, precisely resembling each other in their modes of access, their type, their history, their various degrees of malignity under known circumstances, and the morbid changes they impress upon the several organs of the body, are observed to be endemic in many districts of the inhabited globe. The same description will apply to the fevers of our wide continent, whether on the margins of our great rivers or our interior lakes, upon the swamps of the Atlantic coast or our rich rice fields, and those of the fens of Lincolnshire in England, of Carthagena in South America, of Coranna in Spain, those of Savoy, and the fertile plains of Lom- bardy and of Walcheren in the Netherlands. For this, Batavia in the island of Java, has been called the grave of strangers. By this, the prospects of African colonization are delayed, and Libe- ria and Sierra Leone decimated. It is this, which renders British dominion in the Indies so expensive in European life. To this, is owing the comparative desolation of the ancient mistress of the world—the queen of nations—the eternal city. The malaria arising from the whole surface of the surrounding country,—the solitary campagna, and the Pontine marshes, annually extends its encroachments through her streets and noble squares, and threatens the entire depopulation of her seven hills. It will be noticed, that in a large majority of the situations which I have thus hastily enumerated, a great abundance of water forms a striking feature of the region, and hence it has been supposed that the mere presence of an undue quantity of 58 mal'aria. moisture is sufficient to account for all the phenomena. This was, indeed, the prevailing doctrine before the time of Lancisi, to whose philosophical mind we must ascribe the establishment of the opinions at present received. The old notions have lately been revived and are maintained ingeniously enough by a few writers. A brief reply will suffice. These fevers are not exclusively confined to moist situations. It is easy to enumerate many instances of their occurrence in arid and elevated districts. In Italy they prevail on several elevated ridges; at Civita Castellana; on the summit of the Radicofani, as well as in the marshes of Mantua, and about the Venetian lagunes. Dr. Ferguson, formerly of the British army, whose statements are confirmed by Brown, declares that "he saw remittents and intermittents become epidemic in Dutch Brabant, in the encamp- ments of Rosendaal and Oosterhout, upon level plains of sand, with a perfectly dry surface." He speaks "of villages in Spain, near the confines of Portugal, upon the banks of the Tagus and Alagon, pure and limpid streams, running through a rocky san- dy district, so unhealthy during the autumnal months, that every person makes his escape who has the means; and even horses and other domestic animals are removed for fear of fever. One of these villages he describes as the most parched spot he ever saw; the loose dry sand actually obstructing the doors and win- dows of the houses." Farther—it is not during the rains that the malignant fevers of Africa arise. On the banks of the In- dian rivers in Burmah and Siam, those have the best chance of evading the jungle fevers, who live in houses built in the water upon piles, and approachable only in boats. Among the bayous of lower Louisiana, Dr. Cartwright affirms the entire absence of malaria fevers. If he is right in attributing their salubrity, as he does, to the presence of the jussieuia, still this leaves the argu- ment against their aqueous origin untouched; for although this vegetable may produce an agency counteractive of a specific poison, as it has no tendency to diminish the amount of atmos- pheric moisture, it cannot prevent diseases derivable from that source alone. In our own district of country it is not always the immediate dcinity of the lake, mill-pond or river that suffers most. Those Wal'aria, 59 dwelling in the valley or on the river bottom often escape, while the residents on the hills or bluffs adjoining suffer. But no one can imagine the higher air to be more imbued with moisture than the lower strata. Besides this, the amount of water spread over the surface of our country, is undoubtedly decreasing in a perceptible degree with the clearing of our forests; nay it is asserted, and seems to be sustainable by proof, that every where as far as observation extends, the quantity of water is becoming proportionally less, whether we regard the stagnant masses or the cm-rents of rivers. Now, so far from the diminution of mois- ture being followed by any alleviation of the evils we have attributed to malaria, we cannot shut our eyes to their regularly progressive increase. The trim avenues, and well built man sions, scattered over the face of our low country by the several generations of our predecessors, may be seen in the majority of instances, fast falling to decay—the period of safe residence in them having become obviously shortened. The middle districts of our state have undergone a striking change for the worse. Many spots formerly resorted to by the inhabitants of our city and the low country generally, are now abandoned or nearly so. Some of the beautiful country seats in the neighborhood of Philadelphia, are, for this cause, deserted ; and the physicians of Massachusetts and Connecticut tell us, that intermittent fever is gradually extending its limits farther north, and still seems dis- posed to progress, attacking one neighborhood after another. These are facts which it is impossible to reconcile with the doc- trine which ascribes all this class of maladies to the influence of moisture alone, and not a specific poison, and it is upon facts like these that Ferguson has based the novel and contrasted theory "that one condition only, is necessary to the production of febri fie miasm or malaria, and that is—paucity of water where it has previously and recently abounded." Paucity of water, how- ever, can never be predicated of our inexhaustible swamps or of the Indian jungles, so that these views are quite as untenable as those for which they are substituted. __, With respect to the inquiry, whether salt marshes are as inju- rious as fresh swamps, I would incline to the negative reply, notwithstanding the experiments and opinions of Sir John Prin- gle. The venerable Robert Jackson tells us, that "the usual 60 mal'aria. endemic of warm climates is less frequent and formidable on the banks of rivers after their waters become mixed with those of the sea, than before this has happened." The experience and obser- vation of our own Southern country confirm this view and speak loudly in favor of our sea-shore settlements, as Sullivan's island, Eding's bay, etc. It is not to be denied, that the troops in garri- son at Fort Moultrie have been as healthy as those at any other military station in the United States. It is a curious question, but one of great difficulty, whether there is any difference between the results of the decomposition of different vegetables. Some strong statements, and ingenious speculations, have been offered to prove that there is such a dif- ference. The plants which have been pointed out as most injurious, are those which grow most luxuriantly in damp, rich soils, and those which contain most succulent juices. The white or Caucassian race cannot, in any portion of the globe, cultivate rice with impunity. The recent report made by a committee of Italian savans at Lucca, is decisive on this subject. The rotting of flax and the steeping of indigo are rather less dangerous, yet still notably so. These agricultural products all require for their perfection and preparation much moisture. Few observations seem to have been made by physicians in reference to these de- tails, and yet it is thus only that we can learn definitely any thing. They are surely worthy of more attention than they have yet obtained. The generally received opinion or doctrine among medical writers is, that the febrific poison, known as malaria, is the pro- duct of vegetable decay or disorganization, a notion expressed in the common phrase marsh miasm, and a great mass of facts may be adduced in its support. A high temperature with moist- ure, not only favors the rapid and extensive growth of vegetables, but hastens their maturity and fosters their decomposition. In hot, moist and fertile districts of country, then, we should find the greatest intensity of malaria influence, and observe most frequently its effect upon the human system. I need not remind you that such is, indeed, the fact, and that many of the finest portions of the earth's surface, vast tracts of the most productive soil, the best calculated for supplying man with food, are thus rendered almost or absolutely uninhabitable by the mal'aria. 61 higher races—the thick and clustering vegetation thrown forth in such spots serving only as a den for wild beasts or inferior and savage tribes, and a shelter for venomous reptiles. From this cause, either wholly or in part, authors derive the existence of most of the dreadful forms of fever. Both yellow fever and the plague are supposed to be developed under its influ- ence, combined with other agencies, not well made out. We find the intensity or malignancy of the diseases produced by it, very directly proportioned to the degree and permanency of the heat of the locality affected. Thus, in low latitudes, besides the terrible forms of pestilence just mentioned, we have malignant remittents and intermittents, of great proportional mortality, and violent dysenteries and acute hepatic disorders. As we proceed northwardly, we encounter the less severe remittents and inter- termittents, chronic hepatitis and splenitis and dropsy. Now it is a very striking circumstance, that we can often trace these dis- eases to narrow and limited sources, where no special condition is present but the obvious putrefaction of vegetable matter, which seems indeed to prove the evolution of the marsh poison malaria, as well in the confined air of a fruit or potato cellar, and in the dirty hold of an ill-ventilated ship, as in the neighborhood of a mill-pond, or pervading the atmosphere of Egypt, on the subsi- dence of the sacred river. In a perfectly dry air, vegetable decomposition is arrested, or proceeds with extreme slowness and in a peculiar manner. Cold also retards the process, and when it reaches the freezing point, altogether prevents it. During even the mildest winters, the changes of decay must go on very slowly, and the comparative- ly small amount of effluvia given forth from time to time, diffu- sed widely through the air and largely diluted. During the reign of frost the agriculturists of our low alluvial country, think them- selves safe from the ravage of miasmatic pestilence. Released from their summer residences at the commencement of winter, they remain upon their plantations until the return of spring, whose balmy zephyrs waft us on their soft warm wings the ele- ments of destruction. I do not know that fruit ripens with us earlier than in years past, nor is there any proof of a more rapid precession of the seasons, or of the abbreviation of our winters. Yet it is certain that the period of annual return of our endemic vol i.—6 62 mal'aria. fever has undergone a notable anticipation. Planters in the olden time remained, they tell us, safely among the rice fields un- til June or July. It is now attended with some danger to delay their removal later than the beginning of May—nay I have seen cases brought on from exposure in the latter part of April. These facts are not easily accounted for. In a new country, to use an American phrase, the upper stratum of soil is composed of the remains of leaves from the forest-branches which from time immemorial have overhung and shaded it, and of the shrubs and weeds which have flourished and died in succes- sive generations upon it. The clearing then'of such land, must expose to the direct rays of the sun an immense amount of miasmatic material, and occasion a rapid and abundant evolu- tion of the noxious principle. Thus our early settlers, the pio- neers of our migratory population, are exceedingly liable to fever, as if the genius of our ancient forests were determined to avenge the invasion of his long undisturbed and solitary domain. This layer of vegetable soil being superficial, and on the uplands of no great depth, is in no very long time destroyed, and such positions become free from disease. But there are alluvial lands, such as our river bottoms and rice fields, formed * to indefinite depths of such vegetable mould; here the quantity of material being absolutely inexhaustible, the generation of malaria will progress interminably, and these localities will be forever un- friendly to the constitution of the white race. It should be remarked, that although partial clearing must, as has been said, increase, at least for a time, the insalubrity of the climate, yet the entire removal ultimately of the vast masses of wood which still cover the face of our country, besides cutting off the farther supply of material, will, by permitting free circulation of air and agitation of winds, occasion a diffusion of the malaria de- veloped, and dilute away much of its noxious influence. This question of "dilution" has, however, been seriously ar- gued by some writers, (vide MacCulloch) who maintain the capacity of indefinitely small portions of malaria to produce the most intense results. This is a gross error. A distinction has been offered by sounder pathologists, between a virus and a poison, on this ground, that the smallest effective amount of the former, as the matter of small pox contagion for example, mal'aria. 63 will produce in the system which it affects, all the changes which follow the introduction of the largest possible quantity, while on the other hand, the effects of all poisons differ accord- ing to the dose administered, and may thus be regularly gradua- ted. But it must not be forgotten that they may both be diluted to absolute inertness. The influence of moisture in promoting the development of the diseases attributed to malaria, is undeniable, and seems to be two-fold. Besides fostering the decay of vegetable matter, it appears to enter into intimate union with the noxious agent, perhaps effecting indeed, an actual solution of it. Fogs have in all ages and among almost all nations, by the vulgar, by poets, and by philosophers, been considered as either insalubrious in themselves, or as the medium.of conveying misasmatic princi- ples diffused in the atmosphere. They are not in themselves febrific, for they are frequent in many regions where malaria fevers are unknown, as over the rivers of New-England, the peat bogs of Ireland, the Scotch lakes, and the mountainous table lands of our own country. But in miasmatic districts it is matter of constant observation, that the period at which fogs rise into the atmosphere and condense from it, are the most dan- gerous to those exposed. The hour after sun-set and the hour preceding sun-rise are, on this account, to be avoided—so indeed, is the whole time during which dews are falling. The night is a much more perilous season than the day, the least risk being supposed to exist at noon, when the aqueous exhalations are carried up into the higher atmosphere by the heat of the vertical sun. The influence of different seasons upon the salubrity of mias- matic regions, is analogous to what has been stated. A very dry summer and spring are apt to be healthy. A very rainy sea- son produces a like effect, by covering the whole surface of nox- ious material. Heat, air and moisture are equally necessary to the miasmatic decay of organized vegetable matter, which may or may not be identical with offensive putrefaction, but which cer- tainly depends upon the same efficient elements. Thus it happens that in very wet autumns the higher grounds, even the sides of hills and mountains, share the evils which in ordinary and dry years are confined to the vallies, water courses and alluvial 64 mal'aria. plains. I do not pretend to affirm that these remarks are of universal or exclusive application. There are, I acknowledge, many exceptions, but long experience has established their cor- rectness as general rules. In a similar way we explain the immediate effect of rains. If these are heavy and large, they combine with, bring to the earth, and carry off in solution the atmospheric effluvia, washing away in their course also, much of the soft, loose, decaying vegetable surface. Slight showers, on the other hand, falling on the hot soil, are promptly evaporated, and rise again into the air in the shapes of fog and vapor, bearing on their damp wings dense masses of pestiferous exhalations. The action of the electric fluid upon febrific miasm is not well understood. A general opinion has prevailed from time imme- morial, that its agency is highly salutary, whether by any puri- fying effect upon the atmosphere, or by a beneficial influence exerted upon the human constitution. Electricity may act in both these modes; yet the notions entertained on the subject are as yet altogether hypothetical. It must not be forgotten that thunder storms, always esteemed so salubrious, are attended with great agitation of the air and wide tumult of the elements. If good result from these concussions of the tempest, we must not attribute it exclusively to the forked lightnings. Winds disperse the foul mephitic effluvia which "pollute the sky," and driving them forward with infinite force and rapidity, diffuse them through space, and extinguish their malignant activity by de- stroying the concentration upon which depends their virulence. Calms, by favoring this concentration, give to all aerial poisons an indefinite intensity, as has been noted, from the plague of Athens down to the present time. Hence we find the sufferers in cities devoted to every form of pestilence, endeavoring with all the energy of despair, to set in motion currents of air by arti- ficial means—by gloomy fires kept burning in the desolate streets, by the explosion of artillery, and the combustion of large masses of gunpowder. It would be improper to pass here, without notice, some of the objections that have been made to the exclusive veo-etable origin of malaria. It is undeniably true, as has been stated, that we find this febrific miasm existing in a state of powerful con- mal'aria. 65 centration, and exerting its deadly influences wherever marshes, bogs, etc., are spread out under a hot sun; it is alleged, how- ever, that its presence is also ascertained unequivocally in situa- tions where this combination of^ circumstances does not occur. "The malaria of Italy," says an American writer of respectabili- ty, "is found in very different situations, situations indeed, so different, that we can scarcely be justified in believing it always to proceed from the same cause." It is indeed, certain, that many of the districts subject to malaria fevers do not present the peculiarities which we have hitherto been considering as con- nected with, or concerned in the development of this noxious effluvium. The Campagna di Roma, deserted for its insalubrity, except by the herdsman and his flock, "is a territory entirely of volcanic formation, broken into gentle undulations, quite dry," and elevated considerably above the level of the sea. The vege- tation upon its surface is by no means abundant. In a great number of instances the sites of old, extinct volcanoes, are pecu- liarly unhealthy. Such is the fact with regard to Boccano, a solitary post-house about twenty miles from Rome, situated in a sort of valley, perhaps the very crater of an extinguished volcano. In June, 1826, I found more malaria fevers prevailing at Civita Castellana—until lately regarded as the ancient Veii—than in any other part of Italy, the pontine marshes not excepted. This town is situated on a high hill, or rather mountain of volcanic formation. The surrounding rocks are disintegrated, soft, and porous, insomuch that the shepherds have in many places made extensive excavations in the hill sides, sufficiently large to re- ceive considerable flocks of sheep. There can be no stagnant water in its environs, from the nature of this loose tufa, as well as from the broken abruptness of the face of the country, which presents in its rude outlines some resemblance to certain parts of Scotland. You enter the gate of the town by a bridge cross- ing a glen or ravine more than one hundred feet in depth, down which a mountain stream rolls its ever-varying torrent. From our very inn-keeper we received an honest warning of the dan- ger of remaining there a single night, and were urged to pro- ceed, with the emphatic declaration, that "every body in town had the fever." Emerson, in his "Letters from the Egean," gives us some analo- 6* 66 mal'aria. gous statements. "The town of Milo," he says, "is situated, like almost all those of the Levant, on a conical acclivity, towards the summit of which its narrow streets stretch up with a precipitancy much more conducive to cleanliness than to convenience. The climate of the Milots is one of the most noxious in the Levant, and their soil being volcanic, is still boiling and fermenting with intestine fires, and constantly emitting the most unwholesome vapors and deadly miasmata. On this account, they have, by degrees, deserted the former town, which stands near the shores of the harbor, and retired to the more lofty situations and the mount I have mentioned, and even this latter is now becoming gradually unhealthy and deserted. The porous rocks of the hills have been hollowed out, like those of Antiphyllus, into numerous catacombs, but now occupied chiefly as sheepfolds by the peasantry." These facts are, by some writers, regarded as giving founda- tion for a reasonable belief, that the volcanic remains of positions like those alluded to, may, at a certain point of decay and disinte- gration, evolve a febrific miasm, either similar to or identical with paludal malaria. It is well to note, in a definite way, before we proceed farther in this discussion, what are the alleged effects of malaria upon the human constitution. The list of diseases attributed to it by dif- ferent writers, is, indeed, a long and diversified one; but we shall have occasion to comment, as we go on, upon some strange mistakes and exaggerations. Cholera, plague and yellow fever have been too hastily set down on this catalogue, as I shall show in the proper place. Typhus fever is more plausibly derived from this source, yet, for my own part, I would not ascribe to malaria alone, any form of continued fever. Remittents and intermittents are the most familiar and characteristic conse- quences of exposure to its action. Neuralgia, in several of its ill defined varieties, is placed here by MacCulloch and others. With as good reason, we may add cretinism and goitre. Dysen- tery is almost universally considered under this head. Hepatitis and dropsy I am disposed to regard rather as secondary than immediate or direct effects of its action. Dr. MacCulloch gives us the following appalling catalogue of malaria diseases:__"Fever, continuous or remitting, of an endless diversity of character; mal'aria. 67 intermitting fever, almost equally various in its appearances; dysentery; cholera; diarrhoea; apoplexy; palsy; visceral ob- structions and dropsy; the mesenteric affection; worms; ulcers of the legs; elephantiasis; rickets; scrofula; phthisis; scurvy and chlorosis; the pellagra of the Italian Alps;" and even "goitre and cretinage" are mentioned here with "hernia andvarix; angi- na; catarrh reaching to peripneumony; asthma; dyspepsia of an inveterate character ; and oedema of the lungs." He, then, goes on to "propose a large addition in the disorders which he has ranked under the term neuralgia," which, indeed, he has made to comprise almost all the remaining "ills that flesh is heir to," "such as sciatica, toothache, headache, other painful or nervous affections,"—a very sweeping phrase, by the bye,—"and, finally! fatuity and even mania." Among the most striking exaggerations into which half in- formed writers on this subject have fallen, is the statement which they make as to the influence of malaria upon both the average and extreme duration of life. Assuming the mean term of life in England at forty-five years, it has been calculated, in some malaria districts, at not more than 25-22-1S. MacCulloch, and after him, Brown, a recent writer in the English Cyclopedia of Practical Medicine, have rated the extreme term of life in Egypt, and in Georgia and Virginia as not exceeding forty. We cannot but smile at the total ignorance of geography and statistics exhibited in such assertions; but the error should not go uncon- tradicted. In a table of the deaths occurring in Charleston from 1S20 to 1827 inclusive, there are 2,181 recorded of persons above forty years of age, being nearly one-third of the whole amount for that period, 6,953, thirty-one being upwards of a hundred) and two above 110. Yet, I am sure, that the inhabitants of the country included within the limits meant by these writers, when they speak of Georgia and Virginia, would be unwilling that our city should be taken as their standard of salubrity. I am inclined to think, that our average duration or mean term of life approaches very nearly, as, indeed, might be inferred from the table given, to the point they have set down as the extreme; at any rate, I would place it above thirty-five. The venerable Robert Jackson affirms, in his treatise on fever, that at Petersburg, Va., a native rarely reaches twenty-one. He 63 mal'aria. passed through that town during the revolutionary war, when, probably, all its adults were in the field with Lee or Washington, and when, indeed, it had scarcely been settled long enough to give more than twenty years to an infant born there.* ' In all malaria countries the mean term of life of females is beyond that of males, on account of the greater risks to be en- countered, labor to be performed, and exposure to be gone through in the prosecution of all active occupations. Another important point to be determined, is the influence of malaria upon the fertility of our species. It would, at first view, seem reasonable to anticipate an indirect diminution of the num- ber of births in a country subject to malaria on account of the individual sufferings from attacks of disease, yet this effect is not noticeable. In some of the villages beyond Rome, on the road to Naples, Fondi and Itri for example, in the midst of a region, where the delay of a single night in the warm months, is at the utmost risk of the stranger's life, children throng the streets in such crowds that the most careful driver can scarcely avoid crushing them. In the absence—doubtless to be regret- ted—of any statistical details on the subject, we should laugh at any one who would rate the average fertility of marriages in our own Southern country at less than seven or eight. This, though a conjectural estimate, is probably little, if at all exaggerated. It has been much disputed, whether malaria, in producing its effects upon the body, acts primarily upon the skin, the lungs or the stomach. The favorite opinion among the physicians of America has been, that it acts almost exclusively upon the inter- nal surface of the stomach, being mingled with the saliva and swallowed. Hence, the habit of eating previously to unavoidable exposure, and of smoking tobacco while exposed, in the latter of which practices great confidence is placed by many. In Europe, on the other hand, a majority sustain the doctrine of pulmonary inhalation, and believe the lungs to afford the chief inlet of all * There has just been published, February, 1839, a notice of the death of Mr. Boiling, aged seventy-nine—"the first white person born in the town of Peters- burg." Mr. Boiling could not have been more than eighteen years of age when Jackson visited Petersburg. No better comment than this can be offered upon the.crude and careless statements ^oo often made by the best and most authorita- tive writers. mal'aria. 69 aerial poisons. I will not deny the possibility of the admission of malaria into the system in each of these modes, yet, I think it indicated by a variety of circumstances, that the skin is, for the most part, affected primarily by this deleterious agent. We find the state of sleep especially adapted to receive the impression of miasmatic diseases. In all unhealthy countries you are cautioned against sleeping while exposed to the noxious exhalations. The postilion, as he drives you with dizzy rapidity \ through the Pontine marshes, shouts to you to rouse yourself and sit up; while all travellers have felt that this foul atmos- phere is full of drowsy and soporific dispositions, and that the most vehement resolution can scarce resist the temptation to indulge in slumber. Universal experience has proved the danger of sleeping in such situations; but, in sleep, little or no saliva is swallowed, while the skin and lungs continue engaged in their functions of absorption and transpiration. The principal argument, however, in favor of the cutaneous admission of malaria, is drawn from the exemption enjoyed by the lower races of man, and by the inferior animals, from diseases originating in this source. I state the rule here broadly—there are, doubtless, certain exceptions, but these, I think, can be ex- plained without difficulty. In no respect, is the physical difference between the white or Caucassian man and his brethren of the red and black tribes more prominent than in the degrees of their susceptibility to the action of this febrific miasm. The negro constitution, indeed, ap- proaches nearer that of the lower animals than of the white man. He delights in the hot and steaming plains of Africa, and exults in full health and vigor amidst swamps and cane-brakes whose lightest breath is destruction to the European. Without his aid, our rice fields must forever remain uncultivated, and the whole of our fertile low country become again a wilderness. Thus, also, it is only by the exacted civil and military services of the dark natives of Hindostan that the Englishman lives, moves and has his being in that unfriendly climate, from a brief contest with which, he almost always retires pale, sallow and languid, with worn out forces and a shattered constitution. Thus—to return again to our own country—thus it is that the wily savage, taking shelter in the deadly recesses of our South- 70 mal'aria. em morasses and everglades, bids defiance to the utmost efforts of civilization and military science; foiled not by his skill or courage, but by the pestilential influences of his aerial ally. MacCulloch is inclined to rank among the diseases produced by malaria, the epizootics or epidemic ailments which occasionally affect the denizens of the fields and the air, and even those which from time to time destroy in vast numbers the fish of particular localities. He tells us of a canine case of regular intermittent. Ferguson remarks that the inhabitants of some of the Spanish villages remove their horses and other domestic animals for fear of fever. Rush and others have affirmed the mortality of cats in the northern cities during the prevalence of yellow fever. Perlee tells us, that during one of the invasions of that disease, in Natchez, domestic animals suffered, and even the wild deer of the neighboring forests seemed infected. Sir James Fellowes states, that in Gibraltar, in 1820, canary birds died in great num- bers with blood issuing from their bills, and that the sparrow tribe was almost exterminated. I do not know that it is relevant here to add, that during a season of unprecedented mortality from yellow fever in New-Orleans, the fish are stated by the newspapers to have perished in vast multitudes in the waters of the vicinity. Upon all this I would remark, first, that I have already denied that yellow fever is a malarious disease. I shall in the proper place endeavor to show, that although malaria is probably one of the elements essential to its generation, yet the presence of some unknown but pestilential agent must be superadded, before the disease is developed. That this undefined poison may be injurious to animal life generally, I will not gainsay. Secondly, I disbelieve altogether the influence of malaria upon animals of the lower orders. The only distinct case recorded, is that of ter- tian in a dog, to which I attach no weight whatever. As this anomalous fact is single, I shall not doubt its correctness, nor impugn the authority upon which it rests, but content myself with regarding it as an instance of unintelligible periodicity. Amidst the rank grass of Africa, the lion couches, and her forests resound with the roar of her beasts of prey. The jungles of India nourish the elephant and the tiger, and the thick foliage shelters innumerable tribes of apes and serpents. In the swamps mal'aria. 71 and bays of America, the panther and the wild cat seek their food, and the deer hides himself from the red Indian and the hunter. Animal as well as vegetable life, luxuriates in heat and moisture; hosts of reptiles crawl abroad in the mud of each slimy pool, and countless insects sport in every sunbeam that glances from its surface. To man—to the white man alone, is this prolific combination unfriendly. But the structure and functions of the lungs and stomach are not obviously different in the black, or red, or tawney tribes; like the lower animals, they are chiefly distinguished from us anatomically and physiologically, by the peculiarities of the cu- taneous integument. We account then, most readily, for their remarkable difference as to susceptibility of malaria impression, by reference to the structure of the skin, which would therefore seem to be the surface primarily acted on. It is true that negroes born and constantly resident in healthy positions, who have been housed and clothed delicately, will be- come in a certain limited degree susceptible of miasmatic influ- ences. It is possible, too, that animals long domesticated and carefully sheltered and tended, may take on a like susceptibility, though this is not well established. In this part of the world, where we have but too familiar an acquaintance with this subject, we are persuaded that our negroes are comparatively little__our flocks and herds not at all liable, to malaria diseases. If the advocates of pulmonary inhalation, should press us with the apocryphal stories told of the protection afforded by breathing through a silk handkerchief or a folded mantle; or the gastric pathologists urge upon us the proverbial advantage of occupying the stomach with ardent spirits, wine or food, and of chewing and smoking tobacco, it is easy to reply, that there is abundant and equally weighty evidence to establish the preven- tive influence of oil applied over the cutaneous surface, and of the greater safety enjoyed by those who wear, as in ancient times, their woolen garments throughout the summer. A certain period of time, varying under various circumstances, elapses between the efficient application of malaria to the surfaces of the exposed body, and the development of its specific morbid consequences. The length of this latent period has a definite relation, as well to the intensity or concentration of the poison, 72 mal'aria. as to the predisposition of the individual affected. Lind says, that he has "seen a whole boat's crew that had delayed on shore till the setting in of night, seized with bad fevers the next morn- ing." Ferguson tell us, that "the atmosphere of certain marshes of Antigua was so actively pestiferous, that soldiers mounting the night guard were not unfrequently taken ill while standing sentry, and expired with all the horrors of black vomit within less than thirty hours from the attack." In the opposite extreme are the cases affirmed, (vide Bancroft,) to have occurred among the survivors of the fatal Walcheren expedition, as long as four and six months after their return to England. My observations, in reference to our own country, appear to me to confirm the remark of Robert Jackson, that attacks follow rather at septenary periods in preference—the seventh, fourteenth and twenty-first days after efficient exposure. Beyond this last, we are apt to consider ourselves safe. The most severe and pro- tracted case of this kind which I ever saw recover, was seized on the twenty-first day after his return from the country with a very slight chill. The next day fever came on with great violence and was protracted seven weeks. The circumstances which favor the influences of malaria upon the body, are next to be noticed. Besides the condition of sleep already spoken of, great fatigue, want of food of sufficiently nou- rishing or stimulating character, languor and debility indeed from any cause, bring the system into a state of notable predis- position. Heat not only aids in the production of the nervous agent, but by its relaxing and exhausting effect when long con- tinued, prepares the constitution to be acted on by it. It is alleged also to assist in the excitement of some of the most in- jurious consequences, by its characteristic impression upon the hepatic and cutaneous vessels. After this it may seem strange to say that alternations of temperature are more dangerous still, yet such is the fact. Our fevers are more rife, and- most malig- nant in September and October, when the nights are cool, after hot days, and abundant dews settle upon the earth in the even- ing, and fogs rise dark and heavy in the morning—the constitu- tion being agitated by these rapid changes, and the frame pros- trated by alternate constriction and relaxation. It is to this mal'aria. 73 alternation that I would ascribe the long observed severity of our earlier and later attacks, on account of which some planters prefer continuing to reside in the low country until June, rather than run the risk of a removal in May—for as it is next in order to remark, it is supposed to increase the liability to attack, when- ever an exposed subject undergoes a change of residence. The fact I think is fully made out, but it is not easy to explain it satisfactorily. Farther it is not only alleged that one who has remained within a malaria district long enough to become affect- ed by its influences, is more likely to be attacked by fever if he remove thence or change the air, as the phrase is, but it is also abundantly proved that the consequent attack will by such change be rendered far more serious and even malignant. . In truth, the effect of habitual exposure, by continuous resi- dence in such districts, is much more obvious in the diminution of the violence or intensity of the effects of this poison than in protecting against the repetition of these effects. I have known many inhabitants of our lower country who have scarcely pass- ed in their whole lives a summer and autumn exempt from fever. These persons generally suffer from the more protracted forms of intermittents, while a stranger would die at once or recover with difficulty from an inflammatory or congestive remittent. Nor indeed have the former much cause for exultation. Visceral obstructions—intestinal, splenic, and hepatic supervene, and they often sink slowly into the grave, the worn-out victims of ana- sarca or ascites. "How do you live here ?" asked a traveller of the wretched inhabitant of such a country. "We do not live"__ was the gloomy response—"we die." A low and flat position favors the action of malaria, as a long the margin of a slow moving river, or at the bottom of a valley, or on a wide alluvial plain. Hence it has been very fairly infer- red that the particles or atoms of febrific miasm possess a degree of specific gravity considerably greater than that of atmospheric air. An elevation of but a few feet from the surface of the ground often makes a notable difference. A house four feet above the earth is less infested, other things being equal, than one whose floor is level with the soil, or less raised. The lower stories of a house in a foul atmosphere are more unhealthy than the upper chambers. Some have attempted to measure with exactness the vol. i.—7 74 mal'aria. height to which malaria may rise in the air. Humboldt observes that "the farm of Encero, situated above Vera Cruz, is a stranger to the insalubrity that reigns over the whole coast; the elevation of this farm is 3,045 feet." Rigaud de I'Isle considers the limit to vary between 682 and 1,000 feet above the source of the ex- halation. In regard to this matter, however, we frequently meet with exceptions and irregularities, some of which are not easily explained, others we refer to the course and force of winds, and to the wetness or dryness of seasons. The affinity of malaria for moisture has been already spoken of. I look upon this affinity to be so absolute, essential and ex- clusive in its influence, that malaria, if it were possible to prepare it in a dry state, would be totally inert and harmless. Now, as far as moisture may be carried up into the thinner regions of the atmosphere, in any notable degree of density, so far may also malaria rise upward, retaining its noxious powers ; but beyond a certain extent of diffusion, dilution or dispersion of the vapor with which it is combined, it loses that concentration which we formerly maintained to be necessary to its poisonous operation. Although I do not impugn the doctrine which attributes weight to malaria, yet this seems to me the true advantage of elevation; not that the miasm cannot reach a lofty point, but that of neces- sity it becomes, while rising, less and less concentrated, and that the chances of its dispersion are infinitely multiplied. It is also in the less dangerous hours of mid-day that the noxious vapors are carried into the upper air; they are copiously precipitated at sun-set and during the night, and then abound in the lower stra- ta near the earth's surface, in valleys and depressed situations. I have already observed that malaria seems destitute of the quality of self-repulsion, and hence argued that it is probably not a gas. In a great many instances on record, it has failed to affect persons exposed at but a short distance from its obvious source. You will find in Bancroft a collection of such examples. In the history of the Walcheren expedition it is affirmed that the crews of some ships anchored even within one-fourth of a mile of the coast, continued healthy, while every man who had gone on shore was seized with fever. The same statement is more than once repeated in the wri- tings of West Indian physicians. MacCulloch tells us that on mal'aria. 75 one side of the Kent road from London, the houses are healthy, and on the opposite are affected with fever; and it would be easy to furnish similar facts from every part of our own malaria country. As this poison thus seems entirely dependent for its spread and conveyance upon adventitious circumstances, it will be well to ascertain what these are, and their actual efficiency. It is capable without doubt of being wafted by winds to some con- siderable distance, though this has been much exaggerated. The eastern shores of our rivers and lakes, and the eastern bor- ders of our morasses, are more sickly than the opposite, on account of the general prevalence of mild westerly breezes du- ring our summer and autumn. Where malaria fevers occur at a distance from any very obvi- ous source, as Rush has ascribed them to the effect of winds conveying the poison not less than thirty or forty miles, we shall probably by careful examination, detect on the spot some lurking material from which it is evolved. I have alluded to the productive power of small masses of vegetable matter, as in wet cellars, ill ventilated dirty vessels, shaded yards, or ill- drained and ill-cleaned lots. Attention should also be paid to the subsoil; this may be of such a nature, clayey and tenacious, as will not allow the percolation of water, which becomes stag- nant and putrescent. In the progress of malaria from its source, much has been said of its liability to be impeded by certain alleged obstacles. The interposition of a forest, a mountain, a high wall, a tent- cloth ; nay, of a cloak, a mantle, a gauze pavilion, a veil, a silk handkerchief, has been supposed competent to preserve us from the pernicious effects of air charged with this effluvium. As- suming the correctness of the facts stated on this subject, I am by no means satisfied with the explanations hitherto offered. The mechanical passage of miasmatic atoms cannot surely be difficult through apertures which admit air and odors. Nor can I understand the nature of the chemical ehange which some sup- pose to be effected within some of these barriers, by the exhalations from the skin and lungs, collected there, upon the malaria which penetrates within the gauze pavilion, the veil and the silk hand- kerchief. Let us refer once more to the doctrine of the absolute 76 mal'aria. necessity of its solution or combination with moisture. A heavy vapor thus noxiously impregnated, will find a mechanical obsta- cle in a high wall, if borne from its source by a gentle night breeze; if by a strong one, it will be carried over to be sure, but dispersed and diffused, and therefore with loss of concentration and intensity. Dense moist air will not easily pass through a thick canvass or tent-cloth, which thus gives a certain degree of protection. Fires kept burning in an apartment, tend to keep the air within warm and dry. By raising its temperature, its power of dissolving moisture is increased; admit moist and chilly night air charged with miasm into such a chamber, and the immediate solution of its moisture will precipitate the mala- ria, now left unsustained by its ally, in an inert, dry state; or if the affinity be too tenacious to be thus destroyed, will lessen its concentration materially. It is thus I would account for the immunity of the charcoal burner of de I'Isle and others under similar circumstances, and for the attribution of protective power to Venetian blinds and gauze pavilions. The cloak or mantle I look upon as a very efficient protection, and with Brocchi, would lay great stress upon the preference due to woolen garments, to the universal use of which among the lower classes of the Romans, he ascribes the comparative im- munity they enjoyed in a climate since become so insalubrious to their descendants. It is an old notion that the foliage of trees has great efficacy as a defence against malaria, and facts might be given you from Pliny, Varro, Lancisi, Volney, Rush and Johnson, to establish this point. Some consider the obstacle as merely a mechanical one, while others suppose that the deleterious effluvium possesses some inherent and peculiar property, by reason of which it is attracted by, and adheres to such foliage. Both of these sug- gestions are probably correct, for the leaves of trees attract dews and vapor, and of course the malaria dissolved in them. This, however, is not all. Every kind of tree will offer a mechanical impediment to the passage of air carrying malaria ; any foliage will condense the moisture with which it is combined; but it is not the densest forest growth, nor the broadest and thickest foliage which is most efficiently protective. The pine, with its tall columnar trunk, elevated branches and linear leaves, opposes mal'aria. 77 less mechanical obstacle to the transmission of air, and less sur- face for the concentration of dews and vapors than any other of the trees of the wood, and yet seems gifted with singularly salu- brious powers, and imbued with healing and preserving virtue in every bough. Every tree circulates its peculiar fluids, and secretes and eliminates its specific and peculiar effluvia; it does not appear to me unreasonable to believe, that certain of these exhalations may possess chemical properties and affinities ena- bling them to combine with, and decompose or neutralize mala- ria, or the elements which constitute this poison. Dr. S. A. Cartwright, of Natchez, Miss., as already mentioned, strongly contends for the "hygienic or health-preserving proper- ties of the jussieua grandiflora or floating plant of the bayous and lakes of lower Louisiana." He ascribes to its presence and specific qualities "the remarkable exemption of the inhabitants of that section of Louisiana from malarious or miasmatic dis- eases." He affirms, too, "that it purifies all stagnant water in which it grows—that of the lakes and bayous inhabited by this plant being as pure to the sight, taste and smell, as if it had just fallen from the clouds." "The fact," he says, "that the re- gion of country in which this aquatic plant abounds, is exceed- ingly healthy, can be established beyond cavil or dispute. It nevertheless contains more stagnant water and swamps than any other inhabited district, of the same extent, in the United States." It is to the several circumstances successively noted in this essay, which limit the sphere of action of malaria, that we are to attribute the salubrity of our "pine land settlements"—their comparative, I might indeed, with regard to some of them, ven- ture to say, absolute exemption from its pestilential sway, and the happy protection which they afford. The necessary com- bination of this poisonous agent with aqueous vapor; its weight, which prevents it from rising to any great height, and obstructs its conveyance to any great distance, unless when wafted by winds, which at the same time dilute and disperse it; and the attractions and affinities which cause it to adhere to the foliage of trees, and occasion it to be more or less acted on by their exhalations; these are the conditions that control its activity and afford us an opportunity to evade its evil influences. Situated 7* 78 mal'aria. as these "settlements" are, in the very heart of our fertile low country, surrounded by, and closely invested with swamps, rice fields and morasses, their existence is of the utmost importance to the agricultural population. Shaded by the lofty pine, fixed on a soil light, arid and absorbent, and unincumbered by low, thick masses of underwood, we have here united in our favor a certain degree of elevation, these tracts being well entitled to their common appellation of "ridges"—comparative dryness, both of air and surface; sufficient ventilation, free admission being given to the sun's rays and the winds, from whatever direction; the presence of trees, and these of a genus whose terebinthi- nate effluvia are almost universally believed to exert an influ- ence of a balmy and salutary nature. To preserve these advantages in their full value, however, much attention seems to be necessary. The most perfect clean- liness of yards and offices should be observed; nothing should be planted near the dwellings, even the delights of the flower garden being prohibited ; and all offal of every kind, burned or buried at some distance. It has been recommended that a new position should be selected for each house, every fourth or fifth year, and that it should be rebuilt of new materials. Some of these villages, however, have subsisted for a long series of years, and still retain their reputation as healthy residences. Houses in a malaria country, should always be situated on the highest points of land attainable; they should be raised a few feet from the ground, on an open foundation, and great care must be taken that no water be allowed to stagnate under or near them; with this view, drains should be properly and efficiently arranged and covered over; they should be built on the western side of any water course or swamp, if there be one in the neigh- borhood, and until the draining of such swamp be completely accomplished, the underwood should be left to line its banks. A screen of trees should be planted between it and the house, which should be surrounded also, by a considerable body of trees, cleared of undergrowth, and trimmed sufficiently to allow free ventila- tion and the abundant admission of the sun's light and heat. Pines should be preferred; if they are not at hand, I think there is some reason for the selection of hickory. During the sum- mer and more especially in autumn, fires should be lighted at mal'aria. 79 evening, and kept burning until an hour after sunrise. Blinds should be shut in at the same time, and the windows hung with curtains to impede the entrance of the chilly, moist night air. It has been remarked, that the presence of our long gray moss (Tillandsia Usneoides) upon the pine, is an indication of a bad state of the air, and that the gradual encroachment of this para- sitic vegetable upon the trees of a ridge previously healthy, is a fair warning that it is about to lose this general, though by no means universal exemption of our sandy barrens. If the fact be so, it is of easy explanation. The moss delights in moisture, and attaches itself to the growth of moist places. It forms thus a good hygrometer, and gives notice that the stagnant waters of the neighboring low grounds are becoming more abundant, and spreading over a wider extent. We might perhaps avert the threatening, by timely and perfect draining, and it is to be lament- ed that such attempts have not been more frequently and ener- getically made, rather than yield, as we have too often done, point after point, to the pestiferous dominion of this evil spirit of the marsh. The only hope, indeed, of our low country, must be fixed upon the system of general and perfect drainage. The noxious material is inexhaustible in amount; the heat of our climate will remain the same; if then, we cannot convey off the undue moisture, so as to diminish notably the decomposition and evaporation to which it conduces, this fertile portion of our terri- tory must forever continue to be to the same extent as at present, uninhabitable by its owners, and abandoned in great measure to the management of slaves and hirelings. Nor should we be discouraged by the vastness of the undertaking, from a fair and persevering endeavor. By these means many large tracts of bog and morass, as even in the pontine marshes, have been reclaimed, and found richly to repay the labor expended on them. The enterprise of our sister city Savannah has, within a few years past, instituted an expensive experiment of the effect of drainage; and the system of dry culture applied to the rice lands in her vicinity, is said to be already productive of beneficial results. Every southern philanthropist must pray heartily for its entire success. On the same principle as above stated, I account also for the great abundance of insects and vermin to be found in miasmatic 30 mal'aria. situations, and for the common belief, that an unusual multipli- cation of gnats, flies, muskitoes, etc. betoken the approach of an unhealthy season. These little creatures luxuriate m moisture, which, with heat, is so necessary to their production, and so much fosters their increase as to have been supposed by not a few philosophers fully capable of developing or generating them. It is necessary to receive with some modification, the almost universal opinion of the connection of a disagreeable odor with the presence of miasmata. It depends upon the nature of the exhalation; for there are many offensive effluvia, especially those which result from the decay of certain animal matters, which, however they may deteriorate the atmosphere and render it unfit for respiration, yet are not of a febrific character, and therefore do not come under the head of malaria. Nothing is better known than the influence of density of population in diminishing the tendency to malaria diseases. This is accounted for in a variety of ways. The number of culinary fires kept up, must promote a certain degree of dryness of air; the smoke produced in the combustion of coal and wood, and the other chemical changes resulting from such combustion, may affect the nature and properties of malaria; the substitution, in a city, of animal offal, for decaying vegetable materials, must have an effect in diminishing the number and intensity of dis- eases, which are generated by vegetable effluvia. MacCulloch and De I'Isle, however, proceed to a most extraordinary extreme of error, when, fixing their attention upon the topic of malaria exclusively, they venture to assert "that the most offensive quar- ters of a city are sometimes the most healthy." It never can be so ; the cleanliness and free ventilation which promote the sweet- ness and purity of the air, at the same time and of necessity equally conduce to its respirability and salubrity; the opposite conditions of confinement and filthiness first nauseate and dis- gust, and then debilitate and destroy us, though by diseases differing widely from those of malaria origin. I shall conclude this discussion by a few remarks on the im- portant subject of acclimation. I have said, that the most con- tinuous residence of a native in a malarious region, does not give entire immunity from the influences of this pervasive poison, but it is unhappily true, that a stranger has too much reason to mal'aria. 81 dread the fatal violence of its effects upon an unprepared consti- tution. It is in hot climates that these effects are most frequently and intensely developed, and in the persons of new comers or emigrants from higher latitudes. The permanent impression of cold upon the human system cannot be exactly described; we call it tonic, constringent, roborant. That of heat is, probably, directly opposite, and its relaxant qualities are greatly increased by combination with undue moisture. Very different, then, will be the states of constitution resulting from habitual exposure to these two habitual temperatures-—very different the predisposi- tions to disease built up in the constitutions so modified. One who has become familiar with the influences of heat, having gone through a regularly progressive series of effects producible by it, directly or indirectly, in warm climates, by continuous resi- dence, is pronounced, in common language, to be acclimated there; he is now less liable to their endemic diseases. If, how- ever, he returns to his colder home, he loses this assimilation more or less entirely, in proportion to his longer or shorter absence. In like manner, a young native may lose his original assimilation by absence. We recognize as dangerous to such a person, a summer tour at the North or in Europe; but it is not considered as it should be, that an equal, nay, a greater risk is incurred, by spending a winter away from his Southern birth- place. The difference between the warmth of our summers and those of northern countries, even so far as Russia, is vastly less than that which prevails between our winters and their's in severity of cold. Something resembling the effect of such absence upon an indi- vidual may occur to whole communities. Suppose that, instead of our going abroad to suffer a Northern winter, such a winter should come upon us at home. Is it not evident, that the gene- ral constitution would lose, in a greater or less degree, the pro- tection afforded us by previous assimilation, and we shall have become, to a corresponding extent, comparatively strangers? If, in the succeeding summer, the causes which produce the devel- opment of malaria, should be active, we shall be found specially liable to its influence, and its spread will be extensive. Facts, I think, will be found to confirm these views. Observe then carefully, collect diligently, and record faithfully S2 SERIAL POISONS., ETC. all the facts which may hereafter come within your reach relative to these interesting topics. I will not abandon the humble but consolatory hope, that it is yet reserved to our profession to dis- cover means by which we shall neutralize and destroy this most virulent and widely distributed poison. In order to do this, however, we must detect its sources, ascertain its nature and constitution, and clearly trace its modus operandi. Such know- ledge must be gradually acquired, and each of us may and ought to add something to the accumulating mass. CHAPTER IV. SERIAL POISONS--ANIMAL PUTREFACTION. Among the aerial poisons, we must enumerate the products of animal putrefaction. As in the instance of malaria, the presence of which we infer in certain atmospheres, though undetected by endiometrical experiments or chemical tests, so in the present case, we suppose that certain deleterious substances are produced or eliminated, besides the gases which we can collect during the process. Our senses, indeed, are highly offended by volatile matters of disgusting odor ; and nausea, syncope, and even as- phyxia, are known often to follow exposure to these revolting exhalations. It is evident, that these effects are not accounted for by the gases which are released during the decomposition of animal matter ; it is equally evident, that it is not merely the unpleasant impression made upon the olfactory nerves and the sympathetic disturbance thereby excited ; for many persons are sickened who feel no disgust, and in whom prostration and fever are not pre- ceded by nausea. It is farther true, that in some places where the most offensive collections are presented, the residents enjoy apparently good health, as in the knackeries near Paris, and in the establishments for the manufacture of adipocire at Boston, in England. From such exceptions as these last, a few recent writers have been led, strangely enough as it seems to me, to -