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ESSAYS
ON
PATHOLOGY  AND  THERAPEUTICS,
BEING THE
SUBSTANCE OF THE COURSE OF LECTURES
DELIVERED BY
\y
       SAM'L HENRY DICKSON, M.D.,

PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE, IN THE MEDICAL COL-
          LEGE OF THE STATE OF SOUTH CAROLINA.
VOL.  II.     ^*

          NEW-YORK:
SAMUEL S. AND WILLIAM WOOD
         No. 261 Pearl Street.
               18 4 5. 

WB
D55^1e
 1345
 V.  x
Entered according to the Act of Congress, in the year 1845, by

          SAM'L HENRY  DICKSON, M.D.,

  In the Office of the Clerk of the District of South Carolina. 
INDEX  OF  CHAPTERS.
                           CHAPTER XXII.

Diseases of Digestive System;—Dyspepsia ; nature or constituent cause;  not to
  be confounded with Indigestion; remote causes; history and effects;  treat-
  ment.

                           CHAPTER XXIII.

Gastritis;—acute; seldom  occurs  alone  or idiopathically;  history;  causes;
  effects;  autopsy;  treatment.  Chronic; more frequent; follows protracted
  dyspepsia; causes, often obscure; history;  results; diagnosis; treatment.

                           CHAPTER XXIV.

Enteritis:—acute; not unfrequently combined with gastritis; history; causes;
     gnosis; prognosis; results; autopsy; treatment.   Chronic;  causes; his-
    y;  diagnosis; prognosis; treatment.

                           CHAPTER XXV.

Milk-sickness;—an Epizootic and Endemic  in  the Southwestern U. States;
  generating source obscure ;  in man, produced by eating milk, butter and flesh
  of diseased animals; description; diagnosis; prognosis: treatment;  means
  of prevention.

                           CHAPTER XXVI.

Colic;—1. Flatulent  Colic; description;  pathology and  nature  and seat dis-
  cussed;  causes; diagnosis: prognosis;  autopsy; treatment. 2. Bilious Colic;
  pyrectic; malarious; history; exciting causes; diagnosis; treatment.   3. Co-
  lica  Pictonum, Rachialgia; result of poisoning by  lead; history and nature;
  effects;  autopsy ; diagnosis ; treatment; prophylaxis.

                          CHAPTER XXVII.

Cholera;—!. Common or  Sporadic Cholera;  history;  causes; treatment.  2.
  Cholera Asphyxia—Asiatica—Epidemic;  history; pathology; cause  and
  modes of extension and spread; diagnosis; prognosis;  autopsy;  treatment. 
iv.
INDEX OF CHAPTERS.
                           CHAPTER XXVIII.

 Diarrhoea;—acute  and chronic;  pathology;  history;  causes;  results; obsti-
   nacy; treatment.

                            CHAPTER XXIX.

 Dysentery;—!. Acute; pyrectic; maybe asthenic  or typhoid; often epidemic;
   pathology  complicated;  history; causes; contagion alleged;  autopsy; treat-
   ment.  2. Chronic;  causes;  connection with  hepatic disorder; history;  te-
   nacity ; results; treatment.

                            CHAPTER XXX.

 Cholera Infantum;—scarcely definable; including many elements and modifica-
   tions; general history ; causes; treatment; prophylaxis.

                            CHAPTER XXXI.

 Helminthia;—verminous irritation; numerous  varieties; modes of disturbance
   not specific; anthelmintics; formulae for removal of taenia.

                           CHAPTER XXXII.

 Hepatitis;—Acute;  not frequent; description;  causes; results; autopsy; treat-
   ment.  Chronic; a  common malady in hot, malarious countries; history;
   diagnosis;  prognosis; effects ;  autopsy ; treatment.

                          CHAPTER XXXIII.

 Icterus, Jaundice;—variously divided, by hue, as yellow, black,and green jaun-
   dice ; by pathology,  as resulting  from hepatic torpor—from the  presence of
   biliary calculi—from obstruction of biliary ducts, spasmodic or inflammatory,
   etc.  Hepatic Concretions described ; differ in form and composition;  symp-
   toms and history ;  diagnosis; results; autopsy;  treatment.

                          CHAPTER XXXIV.

Splenitis;—rarely acute; chronic not  frequent:  ague cake,  a  congestion or
  hypertrophy;  sometimes degenerates into splenitis; history; diagnosis; con-
  sequences ;  treatment.

                           CHAPTER XXXV.

Parotitis, Mumps;—description;  history: contagious; epidemic; metastases 01
  results;  treatment.

                          CHAPTER XXXVI.

Sore  Throat, Pharyngitis;—varieties—inflammatory, malignant;   superficial
  ulcerous, phlegmonous; sporadic and epidemic.  Diphtherite.  Causes; his'
  tory;  treatment. 
INDEX OF CHAPTERS.
V.
                            CHAPTER XXXVII.

  Diseases of Respiratory System—Exploration of Thorax;—modes of examina-
     tion > percussion;  auscultation  mediate and  immediate;  the stethoscope;
     mensuration;  succession.

                            CHAPTER XXXVIII.

  Croup, Cynanche Trachealis, Acute Laryngitis;—history; pathology;  diagno-
     sis ; autopsy ;  treatment; tracheotomy discussed.

                            CHAPTER XXXIX.

  Chronic Laryngitis, Laryngeal Phthisis ;—history; pathology; causes;  diagno-
     sis; prognosis; results; autopsy;  treatment.

                              CHAPTER XL.

  Bronchitis;—Acute, described;  diagnosis;  causes;  results; autopsy;  treat-
     ment.   Chronic Bronchitis or  Catarrhal Consumption;  often follows Acute
     Bionchitis; sometimes original;  history; diagnosis;  prognosis; autopsy;
     treatment.  Peripneumonia Notha.

                              CHAPTER XLI.

I  Pleuritis, Pleuro-Pneumonia, Pneumonitis;—description  and history;  patho-
'«     logy;  diagnosis ; prognosis ; autopsy ; treatment.

                              CHAPTER XLII.

   Plithisis  Pulmonalis, Apostematous Consumption,  Chronic Pneumonia with
     Abscess;—history; pathology; diagnosis; prognosis; autopsy; treatment.

                             CHAPTER  XLIII.

   Phthisis Pulmonalis, Tubercular Phthisis, Consumption in the Scrofulous Dia-
     thesis ;—pathology; tubercle  described;  symptoms; diagnosis;  prognosis;
     treatment; prophylaxis.

                             CHAPTER  XLIV.

   Asthma;—defined; described; pathology; causes; diagnosis; prognosis;  results;
I    autopsy; periodicity;  treatment during paroxysm; during interval.

                              CHAPTER XLV.

   Pertussis;—Hooping Cough; pathology; history; contagious; epidemic; attacks
[     but once;  autopsy; treatment.
           1* 
VI.
INDEX  OF CHAPTERS.
                           CHAPTER XLVI.

Diseases of Sensorial System;—Phrenitis; acute, described; seldom idiopathic;
  causes, predisposing and exciting; diagnosis; prognosis;  consequences; au-
  topsy; treatment.

                           CHAPTER XLVII.

Chronic Phrenitis;—Insanity; varieties described  and defined; causes, moral
  and physical;  hereditary transmission; pathology; autopsy ; prognosis; treat-
  ment.

                           CHAPTER XLVI1I.

Mania a Potu;—Delirium  tremens; pathology obscure; cause well established
  and exclusive ; history; diagnosis ; prognosis ; treatment.

                           CHAPTER XLIX.

Apoplexy;—defined; described;  various  forms;  sanguineous, serous, cerebral,
  meningeal; diagnosis; pathology; autopsy;  causes ;  results; treatment.

                             CHAPTER L.

Paralysis; general history; universal and partial paralysis; the first  rare, not
  to be confounded with apoplexy; described; causes; treatment.   Partial par-
  alysis subdivided into—1. Hemiplegia; described; pathological analogy with
  apoplexy; causes the same ; frequently precedes or follows it; autopsy; treat
  ment. 2. Paraplegia; spinal injury most common cause; other causes; pa-
  thology ; autopsy; treatment.  Paralysis Agitans, Shaking  Palsy;  causes ;
  history;  treatment.  4. Paralysis Vacillans, Chorea Sancti Viti;  description
  and history; seat, nature and pathology, obscure;  causes;  treatment.

                             CHAPTER LI.

Epilepsy;—Falling Sickness; paroxysmal; recurrent; periodical;  description;
  autopsy; pathology  unsettled;  variety  of forms;  causes; prognosis;  treat-
  ment  during paroxysm,  or palliative; during interval; prophylactic.

                            CHAPTER LII.

Neuralgia;—nature, history and pathology, ill defined; varieties  described; tic
  douleureux, etc.; alleged causes; diagnosis; prognosis;  results ;  treatment.

                            CHAPTER  LIII.

Diseases of Motory System;—Gout; Arthritis; Podagra ; Constitutional diathe-
  sis; local inflammation; history; regular; irregular; misplaced; retrocedent■
  atonic;  causes; results^  treatment;  prophylaxis. 
INDEX  OF CHAPTERS.
vii.
                            CHAPTER LIV.

Rheumatism;—acute;  inflammation of fibrous  tissues;  carditis;  pathology ;
  specific nature ; history; metastases; diagnosis ; causes ; treatment.  Chronic
  Rheumatism ;  obscure in nature, history and pathology; great tenacity;  diag-
  nosis ;  causes; treatment.

                             CHAPTER LV.

Diseases of Excernent System;—this system itself not readily set apart, except
  as to the kidneys, which excrete only; the lungs and skin excrete, but imbibe
  and recompose also; the liver secretes bile, which is not altogether effete. Cu-
  taneous affections numerous and diversified ; febrile ; the exanthemata; sell-
  limiting ; contagious attack but once; eruption an essential element; connection
  with constitutional disorder ill understood; whole pathology unsettled. General
  history of cutaneous diseases ; tables given from Dunglison and Craigie ; divi-
  sions,  and subdivisions; seated in different portions of integument;  simple ;
  specific; local; constitutional;  contagious,

                             CHAPTER LVI.

Variola;—Varioloid Affections ; Varicella; history and description ; contagious;
  epidemic ; inoculation ;  autopsy; treatment.

                            CHAPTER LVII.

Vaccinia, Vaccine;—antiquity; discovery by Jenner; influence as a preventive ;
  as a modifier; re-vaccination.

                            CHAPTER LVIII.

Rubeola, Measles;—origin ; history; description ; contagious; attacks but once;
  self-limiting; diagnosis; varieties; incocta; nigra; maligna; sequelae; treatment.

                             CHAPTER LIX.

Erysipelas, Ignis Sacer, St. Antony's Fire, Rose;—its place among the exanthe-
  mata disputed; nature doubtful; not self-limiting;  may attack many times;
  description; diagnosis; varieties of seat and character; treatment.

                             CHAPTER  LX.

Scarlatina, Scarlet  Fever; a contagious exanthema;  self-limiting; attacks
  but once; history;  varieties described ; sequelae; diagnosis; prognosis; treat-
  ment; prophylaxis; belladonna. 
Vlll.
INDEX  OF CHAPTERS.
                            CHAPTER LXI.

Dengue;—a new exanthema; contagious; self-limiting;  epidemic; a transient
  visitor; history ; description ; pathology ; consequences ; treatment.

                            CHAPTER LXII.

Diseases of Urinary Organs;—kidneys the only  exclusive  depurators;  renal
  affections; diabetes, mellitus, insipidus ; anuria; morbid urines;  gravel;  re-
  nal calculi; nephritis;  acute  and chronic; Bright's disease;  albuminuria;
  granulation of the kidneys; nephralgia;  nephritic colic.  Vesical affections :
  cystitis;  cytherismus; stone in the bladder;  lithic diathesis* 
PRACTICE  OF  PHYSIC,
OR
THERAPEUTICS.
                   CHAPTER XXII.

           DISEASES OF THE DIGESTIVE SYSTEM.

  We come, next in order, to speak  of the diseases  of the Di-
gestive System, and shall include under  this head, not only the
morbid affections of the stomach and bowels, but likewise of all
those parts and organs which concur in the reception of food, its
solution and conversion into aliment, and the separation and ex-
pulsion of the portions rejected.  That the animal body may re-
ceive its proper nutriment, the teeth must masticate thoroughly
the food made choice of; the salivary glands must afford a cer-
tain amount of their peculiar fluid to lubricate the mass, with
which  the varied muscular actions of the tongue and  cheeks
must mix it intimately; the pharyns: must receive and contract
upon it;  the muscles of deglutition must transmit it along the
eesophagus to the stomach, in which it is to be dissolved by that
wonderful menstruum the "gastric juice," far  exceeding in its
actual powers all that an insane philosophy dreamt of in its fu-
tile researches after the "universal solvent."  The soft, pulpy
chyme receives farther elaboration by means of the pancreatic
fluid and the bile, and  in a state of close  union with these, is
subjected to the action of the lacteals, through which it passes, 
10          DISEASES OF THE DIGESTIVE SYSTEM.

after a process which some regard as a progressive animalization
or vitalization, others, merely as a  mode of straining or purifi-
cation, into the current of venous blood.
  Of the numerous organs thus engaged in the business of di-
gestion, it is difficult, nay, impossible to point out in separate de-
tail, the specific function of each. Some physiologists have chosen
to speak of the stomach and small intestines as  exclusively en-
gaged in  digestion, considered  as a particular office; while all
the other organs, which concur in the promotion of the general
end, are regarded as collateral or collatitious ; for example, the
liver, the  pancreas, and more  doubtfully, for its true office is as
yet unknown, the spleen.  The large  intestines are, by modern
physiologists, supposed to be something more than mere sewers
or receptacles.  The  change in the contents  of this portion of
the tube, is  very remarkable and uniform; it is not perfectly
understood how this  change, which  is termed  fcecification, is
effected, but it is known to be an  essential coincident of healthy
digestion.
  Naturalists assert that the stomach is the organ most invariably
met with as a part of  the organism,  in all the classes and varie-
ties of animals.  From this fact it would seem to be very nearly,
if not absolutely indispensable  to the  existence of this form of
life;  the hydatid, the lowest of the  class, is all stomach "et pre-
terea nihil," and in the highest it exerts an influence as extensive
as ceaseless.   Its sympathies are almost indefinably  powerful.
With its tone, the whole system corresponds;  it is in a strong
sense, as Dr. Kitchener calls it, "every man's  master;" its  de-
mands require ready compliance ; its morbid  conditions imply
discomfort and disorder every  where throughout the system;
"ventriculo  languido omnia  languent."   This  universal exten-
tion  of its morbid  influences, when distempered, gives rise to
many irregular anomalous  and inexplicable phenomena, which
have been much dwelt on by pathological and practical writers,
and  which, to our  ceaseless annoyance, patients, who suffer
greatly and are often much alarmed  by them, are perpetually
urging upon our attention for explanation and relief.  A morsel
of undigested food or  improper aliment, will, in one person, give
rise  promptly to a paroxysm of gout, in another to a troublesome
cutaneous eruption ; and in a third to an oppressive dyspncea.   A 
DYSPEPSIA.
11
blow upon the pit of the stomach will often prove instantly fatal;
so will a large draught of alcohol and some other poisons ; by
what strange impression upon the sensorial and circulatory func-
tions, it is beyond  our comprehension to perceive.  I  might go
on to multiply examples  of this sort, almost without limit; as,
when we  have cramps  from nausea and  vomiting, extending
even to the fingers and toes, and convulsions from worms or from
irritating ingesta, and the like.
  It is well, too, to remind you that these sympathies are recip-
rocal ;  that, the functions of the stomach are impaired or inter-
rupted in every general derangement of the constitution ;  that di-
gestion ceases whenever  any strong mental emotion is excited;
that fatigue impedes it; that pain from whatever cause, puts an end
to it, when intense; and that all fevers, with scarcely an excep-
tion in any of their varied types, necessarily imply diseased con-
ditions of  this important organ.

                         DYSPEPSIA.

   I shall place first on the catalogue of diseases of the digestive
 system, a  morbid condition of the  stomach, which however fa-
 miliar to the practitioner, the pathologist has always found  it
 difficult to define.  Under the term Dyspepsia, we have become
 accustomed to comprise an  extensive variety of troublesome
 symptoms which occur so often in  connection  with  each other,
 that it seems reasonable  to refer them to a common cause, and to
 regard them as resulting from the  same morbid  state of the or-
 gan primarily affected.
   I would describe Dyspepsia proper, as a Gastralgia, in which
 the functions of the stomach are not properly performed; and
 this brief  definition, it seems to me, will include all that is neces-
 sary to a fair comprehension of our subject.  If there be, as has,
 been affirmed, any true gastric neuralgia which does not interfere
 with digestion, it does not come under our present head.   And
 surely the phrases are sufficiently analogous in etymology to ex-
 press the fact with a due degree of clearness, that dyspepsia neces-
 sarily implies suffering in the stomach, which suffering is increased
 by the presence of food, and during the process of digesting it.
    The Symptom most prominent,  and most uniform perhaps, is 
12
DYSPEPSIA.
anorexia, defect or irregularity  of appetite.  This is  often  en-
hanced into nausea, more or less intense, and perhaps protracted
for weeks without intermission ; sometimes it is attended with
occasional vomitings,  either of the secretions of the stomach or
of the food and drinks taken.  As  inevitably connected with
this oppressive uneasiness, there is great depression of spirits, ex-
treme languor, both mental and physical, a gradual emaciation of
the body,  and constipation, or an irregular state of the bowels.
Many dyspeptics, however, enjoy, if I may thus misapply the word,
a good appetite ; nay, it is  not  rare to see them eat voraciously.
But the food taken, either lies heavily on the stomach, or is thrown
up acridly fermented, or passes into the bowels undissolved, giving
rise to colics and cramps and  diarrhoea.   The tongue is foul,
with offensive breath and a disgusting taste in the mouth ; there
is a distressing sense of weight, tension and fulness of the abdo-
men ; some complain  of a perpetual dragging downwards of
the bowels ; there is frequently tenderness on pressure, chiefly at
the epigastrium, and bands or ligatures cannot be borne on any
part of the trunk.
   Cardialgia or heart-burn, an annoyance which often follows any
single attack of indigestion, is a very familiar symptom in dys-
pepsia.  It is too  readily assumed to depend of course upon the
presence of acids.  This is very commonly the case, no doubt,
and the patient is troubled with eructations of a fluid which set
the teeth on edge.  But the fluids of the cavity diseased, though
apt to fermentation, are  sometimes alkaline, and besides these.
there are other irritants neither acid nor alkaline, which will
induce heart-burn; nuts and tobacco juice will do this.
   Pyrosis or Water-brash, a not unusual  attendant on dyspepsia,
consists in abundant secretion and ejection from the stomach and
fauces, of a thin  mucus, sometimes  sour, sometimes limpid and
tasteless ; sometimes this is accompanied by nausea, but not uni-
formly.   It is also generally, though perhaps not always, associ-
 ated with Gastrodynia, an acutely painful affection which some
 attribute  to spasm or irregular contraction of a  portion of  the
 muscular  fibres,  but which I am disposed to  regard as properly
 a neuralgic symptom.   The sensorial system rarely escapes sym-
 pathetic disturbance.   Headaches, of  great variety, present them-
 selves ;  vertigo,  very commonly;  dim   and imperfect vision 
DYSPEPSIA.
13
sometimes  double vision;  morbid vigilance, with or without
light  delirium ;  vapors, a species of mental  delusion chiefly oc-
curring at  night, in which phantoms appear before the eye and
are heard to speak.
  The respiration is not unfrequently disordered, when we meet
with asthma, or  a form of recurrent dyspnoea undistinguishable
from asthma ; nay, Wilson Philip traces one of the varieties of
phthisis to dyspepsia, as its legitimate source.   The circulatory
function is not  so apt to be  affected, but may be variously de-
ranged.  Palpitation  of  the heart is occasionally complained of,
and in some patients  becomes so prominent as  to arouse serious
fears of organic disease.   The pulse is, for the most part, natural;
but may become very slow, and rather  soft or weak.   I have
seen it, in one case, as low as 34 in the minute,  in another at 40,
and in  a third from 50 to 55 repeatedly.  I have met,  more than
once, with a sudden and remarkable sinking of the pulse, coin-
cident with great prostration of  muscular strength.
   In this long list, to which I might  have made many irregular
additions,  I have not enumerated a single  symptom  which has
not occurred under my own observation; and  their singular di-
versity will  serve, without comment, to  exhibit to you the pro-
teiform nature of this distressing malady.  We  are prepared then
to  anticipate the formation of a great variety of theories among
the pathologists who treat of dyspepsia.  In  discussing  thesej
let me  remind you of the importance  of distinguishing between
mere occasional indigestion, and the morbid  condition which
constitutes the subject of this essay. Indigestion, in all its modes,
may be the result of causes which have no  tendency to affect
permanently  the functional capacities of the  stomach.   Thus
fever, which while it lasts, prevents  digestion, as well  as all or
most of the other natural actions of the organs, leaves behind it,
 when it disappears, an  appetite and a power of converting food
 into  aliment, which  are  often extraordinary.   Intemperance,
 however, either in food  or stimulant drinks, or  the use of opium,
 not only interferes at the time with the process of digestion, but
tends to the production  of a permanent morbid state, which de-
 mands and has received a specific appellation.  Let us enquire
 in what this  morbid condition  consists.  Dr.  Parry, whose pa-
 thological reasonings are always  ingenious and  plausible, attri-
        vol. n.—2 
14                      DYSPEPSIA.

butes all the phenomena of dyspepsia, to a mere fulness of the
vessels  of the stomach, a hypersemia.  Broussais, and  a great
number of others, confound it with chronic or sub-acute gastritis.
Barras regards it correctly (as I have above remarked) as a mode
of gastralgia;  and Wilson Philip, dividing it into two stages,
describes it, as primarily an  affection of the nerves of  the sto-
mach, which becomes by protraction a vascular or inflammatory
condition.  In proof of the doctrine (scarcely  disputable, I sup-
pose,) that nervous irritation may and does produce vascular and
structural disease, Dr. Wilson Philip has referred to an experi-
ment, detailed by Sir Benjamin Brodie.  "A silk thread being
passed through the  substance of the nerves of the eighth  pair,
exposed in the neck of a rabbit, after the manner of a small seton,
the animal in the course  of twenty-four hours, was observed to
breathe in a laborious and hurried way.  In fourteen hours after,
it died.  On dissection, both lungs were found loaded with blood
and inflamed,  the left in the  greatest degree,  its surface  being
encrusted with coagulable lymph, which was  also effused in se-
veral places  in the thoracic cavities."   He  remarks  farther,
"that a stone passing down the ureter occasions pain in the testi-
cle, which, after a certain length of time, is followed by swelling,
tenderness and actual inflammation.  Worms in the intestines
occasion pain  in the chest and dyspnoea, which symptoms are
entirely removed, provided the worms are quickly got rid of; but
if this  nervous and sympathetic irritation continues long, how-
ever, actual  inflammation and suppuration of  the  lung  take
place."
   Now, it  is  obviously  an error, to confound these secondary
changes of structure, and lesions of tissue, with the sympathetic
irritations or impairments of  function which give rise to them;
and yet, this is precisely what Dr. Philip goes on to do, when
he treats of inflammation of  the stomach as a stage of indiges
 tion or dyspepsia.   I  am not sure, that every variation of the
 nervous condition of an organ, predisposes  it to  inflammation,
 nor that all the changes of structure which may result,  are to be
 regarded as inflammatory.  When there is deficient supply  of
 sensorial influence  to  any part, atrophy is, at least, as  likely to
 occur as hypertrophy—anoemia as hyperoemia; yet Parry hastily
 assumes the latter to be  the constant condition of the gastric sur 
DYSPEPSIA.
15
face in dyspepsia.  I  do not, by any means, deny, that this is
sometimes the fact, but I regard the actual morbid state as being
considerably diversified.  It is usual to speak of atony or de-
bility of the stomach, as an essential part of the disease under
discussion;  but there has been little effort made, to define the
true meaning of the terms as here applied, and the carelessness or
obscurity of writers has caused much confusion.   Neither with
regard  to this, nor any other malady, will I admit, that the
phenomena are satisfactorily to be  explained  by a reference to
the  mere increase or diminution of action or power of action in
a part, an error which pervades the Pathology, in succession, of
Brown, Rush,  Parry,  Broussais, and  numerous other  inferior
names.  I do not doubt, that in dyspepsia, there  is  not only a
difference in degree, but in the kind  of action of the vessels,
which results in a morbid alteration  of the qualities  of their
secretions.  The gastric juice of a healthy animal, dying sud-
denly, will  dissolve the coats of the stomach in which it has
been poured forth, and  even out of the stomach, exhibits the
most astonishing powers of solution, and will resist successfully
all tendency to the ordinary chemical  changes in articles sub-
jected to its influence.  But, in  the  dyspeptic stomach, the
plainest food will remain long undissolved, or will be  melted
down slowly and imperfectly, in the meanwhile undergoing the
same fermentations and decompositions  that it is liable to out of
the  body, though perhaps in  a modified way.  And here, per-
haps, I should object, in passing, to  the introduction of Pica and
Bulimia among the phenomena or modes of dyspepsia.   The
former  I  look upon as a true cachexy—generally, perhaps, of
scrofulous character.   The irregular appetite is not for food, but
for absorbent substances, which palliate, by some  mechanical or
chemical  influence, the irritation of the morbid gastric  secre-
tions.   Of this nature, is the ckxy or dirt-eating of our  malaria
regions, which, at first the result of an instinctive craving, soon
becomes an  uncontrollable habit.  Many women, subjects of the
transient pica of pregnancy, take food freely and  digest  it well.
Such persons cannot be regarded as dyspeptics, whose irregular
appetite is always attended with more or less difficulty and suf-
fering when ordinary  food  is  taken.   Still less reason  is there
for considering bulimia under the head of dyspepsia—canine 
16
DYSPEPSIA.
appetite being always, so far as I have  known, connected  with
great powers of solution and assimilation.
  In dyspepsia proper, there seems to be combined a number of
elements, which must co-exist in varying number and intensity,
in order to  produce the symptoms  presented in the different
cases.  1. The most  prominent, as it  is the most  essential, is
abnormal innervation. It is difficult to know, whether we should
place this first in point of time, as primary or consequent, cause
or effect.   I have  said abnormal, because I mean morbid inner-
vation, which may be either defective or superfluous, but which
is always specific in its  nature.   2.  Morbid condition of the
vessels of the gastric surface.  There may either be redundancy
or deficiency of blood in  the tissues of the stomach, anasmia as
well as hyperasmia.  3. In either  case,  as the nervous influence
is not  acting regularly, we  have depraved  secretions.   These
also may be  in greater or less amount than the average, but will
be found always  morbid.  4. There are many circumstances
which  go to show, that  the muscular or contractile powers of
the stomach  are impaired in dyspeptics  generally, so  that  its
peristaltic movements are  not properly performed, and  the ne-
cessary agitation and mixture of food  with the gastric juices
cannot take place.   5. To these, Todd  adds, not unreasonably,
the  probable suggestion,  that the  absorbing power  of  the sto-
mach is diminished, and thus the digestion of fluids rendered
more difficult.
  The Causes of  dyspepsia have been well divided, by Cullen,
into  the  direct and  indirect;  the former  acting immediately
upon the  stomach itself—the latter  acting  upon other parts of
the general system in such manner  as  to disorder  or derange
that  important  organ.  The first of  the direct  causes  of dys-
pepsia, which I shall mention, is imperfect mastication.   Diges-
tion  may truly be  said to begin in  the mouth,  the food being
here comminuted and intimately mixed with saliva, which  fluid
was  formerly looked on  as  aiding in  its  solution,  but is now
regarded as principally, at least, a mere lubricant.  Experimen-
ters  tell  us, that  the  mass of food in the stomach is gradually
melted down by  the gastric juices,  the portions  nearest  the
inner surface of the  organ being  first  dissolved and  pressed
away toward the pylorus by the peristaltic motions of the organ 
DYSPEPSIA.
17
Hence, it is plain, that in definite proportion to the tenacity or
solidity of  the meal taken, will be the slowness and difficulty of
its solution.  "There is no person," says Spallangani, "who has
not, some time or other, been subject to indigestion from want
of having  duly chewed  his food.   I took  two pieces of  a
pigeon's heart, each weighing  forty-five grains,  and  having
chewed one as much as I used to chew my food, inclosed them
in two spheres, and swallowed them at the same time.  Both
these tubes happened to be voided together.  Of  the masticated
flesh, there remained only  four grains, whereas, of the other,
there were eighteen grains left."  The result of similar experi-
ments, made by him with mutton and veal, was the same, and
it was uniformly confirmed by the careful observations of Beau-
mont.  Imperfect mastication is usually a matter of habit; it is,
in our  own country, the frequent consequence  of excessive
occupation  and the  hurry of  pressing business;  it  is often
owing, too, to decay and loss of teeth, whose diseased conditions
are, indeed, supposed to be  capable of determining  dyspepsia,
independently of the defective mastication which  must  attend
their  deficiency in number.
   Excess in the amount of food taken, is a common cause of
dyspepsia.    This sometimes results from the influences  just
spoken  of.  Food not broken down and mingled with the saliva,
is but imperfectly tasted; the appetite, therefore, is not  satisfied
by the proper and natural impressions on  the  gustatory nerves,
and  morsel after morsel is  swallowed so rapidly and  in such
condition, that the stomach is overloaded and  oppressed before
satiety is induced—but satiety  is our  only physiological  and
instinctive  safeguard against excess.  Besides this, the  art of
cookery has always, in  civilized  nations, aimed  as assiduously
at the gratification of the palate as the nourishment of the body.
Our dishes are  carefully seasoned, and a nice management is
displayed in graduating the excitement of  an  artificial  appetite,
by presenting, in regular order, a series of courses, each more
tempting than  the one which preceded it.    Gluttony is thus
made a scarcely less fatal mode of indulgence  than intempe-
rance in drinking, that magna parens malorum.  It is worthy
of particular  remark, that dyspepsia seldom, if ever, originates
from  any peculiarity in the  quality of  food, however improper
      2* 
IS
DYSPEPSIA.
or deleterious it may seem.  The human stomach is gifted with
inconceivable powers of solution and assimilation.   "The Hin-
doos live entirely on fruits and grain ;  the Tonguses on berries,
the refuse lichen found undigested  in  the  stomach of the rein-
deer, dried fishes and beasts of prey ; the Californians on rats,
lizards, snakes and wild herbs."  Some hordes of Nomade Tar-
tars, subsist chiefly on  mares' milk, and the  curds and cheese
made from it; and the Esquimaux, and  other Northern tribes,
on whale oil, blubber and rancid  fish, with  raspings of wood.
The influence of habit over the modes of life, is proverbial,  and
almost omnipotent.  Yet we perpetually hear  certain articles in
familiar  use  as  food  and drink, accused of causing dyspepsia
specifically.   The bread we eat, in all its varied forms of prepa-
ration ; meats of every kind, however cooked—nay, milk itself,
and the delightful infusions of tea and coffee, are thus stigma-
tized, how irrationally, you may decide for yourselves.  Of tea
and coffee, against  both of which,  so  loud  a  clamor  has been
lately raised, we may  observe, that  the Chinese, and the Turk,
from whom we learned their use, seem to have failed to discover
their alleged deleterious influences.   It is possible, that the high
temperature at which  we drink our tea and coffee, may be inju-
rious ;  but this  is  not  clearly made  out,  and, moreover, their
aromatic properties  seem counteractive, in  a notable  degree, for
warm water, taken  in the same quantity and at  the same times,
has, in numerous instances, appeared to me decidedly injurious.
   It is not to be doubted, that the  free or customary employ-
ment of many medicinal substances,  with  whatever views,
ought  to be enumerated among the  causes  of dyspepsia.   Of
these, the chief, perhaps, are tobacco, rhubarb,  aloes, and alcohol.
I do not  here speak of idiosyncrasies, upon which  Cullen  has
laid more stress than they merit   He gives us an example, in
reference to tobacco, of  an  individual whose  appetite would be
destroyed for a whole day, by  a single pinch  of snuff taken in
the morning, and, of  another, in whom snuffing  regularly
brought  on pains in the stomach. I am certain, that such is the
tendency of all narcotics.  It may be  counteracted by vigor of
constitution, and lessened by habit, yet few are so fortunate as
to escape it altogether.  The amount of quantity which can be
borne, is in inverse relation to the  intensity of narcotic  power • 
DYSPEPSIA,
19
hence, tobacco and alcohol,  are  less injurious  perhaps than
opium, in this  particular  mode.
  Of the second class of causes  of dyspepsia,  those  namely,
which act upon the stomach indirectly, through and by  means
of their effect on the general system, the  number is almost infi-
nite.  It is under this head, that we must consider the sedentary
habits connected with so many various modes of  life, and so
many occupations.  The student, who, with a happy but delu-
sive forgetfulness  of self, barters  for intellectual improvement
his physical powers of action and enjoyment;  the indolent vo-
luptary, whose existence,  for it cannot be  called life,  is  spent
either at the table  or  in bed, ("du lit a la  table, de la table au
lit;") the imprisoned  slave of commerce, chained to the  count-
ing  house, the ledger and the desk; the pale artizan  whose
heavily passing hours find him still seated at his  work bench ;
these are the  fated victims of dyspepsia.  The passions and
emotions of the mind, must next be enumerated here.  Anxiety,
when intense, stops the process of digestion  as promptly as if
the eighth pair of  nerves were cut and destroyed, and the same
may be affirmed of all the rest, in  greater or less degree.   Long
protracted or very violent fatigue, loss of rest, the bad air of ill
ventilated apartments, sudden changes of climate  or even of
temperature, and excessive venereal indulgencies,  are also  to be
mentioned.   These  produce dyspepsia in  two  modes,  either
separately or combined.   They tend to exhaust the sensorial
power by an  undue determination of it to  particular organs or
tissues, which are  kept in action  unduly;  or  they  depress the
tone, the vitality of the general system, which exhibits the effects
of such depression early, though secondarily,  in  the organs of
supply, the great channel of the restorative energies.
   The terminations  or consequences of dyspepsia  vary some-
what with the predisposition of the subject, and  the local and
other climatic agencies which  exert an influence  upon him.  It
will readily be supposed,  that undigested food remaining in the
stomach shall give rise to irritations of that organ,  which may
under certain  contingencies,  become  inflammatory.  Thus we
have a  chronic gastritis  aroused, a condition not unfrequent
among dyspeptics, but exaggerated by Parry, into the constitu-
ent or proximate cause of the symptoms, and regarded by Wil- 
20
DYSPEPSIA.
son Philip, as a second stage of the disease which preceded  it.
This is an incorrect view of the matter, however; it is but one
of a train of consequences, variable, incidental  and irregular.
Diarrhoea is another of these, owing to similar irritation  of the
upper intestine by crude ingesta. Aphthous inflammation of the
whole  tube, is sometimes met with, sometimes chronic hepatitis,
and occasionally a true nephritis.  But these are all alike irregu-
lar and unessential.   Malaria itself,  has  not  been accused  of
originating a longer catalogue of maladies, than have  been at-
tributed to dyspepsia.
   The Treatment of dyspepsia need  not detain us long, if it
were in our power to communicate to our patients the disposition
and the ability to follow out the few brief rules which we should
lay down for their observance.  There is no single disease recog-
nised by nosologists, so completely under our control—"Fling
but a  stone, the giant dies."  Exercise  and temperance, un-
der which last term is included the entire regulation of all our
passions and appetites—exercise and temperance are fully suffi-
cient for the absolute renovation and restoration of the digestive
function, in dyspepsia proper, that  is, while yet  no organic de-
rangement or structural lesion  has supervened.  But  unfortu-
nately, we should in vain employ the  eloquence of an  Erskine,
to inculcate upon our unhappy patients the importance and ne-
cessity of the avoidance of the remote  causes  of this disease,
which may, with few  exceptions,  be  comprehended under the
heads of indolence, excess, and sedentary labour.  A very large
majority are incapable, however well  convinced, of following
our  advice; and of the  remaining few,  more  than  a moiety
would turn  a deaf ear  to our exhortations.   The student will
not set a limit to  the acquisition of knowledge, though  made, as
he is but too conscious, at the expense of his  health, and ulti-
mately of his very Hfe.   The idle  sensualist cannot be  spurred
to exertion,  but prefers the indulgence of his contemptible slug-
gishness.   The poor artist and mechanic, though writhing under
the pressure of pain and  infirmity, cannot remit exertions, on
which depend their means of daily subsistence.   Nor have we
yet learned  to "minister to a mind diseased," to calm the tumults
of passion,  to soothe  into tranquility the grief of the mourner
and the anxious fears  of the distressed.   We must, then, be con- 
DYSPEPSIA.
21
tent to palliate evils, which we have not the power to shun or
take away, and  this,  in truth, constitutes the purpose  of the
medical practice in dyspepsia.  To the  student, we must pre-
scribe hours of exercise; to the glutton, measured intervals and
quantities of food; to the voluptuary, rules for the government
of his  headlong appetites;  otherwise, the  continued application
of the causes which have produced,  will perpetuate or renew
the disease in spite of all our remedies.
   The dyspeptic, then,  should sleep on a firm and hard mattrass,
rather than an ordinary feather bed, should avoid late vigils and
rise moderately  early.   His breakfast should be a light one, and
taken  soon after rising,  to fit him for  his accustomed exercise or
occupation.  He should enjoy free access to the  open air, and
shun all close and ill ventilated apartments.   If urged by appe-
tite, or prompted by an uneasy  feeling of hollowness  at the
stomach, or debility, he may take a little nourishment at or about
noon.   His dinner should be moderate, and rather an early than
a late one.   If  he can,  he should  follow the old maxim, "after
dinner, rest awhile;" yet, unless specially feeble,  I  would not
 encourage any  indulgence in the recumbent posture, or in sleep.
 The question as to  the propriety of taking supper, has been
 warmly discussed; but the answer seems to  me an easy one.
 If there has been bodily labor, or active exercise  after dinner, a
 slight meal should be allowed, otherwise  not.
   The term exercise, comprises a variety of modes, all of which
 tend to the same purposes.  Frictions over the whole cutaneous
 surface, but particularly the abdomen, do much good by exciting
 the vessels and disposing  to perspiration.  If  the bowels be
 pressed and kneaded, it is said to arouse  their peristaltic action
 and relieve constipation.  This was  Halsted's method of treat-
 ing dyspeptics, at one  time  so famous  in New-York.   Playing
 with  the dumb bells, swinging, leaping  the  rope, fencing, and
 other gymnastics, should be resorted to in bad weather.   Riding
 in a carriage and sailing, are of  great service;  but horse-back
 exercise is probably most beneficial to  the majority.
    I have taken great pains to impress  upon  you  the principle,
 that the quantity of food and drinks is of much more importance
 than  their quality.  An intelligent dyspeptic cannot but smile
 at the efforts which have been made by  acute and experienced 
22
DYSPEPSIA.
physicians, to select particular formularies of diet for him.  One
prescribes an exclusive use of milk;  another of broths and jel-
lies ; a third confines him to bran and  water; while  a fourth
enjoins upon  him the necessity of a resort to the most stimula-
ting articles,  as  beefsteak with  cayenne  and brandy.   In the
midst of all this contradiction and uncertainty, it is difficult, but
not yet I trust, impossible, to lay hold of the definite truth.   No
two stomachs agree entirely, as to the kind of food  which de-
serves a preference.  Habit exerts much control in this matter,
and should always be attended to, and within certain reasonable
limits may be allowed very great weight in our decision.   Be-
yond this, I will venture to  lay  down two rules—1.  That no
exclusive diet can be proper; and 2.  That too great abstemious-
ness is as much to be shunned as excess.  Without variety, the
appetite palls, and the stomach depends so much, for its tone,
on the influence of the gustatory nerves, that unless these are
properly stimulated by sapid and desired food,  the secretion of
the gastric  juice is both deficient in quantity and  imperfect in
quality.   Hence we see patients emaciating  and suffering under
the milk diet, the rye mush, the bran  biscuits,  and  even the
ever 'recurring  beefsteak, which they have learned  to  loathe.
A change arouses the mind and  excites the secretory vessels.
As  to the second point stated above, I do not doubt the  benefit
of moderation, or even of occasional  abstinence and total  fast-
ing, but I fully  believe that infinite harm is done by the modern
system  of .confining the patient to a measured amount of the
insipid aliment  allowed  him.  "Rise up  from table hungry,"
says the philosopher.  "Get an appetite," says nature,  "and  sat-
isfy it."   This can always be done safely,  if the food be plain,
moderately varied, not too highly seasoned, and masticated per-
fectly.  We do not improve the  strength of a feeble muscle, by
forbidding  it  to  lift weights, or give  vigor  to  the intellect by
abstinence from all difficult efforts.   Sir W. Temple, I think,
was the author  of the quaint phrase, that  "the  stomach  is like
an  idle school boy, always doing mischief when  unemployed."
A similar prejudice is embodied  in  the  vulgar maxim,  "to eat
little and often," unfortunately not confined to the  vulgar only.
Nothing so much wears out the powers of the stomach, and by
preventing the possibility of a full development of the natural 
DYSPEPSIA.
23
appetite or hunger, it  keeps the harrassed organ in a perpetual
condition  of sickly satiety.
  I am very little disposed to enter into the debates concerning
the solubility or digestibility of various articles of ordinary food.
I generally select for my patient, among the common materials
of his  accustomed diet, such as are  not  objectionable by any
known property.  I advise him to  limit for himself the quantity
or amount of each meal;  to make the intervals between them
as long as he can bear without faintness or other inconvenience ;
to chew thoroughly and eat slowly, and to make frequent changes
in his  diet, avoiding the use of more than one or two articles at
each meal.  Among the received opinions on the subject of diet,
are the following.  Animal matters are more easily digested than
vegetable; the flesh  of those  of  mature  age, than that of the
very young;  meats roasted, than those  prepared in any other
mode; lean meats, than fat; fresh meats,  than those which have
been smoked,  dried, salted or pickled ;  eggs, raw or  soft boiled,
milk and jellies, are also supposed to be readily soluble;  so also
the various mucilages.  There are a thousand whimsical notions
in existence, concerning our  bread stuffs.   The Grahamites pre-
fer bran to fine flour.   The Scotch have  much  to say in praise
of oat meal.   Good  wheat, well  raised  and allowed to cool
thoroughly or become a little stale, is unobjectionable.  Corn, rye
and barley make a very good  bread,  if well prepared.   Rice is
nourishing and light.  The Irish  potatoe, when mealy, is both
nutritious, and by common stomachs, digested without trouble.
Once  for  all, let me protest against the idea of rendering our or-
dinary diet, in any mode or degree,  medicinal.   If homony or
rye mush, or wheat bran prove laxative, the very fact shows that
they are unfit for food,  and so of all other articles.  Let us keep
absolutely separate the  mat: med:  from the mat:  alimentaria.
   As  to condiments, which some so strictly prohibit, I am rather
 in favor of their being  allowed.   It is useless to discuss the em-
ployment of pepper and salt, for they must and will be employed.
Salted meats and fish deserve to  be considered in this relation,
rather than as articles of  diet.  Ham, for example,  forms an
advantageous  addition, for the most  part, to  the  breakfast of a
 dyspeptic.  Many find mustard and cayenne of service.
   Of  drinks,  "water is best" on every account, both for dilution 
24
DYSPEPSIA.
and to quench thirst.  Its temperature is a point of some conse-
quence, as in warm climates we are tempted to reduce it unduly.
Iced fluids may become injurious if taken in excess—lemonade,
etc., as well as frozen confections, custards and creams.  Of tea
and coffee I have already spoken.  Wines and  malt liquors,
occasionally  but  not habitually,  and in  reasonable  amount,
may  be taken without  any injurious consequences.   Ardent
spirits I mention, only  to reprobate their  use in any mode
or quantity.   In health,  they  should  find no  place on our ta-
bles ;  and in  all chronic diseases, they  should be  absolutely
prohibited.   The temporary relief, which they have  occasion-
ally afforded to  dyspeptics,  is infinitely more than  counter-
balanced by the permanent evil  they have  inflicted.  If I can
prevail on you uniformly to discountenance their administrati on
except in the rare exigencies of acute disease, I shall not in vain
have  occupied this chair, or written and  delivered in  vain, this
series of lectures.
  As to the Medicinal Treatment of dyspepsia, there is no degree
of certainty.  It has very generally been assumed that the most
essential portion of the malady consists in a debility of the sto-
mach, and that the remedies most distinctly indicated,  therefore,
were  chiefly to be found among  the tonics.  After what  was
formerly said of the complicated  elements which enter into the
pathology of dyspepsia, you will find no difficulty in accounting
for the ill success, so much complained of, of the choicest and most
powerful tonics, when administered solely with a view to their
tonic  influence.   The precise modus  operandi  of this class of
medicines, we do  not clearly comprehend, but we do know that
it is by no means so simple  an affair as was once imagined. The
specific differences, which  they  exhibit in  their influence on
the body, are very remarkable ; it may be said indeed that they
possess no trait in common.  They  cannot, therefore be used
promiscuously, but require  to be carefully adapted to the parti-
cular conditions of the dyspeptic.
   You will meet with no class of patients in your  future  prac-
tice, who will require from you so constant an attention to their
symptoms, the consequences or effects of  the morbid  condition
under which they labor.  You will often  find it essential, in the
very  first instance, to remove the crudities which have been 
DYSPEPSIA.
25
allowed, on account of the torpid state of the digestive tube, to
accumulate in the stomach and bowels.   For this purpose, an
emetic is occasionally demanded, as when the tongue is foul, the
breath foetid and the stomach oppressed.   A free dose of ipecac,
will do good here, not only by the  removal of offensive secre-
tions, both upward and downward,  but by the impulse given to
the liver and secretory surfaces universally.   You must not be
led, however, by the transient relief afforded by the act of vomit-
ing, to its too frequent repetition—an error common  among the
ancient Romans and the modern West Indians.
   Constipation is one of the most ordinary attendants on  dys-
 pepsia, and many patients spend their lives wretchedly,  in the
 constant use of purgative formulae,  which, by their irritation and
 consequent exhaustion of the excitability of the  parts acted on,
 increase the evils they are meant to relieve.  The favorite laxa-
 tives are rhubarb, aloes and the blue pill.   Magnesia will answer
 our purpose,  when there is an abundant acid in the stomach, but
 should not be employed in too large an amount,  as great masses
 have  been found impacted in the alimentary canal.  It is highly
 probable that a deficiency of  acid,  the hydro-chloric or muriatic,
 which ought to be found in every healthy stomach  m a definite
 proportion, is now and then a concomitant of dyspepsia.   I pre-
 fer to enjoin upon my patient a regular and punctual effort at an
 alvine evacuation to be made daily, which, with  proper attention
 to due habits of exercise, will rarely fail to remove costiveness.
  Next in order,  I advise the daily use of  enemata, of mere  water,
  or if necessary of some more active material;  a system  much
  preferable to the use of cathartics.  If, after all this, they cannot
  be dispensed with, we must exhibit them at the longest possible
  intervals, and of the mildest ingredients.   Many persons find a
  half grain or grain  of calomel, taken over night, act gently next
  day.  Others prefer a moderate dose of rhubarb with an  alkali,
  the carb: sodae for example,  and an aromatic as ginger, mint or
  aniseed.                                             .
     If there be  permanent  uneasiness of the stomach, with pain
  at the epigastrium, increased on pressure, it may be well to insti-
  tute a slow alterative course.  Blue pill, in the small amount of
  a grain or  two, or  calomel in the dose of one-half or one-third
  of a grain, combined with an equal proportion of ipecacuanha,
         VOL II.—3 
26
DYSPEPSIA.
may be administered nightly until relief is afforded.  Dauben-
ton speaks highly of the latter article as an alterative and a tonic,
when employed in these minute quantities.   Under similar cir-
cumstances, advantage  may be obtained from the application of
cups or leeches to the epigastrium or abdomen.
  Under this  head  of alteratives, I will here recommend the
sub-nitrate or white oxyd of bismuth, which has also been recog-
nized as a deobstruent and a tonic, and  a sedative or anti-irritant.
It is perhaps more generally adapted in the treatment of dyspep-
sia than any other remedy,  and my own experience enables me
to speak  with confidence of its utility.  I  usually prescribe it
in the dose of 5 grs. ter die.
  Gastrodynia or  simple pain in the  stomach without heat or
burning,  may arise from  a variety of causes.  It depends some-
times on  the mere distention of the organ by air evolved in its
cavity.   This is  often relieved by aromatics, as mint, ginger,
camphor; or  relaxants, as  tobacco smoked.  It  is occasionally
so intense as to demand immediate relief by free doses of opium
or other narcotics, which should, however, be avoided as much as
possible.  Fomentations  may be laid  externally to the surface
with  good effect,  or a laxative  enema given.  It is here that I
have seen most benefit from prussic acid, so highly but vaguely
eulogized by Elliotson, who declares  that it often  acts "like a
charm, giving instant relief."  He  begins its exhibition with a
single minim, which he increases to 3, 4, 5 and even 6.
  One of the forms of gastrodynia attends upon and  seems to
be terminated by  the secretion  of a thin mucous fluid which is
thrown out from  the stomach in large quantities by vomitino- or
a movement similar to hiccup; and  these  symptoms have  re-
ceived the  separate name of pyrosis  or  water brash, which in-
deed, Cullen, and after him, Wilson Philip, regard as a distinct
affection of the stomach.  The fluid thus brought up is usually
tasteless, though sometimes  slightly  acid ; the  patient  suffers
from thirst and emaciates  perceptibly, though there is for the
most part, no loss of the desire for food.  I have met with pyro-
sis most frequently in women, as is also affirmed by Pemberton and
others.   I am unable to ascribe it definitely to any thing notable
in the mode of living or in the diet or drinks of those subject to
 it.   Percival suggests, that the secretion  may be from the pan- 
DYSPEPSIA.
27
creas;  but this  is mere conjecture.   I have found the astrin-
gents of most service here ;  the preparations  of iron are among
The best, but  cinchona,  kino, alum,  and catechu, have  been
administered with success.  I have seen a few cases of pyrosis
unconnected with gastrodynia, and apparently dependent  upon
other conditions.
  Cardialgia is a well known symptom, in which the suffering
complained  of, is almost exclusively a sensation of morbid heat
m the stomach, hence called heart-burn.  Generally speaking, it
is dependent upon the  formation of acid  in the stomach, and
attended by eructations  so sour as to set the teeth on edge, and
produce an  acrid irritation  in the throat  and fauces.   This is
easily  relieved, for the  time, by the use of  alkalies, soda, carb:
potassae, magnesia and lime-water.  As it seems to be the result
of fermentation, it can also  be removed by the  mineral acids.
The vitriolic elixir, and the muriated tincture of iron, may be
taken  for this purpose, and  the latter  especially is well adapted
here.  Cardialgia is not, however, exclusively a  result of acid
fermentation, as I have elsewhere observed,  but may arise from
varied modes of irritation.   Some tobacco chewers are always
attacked by it, if they happen to swallow any portion of their
saliva.  Some dyspeptics suffer from it whenever they eat nuts—
some from cheese, etc.  These put an end to it, by stimulants
and aromatics.   Some  drink vinegar, and as they affirm, with
immediate relief.
  Among the severest sufferings endured by dyspeptics is  flatu-
lence, which, indeed, is  often unaccountably annoying.  I have
known more than one  instance in which it occurred regularly
after every meal, no  matter  how moderate, or of what article or
articles of diet, beginning about an hour after eating  and con-
tinuing from one to two hours.   In the worst of  these cases, it
was strange  to  observe, that a similar attack of flatulent colic
took place,  and with  peculiar violence whenever the  habitual
meal was abstained from or delayed.  In two of the patients
thus affected, after the total  failure of  purgatives, tonics, aroma-
tics  and opium,  the  flatulence gradually subsided under the
moderate, but  steady, use of wine—Madeira and Sherry and
Lisbon, with every thing eaten.   The moderate and regulated
use of wine, I  have found serviceable in  cases of continued 
2S
DYSPEPSIA.
 nausea.  This may be  combatted, too, with camphor, in small
 doses, with iron and with the oxyde of bismuth.
   The connection between  physical and  intellectual health, as
 pointed out  in the old maxim, "mens sana in corpore sano," is
 no where more strikingly displayed than in  dyspepsia.  The
 mental dejection—the profound depression of spirits, which is
 so constant a  symptom of the disease, proceeds very often into
 a gentle, but gloomy insanity, and occasions, as I verily believe,
 a majority of the instances of suicide which, from time to time,
 strike us with  horror.   I  speak with  a  personal  and  feeling
 knowledge of  the subject, when I say, that from this cause, life
 becomes an intolerable burden, the capacity for enjoyment being
 absolutely destroyed, and, from a morbid increase of nervous
 sensibility, the  susceptibility to  painful impressions augmented
 an hundred and a thousand fold.  The unhappy patient, under
 these circumstances, ignorant of the true source of his unspeak-
able  sufferings, fixes his fancy upon an infinity of imaginary
evils  and vain anticipations, and in the  contemned name  of
hypochondriac, loses all  claim to  the  sympathy even of his
friends.   Wearisome vigilance, or a troubled  and unrefreshing
 sleep, dreams  dark  and heavy, or  the  suffocating nightmare,
 beset  his couch; and the very thought of the  long—long night,
 becomes a terror to him.  Horrible shapes surround him, gloomy
 forebodings fill his ear, and the  morning, which  brings him a
 light and interrupted slumber, finds him languid and exhausted.
 The company and conversation of the day. furnish  him suffi-
 cient  excitement  to restore, in  part, his powers mental and
 physical, and at evening he attains a comparative  degree  of
 cheerfulness, until he  retires, when the  same  succession  of
 phantoms haunt his pillow and embitter his hours of repose.
  In the more severe cases of this character, we must resort to
 the narcotics—lactucarium, hyosciamus and opium.   Wine and
 camphor sometimes  give relief.  I have seen good done appa-
 rently, by the  infusion  of  soot, a favorite prescription of Dr
 Physick and Professor Ives.
  To the dyspeptic, perhaps, more than any  other among the
 numerous sufferers from chronic disease, the various medicinal
 springs diffused over all regions of the globe, are valuable and
 useful.   Of these, there are two  classes from which he may 
DYSPEPSIA,
29
derive special advantage—the chalybeate and the mildly purga-
tive.  Both  these appear  to  have their remedial virtues much
heightened by impregnation with carbonic acid gas, a chemical
agent fatal when introduced into the lungs, but  grateful  and
pleasantly stimulating to the stomach.  Common water, indeed,
with which this gas has been combined,  by forcible pressure, is
highly agreeable to most  persons, and will often relieve irrita-
bility of the stomach, remove nausea and check vomiting.
   The  effect of the long continued mild  action of purgatives
upon the constitution, as  an alterative measure, has never yet
been duly appreciated.   We see it exemplified in that form of
hydrocephalus which  results from derangement of the prima?
vise, in morbus coxarius, one of the worst  developments of the
scrofulous diathesis, and in many other  instances of scrofulous
contamination of the fluids,  with or without marasmus.  This
happy influence is  no less  strongly exhibited in the case before
us.   We have no officinal preparation of a purgative, which can
be taken daily in an effective dose, with impunity, by the vale-
 tudinarian  in  chronic  disease.  But,  for  whatever reason, the
 waters of Ballston and  Saratoga form an innocent luxury for
 the sound, while  they benefit, nay, entirely restore  the  other-
 wise hopeless sick.  These natural formulae we imitate in vain ;
 in vain we  combine the agents which chemical analysis has de-
 tected in their composition.  The quantities of iron—of iodine—
 of the various alkaline and neutral salts, and of the  gases thus
 mingled, are so small, that some have considered the benefits
 derived, as the results of  mere dilution.   But these results
 cannot be imitated at home, either by simple dilution, or by any
 artificial combinations.    I  care  not,  then, whether  the  happy
 changes, effected at the watering places of which I speak, were
 wrought by the true medicinal virtues of the chrystal well, or
 by the  mere  mechanical washing out, as  some believe, of the
 primse viae and the excretory tubes, or, as  others maintain, and
 with more reason, by the exercise and agreeable society which,
 in such resorts, entice and amuse the  invalid—I say, I care  not
 whether the restoration  of  health and comfort is brought about
 in either of these  modes, or, as I am disposed to think, by means
 of them all collectively.   It suffices to know, that a few weeks'
 or  months' residence at, and  proper  use  of, these hygeian
        3* 
30
GASTRITIS.
streams, has often given new life to  the  despairing dyspeptic;
and  that many a wretch, who was brought  to  their  healing
fountains a  mass of disease, misery and despondency,  has re-
turned home with a frame glowing with ruddy health, and a
mind bright with cheerful anticipations.
                    CHAPTER X  III.

                        GASTRITIS.

  Inflammation  of the gastro-intestinal  mucous membrane
has, perhaps,  of late years, received  more  attention  from  the
profession, than any other form of disease.   Clutterbuck sees, in
every attack of fever, a case of arachnitis, an inflammation of
the brain or its membranes.  Broussais and his followers, attri-
buted, by a  similar mistaken generalization, all fevers to an
inflammation  of the mucous  membrane of the  stomach  and
intestines.  That such inflammations may excite fever, is unde-
niable; that they often attend upon fever, as among its principal
symptoms, is obvious to  every one;  that they are rather effects
of fever, or coincident effects of the cause which has produced
fever, I have  already maintained—and I believe this to be the
doctrine which now generally  prevails, and  to which, even
Broussais,  seems  to have been compelled  to give a  reluctant
assent.
   Gastritis, like other inflammatory affections, presents itself
under two  general  forms—the  acute and chronic,  the latter
being often  met with in practice, while  the  former is  rare.
When we reflect upon  the immense  number  and  variety of
substances, differing in temperature  and qualities—mechanical,
chemical, and specific, which are received  into  the stomach so
frequently and often in such quantity, and when we  regard the
close and  extensive sympathies  by which it responds to the
impressions, whether natural  or  morbid, received upon every
other part of the system, we are struck with a rational surprise 
ACUTE GASTRITIS.
31
that so few instances of idiopathic gastritis should come under
our notice.   We can  only account  for such exemption, by a
reference  to  the powers of resistance physiologically displayed
by the  principle of vitality, against  the influence of chemical
 and other extraneous  agents.

   Acute Gastritis—I have said, you will seldom meet with.
 Abercrombie  says, "I have been often very much astonished to
 find, in my own observation, how seldom  the stomach shows
 marks of inflammation, even when the organs most nearly con-
 nected with  it, have  been  inflamed in the  highest  degree."
 Broussais tells  us,  that  it never occurs  alone, but  always in
 combination, as a  gastro-enterite.  A far better authority, less
 biassed—less wedded  to  preconceived opinions, far  more accu-
 rate, I  think, in observation—Andral—in his Medical Clinique,
 gives several separate cases.
    It is readily recognized by the presence of severe pain at the
 pit of  the stomach, with  a sense of heat or burning, and intole-
 rable  oppression, nausea, and frequent  and violent vomiting.
 After  a short time, there is extreme tenderness  at the epigas-
 trium, with inability to  bear the slightest pressure;  the  skin
 becomes hot and dry—the pulse is  small  and contracted, but
 hard,  tense, and frequent—the tongue, at  first covered with a
 white fur, becomes clean, and red, especially at the tip and round
 the edges ; there is much thirst, but every  thing taken, is apt to
 be at once rejected, or occasions a sense of weight and brings on
 hiccup.  There is great  anxiety and depression of  spirits,  with
 restlessness and sighing, and a peculiar and striking prostration
 of strength.   "If the stomach  is  inflamed," says John Hunter,
 in his Treatise on the  Blood, Inflammation, etc.,  "the patient
 feels an  oppression and dejection through  all the stages of the
 attack ;  simple animal life seems to be hurt and lessened, just as
 sensation is lessened when the  brain is injured ;  the pulse is
 generally low and  quick;  the pain is obtuse, strong and oppres-
 sive, such as a patient can hardly bear."  As the case progresses,
 the tongue  becomes fiery red, inflames and ulcerates, and the
 lips, gums and cheeks are hot, dry and swollen—the fauces and
 esophagus take on similar appearances, and deglutition is  quite 
■i'c
ACUTE GASTRITIS,
difficult.  The pulse loses  its tension, and is weak and thread-
like and undulatory—the eye is  red  and suffused—the bowels
are often little disturbed, but  usually at first constipated ;  they
are afterwards irritated  into  diarrhoea; the mind  is affected
with  low muttering  delirium;  the matters vomited  are  very
various—at  first the  contents of the stomach, then mucus  with
a little bile,  perhaps, and towards the termination, a diversity of
morbid  secretions, and  not unfrequently the black vomit; the
extremities  grow  cold, circulation languishes,  respiration be-
comes more  and more difficult, and death terminates the suffer-
ings of  the  patient at a period ranging from a  few  hours  after
the first access of the disease, to three, four or  five days,  or a
week.
  The Prognosis in idiopathic gastritis  of acute character is al-
ways  doubtful and usually unfavorable.  It depends somewhat
upon  the probable cause which has given rise to the attack, and
the previous condition of the patient.  If it has supervened upon
a chronic affection of any standing, there is great reason to dread
a fatal issue.   We are guided also in our expectations by the sud-
denness and violence  of  its access, the  apparent rapidity of  its
progress, and the influences exerted upon the powers of life.
  The Causes  of Gastritis are ascertained  without much diffi*
culty.   The acrid  poisons, whether mineral or vegetable, are
perhaps most frequently to be suspected,  and a strict enquiry
is demanded of us.  Mechanical violence from  without, is  enu-
merated by writers among the circumstances to which  it has
been  ascribed—exposure to sudden and impressive changes of
temperature—the inordinate  use of several  common articles of
food and drink, ardent  spirits especially;  violent  passion,  or
emotion of mind;  and the  metastasis of other inflammations, as
the athritic.
  I once saw  acute gastritis occur in every member of a large
family, eleven   in number, from eating a soup which had  been
kept and set on the table from day to day, until it had run into
a state of incipient but obvious putrefaction.   I suspected poison
to have been administered, and on enquiry, was shown this soup,
which was  extremely offensive to the smell.   Mushrooms  as
you are aware, are commonly prepared as condiment  or sauce 
ACUTE GASTRITIS.                   33
and mistakes occur by the substitution of the poisonous for the
edible and innocent; the use of the former being followed by a
severe and dangerous inflammation of the stomach.
  It is not my purpose here to enumerate  the not unfrequent
cases in which gastritis  arises,  sympathetically, in the course of
other diseases ;  these  require notice each in its proper place.  I
refuse to recognize, under this  head too, the host of affections
which the disciples of the French professor, in  their vehement
hatred of what they are pleased  to call ontology, have chosen
to include in the long list of gastrites and gastro-enterites.
  When gastritis is not promptly relieved by the active employ-
ment  of the proper  remedial  measures,  it  may run  into  the
chronic state, to be spoken of by and bye, or it may terminate
in suppuration or gangrene, or end in death, without any local
lesion of structure.  This latter is the most frequent conclusion
of unfortunate  cases.  From the extreme sensibility of the or-
gan attacked, and  the peculiar nature and extent of its sympa-
thetic connections  with every part of the body, every function
becomes disordered by its suffering, and the system rapidly suc-
cumbs under this general disturbance and excessive debility.
Like all the other  mucous membranes too, that of  the stomach
is liable to ulceration, but this is rather the effect of  chronic than
acute inflammation.
  I have not seen  any example of the termination in suppuration
or gangrene described by authors—the fatal cases which I have
met with, having proved so in consequence of the general irri-
tation and subsequent exhaustion, rather than by the production
of any  local structural lesion or injury.   The occurrence of
gangrene is  inferred, when  there has been sudden and complete
relief from gastric pain, with great prostration ; troublesome hic-
cup ;  low delirium ; cold extremities ; countenance hollow and
shrunken ; the pulse is low, and the skin cold and clammy, and
death soon ensues.
   When suppuration has taken place, there is  considerable di-
minution of local  pain, with rigors  or shivering, and a sense of
weight at the scrobiculus cordis ;  hectic supervenes, and the pa-
tient sinks somewhat slowly under  the general irritation which
attends, and the debility produced by night  sweats and colliqua-
tive diarrhoea; unless in a few fortunate  instances, when, as is 
34
ACUTE GASTRITIS.
said to have happened, the abscess has opened into the cavity of
the stomach, the pus has been evacuated by vomiting and purg-
ing, and the ulcer has healed sooner or later.
  Autopsy.  The post mortem examinations which I have had
an  opportunity of making have been few.  They have  shown
the vessels of the stomach turgid, and the whole surface of the
villous coat covered with a scarlet or deep crimson tint. In some
it has been easy to peel off with the nail this mucous turnic, but
I have not found in any case either abscess or a single gangre-
nous spot.
  Treatment.   The indications in  the treatment of gastritis are
obvious and undisputed.   Our attention is  called to the most
prompt and ready means of reducing local excitement and con-
sequent general irritation.  When any acrid matter or poisonous
substance  has been taken, it of course requires to be forthwith ex-
pelled ; and if  the  spontaneous  vomiting which almost always
occurs early, have  not taken place  or have been insufficient to
empty the stomach, an emetic must be immediately administered
for  this purpose, and the  organ washed out  completely with
large draughts of tepid water.  If the milder emetics of the ve-
getable class, as ipecac, will not act quickly enough, and a sto-
mach pump be at hand, I would  without delay employ this
valuable piece  of mechanism, and cleanse the stomach thorough-
ly.  This is far better than to place confidence in any of the
chemical  antidotes, which, however, are often  useful when, by
their union with the poison, they form an inert body. A stomach
pump and a plain well printed toxicological table, should form
part of the furniture  of every physician's office,  and every dis-
pensary and hospital.
  The means  above directed, may apply also  to such instances
as happen from the over distention of the stomach, by food in
inordinate quantity; and I will mention one farther example, in
which I would be disposed to  exhibit the emetic—that namely,
in which,  after taking a full  meal,  the function of the stomach
was suddenly interrupted, and the solution of the aliment put a
stop to by violent passion or emotion of the  mind, as may some-
times oecur.  I have spoken thus particularly of the administra-
tion of emetics in the above contingencies, because of the horror
in which they  are regarded by many physicians of the medicine 
ACUTE GASTRITIS.
35
expectante and physiological  schools, so called.   It is important
here to draw the requisite distinctions.   When  the stomach be-
comes affected with inflammation from any other  causes than
those I have alluded to;  when it  is not stimulated into morbid
excitement by the presence of undigested  or improper food—or
of acrid and poisonous  substances, I fully admit that  nothing
can be more unreasonable or injurious, than to urge on vomiting
by the use of  any emetics, and especially the mineral emetics 1
which are themselves almost all poisons.
  But in the accurately  defined cases  of which I now speak,
nothing but a choice of evils is left us, and it is the province of
wisdom and experience to select the least of those presented.
Substances which irritate the excitable surface  of the stomach,.
whether by quantity or quality, must be  got  rid of with the
least possible delay.  If fluid or soluble, it is true they  may be
drawn off with the stomach pump, but  if not, an emetic of
sufficient efficacy is  indispensable.   After  this  means  of relief
has been resorted to, and at once, in cases other than  such as I
have  pointed out as demanding it, we employ the lancet.  Gene-
ral bleeding has been supposed  by some, to be  forbidden by the
great prostration of muscular strength, and the low state of the
circulation, the pulse being small and thread-like.   But the pow-
ers of circulation are here oppressed, not depressed, that is, in
the early stage of the case, of which we are now speaking.  The
pulse will often rise as the blood flows, becoming  fuller, softer
and less frequent.   It will almost of course, be cupped and buffy.
Venisection must be carried  to the utmost extent,  that a due
regard to the general condition  of the patient will permit.  Next
in order stands topical bloodletting, which should in no instance
be neglected.   Leeches should, in great number, be  applied to
the epigastrium, and both the  general  and local  detraction of
blood be repeated as often as circumstances call  for it, and it can
be borne.  If leeches are not at hand,  cups should be  applied ;
but the former are preferable, on account of the pain sometimes
°iven by the cup at the epigastrium, where the slightest pressure
is almost intolerable.
   Thus far, we have detailed a mode of practice in which all
will agree, but we now approach the debateable question, as to
the  employment of internal remedies.   Those who  take for 
36
ACUTE GASTRITIS.
o-ranted the identity of all  modes  of irritation, and who, con-
ceivino- every impression, made by whatever agent,  to be calcu-
lated to increase irritation, argue logically for total abstinence.
"Water " says one of these writers, "is in some cases too stimu-
lating."  Others allow draughts of cold water, or  bits of ice;
and others still, permit the use of mucilages.  Some venture so
far as to quench thirst with vegetable acids, but beyond this use
no medicines.   I need  not  remind you that I do not belong to
this expectant school, and that I cannot content myself with this
passive supervision  of the  farther  progress  of gastritis of any
other character  than that which has been produced by the acrid
poisons.  In cases of this  kind, I would  assure  myself of the
entire removal of the poison, or by the use of antidotes, correct
the deleterious  quality possessed  by it.   Having done  this, I
might perhaps satisfy myself, when I had  bled the patient gene-
rally and locally, to foment his abdomen  and  extremities and
give him ice and pleasant drinks, believing that the  cause hav-
ing been taken  away, the effects would soon cease, or their vio-
lence, at least, decline.   But where the disease arises  spontane-
ously, as the phrase is, in an  individual in whom the predispo-
sition has gradually been built up,  until some ordinary  exposure
to change of temperature or dampness, or some undue indul-
gence or slight  excess has brought it into action, something more
than the very proper and necessary preliminary measures above
recited, will be  required to save him.   The morbid action which
has commenced, will often prove too obstinate to be thus checked,
and a farther resort to our therapeutical  armoury  will  be de-
manded.
  Experience has shown, that at this juncture it is  of great im-
portance and striking advantage to determine to the intestines,
and procure large and free  evacuations from the bowels.   But
the task is both delicate and difficult, and  in some instances, we '
shall scarcely be able  to offer any formula of internal medicine,
which the stomach will not reject at once.  We must not despair,
however.  Castor oil will  sometimes  be retained  by  patients
laboring under  violent inflammation of the  stomach, "to whom,
in slight indispositions, the article  was always  disgusting  and
emetic.  Some will take readily a simple solution of epsom salts
without any increase of nausea or  gastric  oppression.  Calomel 
ACUTE GASTRITIS.
37
will generally be willingly taken and easily kept down, though it
may not operate  as quickly as could be wished;  small pills
of calomel with opium, will hardly ever be rejected.  Among
these medicines, tact and experience enable us to select, and we
are abundantly rewarded for our assiduities by the improvement
of the  patient, as  soon as  they  prove freely cathartic.   They
must be assisted too, by the occasional exhibition of large laxa-
tive  enemata.  Perseverance in the use  of these cathartics in
sufficient doses, and at proper intervals, so as to  keep up loose
and free alvine  discharges, has been followed,  as  far as my
opportunities for observation have gone, by the most rapid and
complete recoveries.  The occurrence of ptyalism during such
a course, is a circumstance of highly favorable  import, every
unpleasant symptom receding rapidly on its approach,  if this
takes place at any period before the actual disorganization of the
stomach, or the fatal exhaustion of the patient's  strength shall
supervene.
   In some unfavorable examples, we are exceedingly  embar-
rassed to find our patient sinking fast, from the very earliest ac-
cess  of his  disease—the  extreme debility and  prostration  to
 which his system has yielded, scarcely allowing us any oppor-
 tunity for the efficient employment of the measures of depletion
 so obviously indicated.  Few cases can be more hopeless,  but
 we must not abandon our  unhappy client in despair.
   When we can no farther venture on the application of leeches
 or cups, we  may foment the abdomen with warm poultices on
 which mustard has been sprinkled, while sinapisms are exten-
 sively applied to the extremities.  Some prefer to lay on a large
 blister over the whole abdomen, and this measure is often  ser-
 viceable after the first stage of the attack has past.
   In  the meanwhile, we must  give  temporary  support to the
  failing strength,  by such stimulants as will add least to the local
  suffering and irritation.  Turpentine is highly recommended by
  some writers, who advocate its  employment in very large quan-
  tity—half an ounce, an ounce, and even two ounces having been
  administered at a dose.  I will not deny its occasional usefulness
  here,  but it has seemed  to me better  adapted and  safer in the
  treatment of serous inflammations, as  peritonitis, for example,
  than  in those of the mucous  tissue.   Camphor  will sometimes
        vol.  n.—4 
38
CHRONIC GASTRITIS.
be of benefit if sheathed in a mucilaginous solution.  Opium,
in some of its forms, is always more or less available.  Infusion
of cinchona has been tried with advantage, and even the  sul-
phate of quinine in solution, has done unquestionable good.
  Wine whey and weak milk punch, may be added to the num-
ber of our stimulants, as conveying also some  nutriment.  Let
me repeat that  the  employment of the  stimulants, of which I
have been thus speaking, is  to  be regarded as a measure alto-
gether transient, and adopted to meet an urgent and temporary
indication.   We are not justified in resorting to them, unless it
is clear and evident that the patient must sink at once and  die;
if left to his own  energies.   We must closely  watch, too, the
moment of earliest reaction, to diminish, and  soon entirely ab-
stain from them.
  The management of the patient during convalescence, will
require much skill and judgment on the part of the physician,
and on his own, not a little  of self control.   The function of
the stomach is so  much impaired by the attack, it is left so sus-
ceptible of irritation and disorder,  that the nicest attention will
be necessary not to disturb it.  The mind must be kept quiet
and free from care, the apartment  well ventilated, the skin cov-
ered warmly and  by woollen garments, and the diet for a long
while strictly regulated in quantity, and in quality light and
unstimulating,  consisting  chiefly, of mucilaginous  fluids,  as
strained gruel, gum arabic water and  arrow root.  After he is
sufficiently recovered to take gentle exercise,  we may indulge
him in toast and biscuits, with broths of veal and mutton, avoid-
ing spices or condiment of any kind.

  Chronic Gastritis—is a disease of not unfrequent occur-
rence, occasionally  existing  for a considerable length of time
without being suspected.  It is, as you have heard, among the
ordinary consequences of long continued dyspepsia, with which
the patient, and perhaps his physician, still confounds it.  It is
very frequently the cause of much of the sufferings experienced
by old drunkards, in whom, however,  it is combined with such
a number of complicated ailments, the necessary results of their
brutal habits, that it is  often overlooked.   From the slow and
obscure manner in which it is developed,  it is sometimes  im- 
CHRONIC GASTRITIS.
39
possible to trace with any confidence,  the source  or origin to
which we are to attribute it.   The glutton and the sot seem to
have an undoubted right to a malady,  which forms so appropri-
ate a penalty for their  vicious excesses;  but  we meet  with it
also, in the temperate,  the  prudent, and  the  studious,  and in
delicate and refined women, whose whole course of life presents
nothing to censure or correct.
   I have spoken of the obscurity which  often clouds over its
commencement and progress.  Nay, it mSy proceed to a fatal
termination, after causing extensive or deep ulceration of  the
mucous coat, without having been suspected.  It would appear
strange, indeed, that an organ of such sensitiveness and of such
importance in the animal economy,  should labor thus under va-
rious kinds and degrees of inflammation,  without its having in
any manner, sensibly  affected the constitution, or  having  dis-
covered itself by any unequivocal symptoms.
   Yet such, beyond doubt, is the fact occasionally.  Pemberton
 mentions a patient who  died of  some disease of the aorta, "in
 whom there was found a large schirrhus  in  the  stomach, with
 an open cancer, which had made its  way through the stomach
 and into the left lobe of the liver.   Still,  though this must have
 been a disease of long  standing, the body was but little emacia-
 ted, and the subject had never  shown any one symptom from
 which the presence of such  an  affection of the stomach could
 possibly have been inferred."
    Dr. Hastings relates the  case of a woman "whose  stomach
 when examined, was found every where  ulcerated except at the
 large or candiac end,  which was healthy.   This stomach  had
 performed its functions to the last, and  the state of the alvine
 discharges proved that the food had been promptly digested."
    Circumstances since known render it probable that the inflam-
 mation and  ulceration of the stomach found  on examining the
 dead body of the  great Napoleon,  had existed years before his
 banishment to St. Helena;—perhaps the consequence of his early
 misfortune in receiving at Toulon, psora, or some other cutane-
 ous  disorder, and undergoing for  its removal improper and in-
 judicious treatment.
    In general, we may detect chronic or  sub-acute inflammation
 of the stomach by a sense of fullness or  distention at the epigas- 
40
CHRONIC GASTRITIS.
trium, almost constant,  apt to be increased after a full or stimu-
lating meal, and by long fasting.
  In the lighter shades  of the disease, the patient is somewhat
relieved  and rendered  more comfortable.,by a  meal of proper
quality and in moderate quantity—but when  it is more severe,
and approaches  more nearly the character of acute gastritis, all
food occasions distress—oppression and nausea.  There is consi-
derable extrication of gas ; the thirst is troublesome; the tongue
is apt to be smooth  and fiery red, although it frequently retains
for a good while its natural appearance ;—the  appetite is irregu-
lar and depraved ;  the pulse usually small and weak; with some
febrile exacerbation by night, exhibited in restlessness and jacti-
tation, and a hot dry skin; the  strength declines, and the mus-
cles are  flabby and emaciated.  Too much stress is laid upon
the test of pressure applied at the pit of the stomach.  This will
sometimes occasion pain when there is no inflammation present;
and will often fail to give painon the other hand, when the other
symptoms which betray the disease give notice that it exists.
  The Treatment is very similar to that which has been detailed
as adapted to the management of acute gastritis.  General blood-
letting is not often admissible at the late stage at which patients
apply for relief, but topical depletion is almost always  useful.
Leeches or  cups may be  employed  occasionally.  Entire absti-
nence from food for a sufficient  length of time, for the complete
reduction of the morbid local  excitement, would be  impossible;
but the mildest and most unstimulating nutriment must be selec-
ted.  Mucilages are  generally preferred; but  in some patients,
they cannot be borne, as running readily into fermentation, and
thus becoming highly irritating.   I use in  such cases diluted
milk, soft  boiled eggs, and  thin broths, without any  apparent
 inconvenience.
   I need not remind  you that the bowels must be kept in a solu-
 ble state, and by the  gentlest means.  Small doses of calomel__
 from half a grain to a grain, once, twice or thrice a day, with or
 without minute addition of opium, should  be given, and if the
 mouth becomes lightly affected with ptyalism, the patient will
 usually be  much benefited.   The  alkalies  are also useful here,
 whether by merely correcting an  acid acrimony in the morbid
 secretions, or by some other quality, I will not attempt to decide 
CHRONIC GASTRITIS.
41
They seem often to act as tonics.  In combination with rhubarb,
in very moderate doses, I have found  the  carbonate of soda
highly serviceable ; and although it is not difficult to carry the
system of purging in  these chronic affections too far, yet under
skilful direction, it forms one of our most hopeful plans for their
management.  Some of the worst examples that I have known,
have been vastly alleviated, and some perfectly cured, by a few
weeks residence at our watering places—Ballston, Saratoga, etc.
  When the case has progressed to its latter stages—the mouth,
cheeks, lips and gums are inflamed and ulcerated.   Deglutition is
often painful; diarrhoea comes on, and dropsical swellings accu-
mulate.  Tonics  are now indispensable;  and of these, iron, I
think, deserves a preference.  I prescribe the  muriated tincture
sufficiently diluted, or the tinct: aeth: acet.  Of the astringents,
kino sometimes seems best adapted to relieve the diarrhoea which
supervenes, but it is occasionally offensive, and cannot be borne.
I have frequently derived the most  obvious advantage from the
use of acetate of  lead, in small doses, and  in combination with
the tincture of opium, or solution of morphine.
   During this  whole course of treatment, the patient must  be
warmly clothed in flannel; frictions applied  over the skin, the
abdomen especially; and all exposure and  imprudence carefully
avoided.
   He  cannot hope for complete convalesence or perfect cure
unless he assume resolution enough for a  total abandonment of
all the bad habits  of intemperance and excess, which led to the
formation of the  disease.  Of these, as I have already said, you
will find the use  of alcohol, in some mode, to be the chief.
4* 
42
ENTERITIS.
                    CHAPTER  XXIV.

                        ENTERITIS.

  Inflammation of the intestines claims fairly the next place
in our course, as being very nearly allied to gastritis, in history,
causes and treatment.   Indeed, as it  is the same tissue which is
affected in both, the inflammatory irritation is apt to be continued
along the whole tract of digestive  mucous membrane, constitu-
ting the gastro-enterite. so much written  and talked of, at the
present day.
  Acute enteritis comes on usually with  pain about  the navel,
gradually extending over the whole  abdomen, and alternating
with  intervals of ease, so as  to be mistaken frequently for ordi-
nary colic.  The relief from  suffering  is,  however,  rarely so
complete as between  the paroxysms  of colic ;  and the pain is
attended with a sense  of burning, and an indescribable general
uneasiness, and rapid prostration of strength.  There is generally
an inability from the  first to  bear  pressure upon the belly—but
let me strongly warn  you that this is by no means the certain
diagnostic which some writers consider it. I have seen two fatal
cases in which this tenderness on pressure did not exist.  In one
of them the patient usually replied to my question on the sub-
ject by kneading his abdomen forcibly with both hands and tell-
ing me that he could thus excite a  little uneasiness and  but a
little.  He died  with extensive gangrene of the mucous coat.
In  the second I could detect  no shrinking from pressure applied.
and indeed sometimes thought that there was the same indistinct
relief given by it as in so many attacks of colic.
   We draw the distinction  from colic,  farther, by  observing,
 besides the comparative steadiness and constancy of the  pain,
 the countenance, position and manner  of the  sufferer.   The
 countenance is  expressive of intense anxiety and depression  of
 spirits ;  he is dejected and desponding ; he lies on his back for
 the most part, with his knees drawn up,  and though he  tosses
 his arms about, rarely moves his lower  limbs or  rolls  upon his
 face.  Some patients readily distinguish the pain to be different 
ENTERITIS.
43
from mere griping, and they are soon led to remark, with great
disappointment, that they obtain  little  or  no relief from  dis*
charges of wind or alvine evacuations.   The pulse, too, is early
affected, becoming frequent and small;  yet, though much con-
tracted, it retains^ through the first stage, a degree of tension
and hardness, discoverable  on minute  examination.   There is
nausea with vomiting, and the matters ejected  from the sto-
mach, assume a  great variety of morbid appearances.  I have
several times met with black vomit in advanced stages of  the
disease.  Constipation of the  bowels is a common symptom at
first;  but an irritating diarrhoea is apt to come on towards  the
unfavorable  terminations, the stools consisting of mucus with
bile—of serous  and ichorous  effusions, known  as  resembling
lotura carnium, and of black matter similar to that thrown up.
 As the case goes on, the strength and  pulse fail—the abdomen
becomes tense and swollen, and exquisitely tender to the touch—
 the tongue  is red and  dry and smooth, or covered with small
 ulcers—the  breath extremely offensive, and  the  patient sinks
 rapidly with low muttering delirium.
   It is not easy to  distinguish enteritis from peritonitis in  all
 cases—the  inflammation of the internal  mucous surface from
 that of the external serous tunic;  but it is of less  importance,
 as the latter is rare, except in the  puerperal state, and when it
 does occur, demands no material modification in the treatment.
   Acute enteritis finds its termination, for the  most part,  as I
 have said of gastritis, in its general effects upon  the system, the
 vital powers yielding, in a short time, to its oppressive influen-
 ces.   Mortification may take place, as  I have witnessed, to a
 great extent, marked by a sudden relief of the distressing symp-
 toms, with prompt failure of pulse and universal prostration of
 the patient.  Ulceration more frequently occurs, but is not ne-
 cessarily fatal; ulcers of various sizes, and in various  stages of
 healing, having been found on examination of the dead subject.
 Suppuration is affirmed by authors to have supervened, and the
 purulent matter to have been discharged.   I have not witnessed
 any thing of the kind, that is, I have seen nothing that I could
 regard as the formation of gastric  or intestinal abscess. I have
 met with many instances of mucous inflammation of the diges- 
44
ENTERITIS,
tive tube, of or approaching to the character of dysentery, in which
the discharges contained purulent matter variously mingled.
  The Causes  of enteritis have  been already enumerated as
giving rise  to  gastritis; the former  proceeds, however,  more
readily from exposure to changes of temperature—cold applied
generally or locally, as to the feet, or by means of wet garments
or damp bed clothing.
  In the Treatment of enteritis, we are to be guided by the same
principles laid down for our government  in  relation to its kin-
dred malady.  The lancet must be employed boldly and freely;
and in the first stages of the attack, if the diagnosis were  clear,
I should scarcely be  deterred from venaesection by any  infer*
ences drawn from the state of the pulse.  I would rather bleed,
if it were  even experimentally, and carry this mode of deple-
tion as far as possible, nor tie  up  the  arm  until it became una-
voidable from the occurrence of syncope or other sensible effect
of the loss of blood.
  If resorted  to early, and with  proper caution, venaesection is
unquestionably the most valuable and  important of  all our
remedies.   I hope I  need not warn you against the vague, em-
pirical, I may  add,  desperate manner, in which it  has been
employed by some practitioners, who have not seldom carried it
so far, as to sink irrecoverably the powers of the constitution,
and procure, or at least hasten obviously the fatal issue.   The
blood is usually cupped and buffy—indeed, I  have seen it sepa-
rate into lymph and cruor, while flowing from the vein, so as to
present a streaked or purulent appearance.
   Topical depletion  by leeches or  cups, comes  next  in  order,
and we shall very rarely fail to derive, from this means of relief,
definite and striking advantage.   Large numbers of leeches
may be applied from time to time, or the cups repeatedly put on.
Nor should we fail to use the lancet as often as the pulse rises,
and until the inflammatory excitement is fairly subdued.   The
danger  is urgent—the  indication clear  and indisputable; we
must act with unhesitating promptness and  decision, tempered
by prudence and cautious foresight.  Some disputes have, of
late, arisen as to the proper local applications to be farther made
 in this case, and some few practitioners of the (so called) physi- 
ENTERITIS.
45
ological school,  have been bold  enough  to  lay ice  upon  the
abdomen.  I adhere to the established principles and practice of
revulsion, and prefer  the persevering employment of warm
poultices and fermentations.   These encourage the free oozing
of blood from the leech bites and scarifications made, while they
promote derivation from the internal surfaces, and relax tension
and soothe irritation.
   It has been long since a conlested question, whether in enteri-
tis, purgative medicines  are  more liable to do good or harm,
and many physicians,  both  of the old  and new schools, have
affirmed that they must necessarily add to the existing irritation
and inflammation.  However plausible this may seem, no preju-
dice can  be  more ill founded.  Nor do I consider  any point in
practice better settled, than the importance and propriety of the
administration of  purgatives, in the case under consideration.
Nay,  it is asserted in round terms, by one of the most respecta-
ble of modern writers, that  "if in the course of a  reasonable
time,  free feculent discharges can be procured from the bowels,
the pains will gradually diminish, the pulse  abate in quickness,
and the patient be in the way of recovery,  and that the cure
almost entirely depends  upon our success in this  point."  I
would not,  perhaps, express myself so strongly on the favorable
expectations thus  conveyed, nor would I advocate the promiscu-
ous employment of all or any of the articles known as cathartics.
On the'contrary, a very careful selection  is  necessary—the se-
vere and drastic are to be absolutely prohibited, and the most
gentle must be  chosen; and  fortunately  for  our  purposes, the
milder the laxative prescribed,  the more efficient we shall proba-
bly find it.   Castor oil, if it  can be retained,  deserves  a prefer-
ence.  A simple solution of epsom salts, is often unobjectionable,
and if not itself active enough, will admit  of useful combina-
tion with rhubarb, or may be  alternated  with proper  doses of
calomel.  This latter must be  resorted  to, when the nausea is
great, and the vomiting frequent.   It will rarely be rejected, and
deserves our confidence, in almost every  variety of case.  I
would persevere in its employment until ptyalism was  induced,
unless indeed  the patient be  previously restored  to convales-
cence.  If  it proves too  actively  laxative,  small  additions of
opium are called for, and  will do much good.
* 
46
ENTERITIS.
  If the constipation prove obstinate, as sometimes happens, we
must assist the action of the above remedies, by the administra-
tion of enemata, and these  also should  be of the mildest and
most unirritating efficacy.   It will rarely, if ever,  be necessary
to have recourse to the  mixtures which  have been  sometimes
recommended, of tart: antimon:, tobacco or turpentine,  these
being rather adapted to cases in  which the obstruction is pro-
perly or exclusively, as I shall hereafter  describe, of spasmodic
character.
  When the patient will no longer bear even topical depletion,
and the effect of the fomentations above advised, seems to have
been diminished by their continuance and familiarity, we  must,
on the same principle of revulsion, blister the whole abdomen.
Epispastics are also,  with benefit, laid upon the upper and inner
part of the thighs, on the calf of the leg, and on the wrists and
ankles.   They are, in these low stages of internal inflammation,
of service, too, by acting in an unobjectionable way, as stimulants.
  The pulse still sinking, and the powers of life failing more
and  more, we are recommended by many authors, to the exhibi-
tion of the spts: terebinth:  either  with  castor oil, or  in  emul-
sion with mucilage.  It is  eulogized as  an admirable remedy,
in this low and almost hopeless condition of things,  checking
the troublesome hiccup  which is often present,  restraining  the
violent and exhausting vomiting, diminishing the pain, and sub-
duing, as if by a charm, the inflammatory symptoms.   You may
recollect the analogous administration,  and high  praise of it,
as adapted in the treatment of the  last stage of yellow  fever.
   There is a singular circumstance  noticed by some writers, as
occurring in this disease, of which I myself have witnessed a
remarkable instance; and it deserves your attention,  as being
calculated to sustain our hopes, under the most unfavorable ap-
pearances—"that even in the extreme moment of a seeming mor-
tification, a sudden revolution takes place, and stools are evacu-
ated, and this too, after the extremities have begun to grow cold,
and deadly languor  is overpowering the  frame."  Here we must
 seize the opportunity to rouse and restore the sinking powers of
 life, by the timely  application of nourishment and stimulants,
judiciously chosen.
   A very old negro fellow under my care, had sunk  into  this
t 
ENTERITIS.
47
state, after an illness of three days, during which, I had attempt-
ed in vain to procure any alvine evacuations.  He was  pros-
trated to the lowest point, his pulse feeble  and thread-like,  his
countenance haggard, his extremities cold, and his belly tumid
and excessively tender.   There  was a  sudden relief of pain,
which I attributed to the supervention of mortification;  he had
next an inclination to stool, and his bowels became  loose.  Stim-
ulants were resorted to without delay, and he recovered.

  Of Chronic Enteritis,  little is necessary to be said.  Its
existence is known by the same symptoms which mark the acute
form, but in far less striking and obvious  degree; and it often
goes on to ulceration, without having shown itself by any une-
quivocal signs.  The treatment is almost precisely such as has
been recommended in chronic gastritis, with which, indeed, it
is almost invariably connected.   Its causes are likewise the same,
and so are  its terminations.  It, however, serves as the  founda-
tion for a great many varieties of intestinal  disease, according
to the predispositions of the  patient, or the tendencies of the
season and climate.  Diarrhoeas, dysenteries, and dropsies follow
in its train—emaciation and atrophy are its attendants.
   It is important that the patient having been once attacked by
enteritis should be extremely careful to  avoid its recurrence, for
there is, perhaps, no disease which leaves behind so  strong  a
tendency to return and be re-excited.   And such relapses are in
the highest degree violent and dangerous.
   The clothing should be warm, the flannel  roller being worn
round the belly, the diet light and unstimulating, though  nutri-
tious.   If the means of the subject allow it, a proper change of
climate should be made from time to time, so that he may always
enjoy a summer temperature, and free  exercise in the open air
made habitual.  The mind should be  kept, as far as possible
free from care and anxiety, and all prudence displayed in avoid-
ing such food, drinks and exposure, as may give rise to an attack
of indigestion, which would most inevitably  be  followed here,
by acute gastric and intestinal inflammation. 
4S
milk sickness.
                     CHAPTER XXV.

                      MILK sickness.

  This is the proper connection in which to speak of a singular
form  of disease, known  exclusively,  so fur as I am aware,  in
the southern and  south-western  States of our Union.   I have
never seen an instance of it, nor has it yet found a place in any
regular or systematic treatise which may fall into your hands;
yet, I think  that there can be  no reasonable doubt  of  its exis-
tence, as a separate and distinct malady, worthy  to occupy our
attention for a few minutes, as some of you are very likely  to
follow the practice of your  profession in the  very  regions  in
which it occurs.
  The fertile coves or deep rich valleys among the mountains
of our own  State, Tennessee, North-Carolina, Georgia, are sub-
ject to this singular malady, neither the nature nor the cause of
which are clearly  set forth in the few  monographs which have
appeared in  the journals concerning it.   Some attribute it to the
ordinary malaria, which, before and since  the time of  McCul-
loch, has been supposed  capable of originating every malady in
the long catalogues of nosologists.  Others again, as it seems to
me, with  more  reason, have ascribed  it to  some unknown and
undiscovered vegetable poison, confined in its growth to the
spots  above  alluded  to.   Others still  look upon it, reasoning
from  analogies  of symptoms  upon which they found their
opinion, as  the  effect of mineral exhalations—perhaps of lead
or sulphur  or arsenic.
  Whatever be  the cause which gives rise to it in the lower
classes of  animals, it would seem that  it never affects, directly,
the human subject.  Man is not attacked by the disease, unless
after  eating the flesh of  herbivorous animals exposed to receive
it, or  using the milk or butter obtained from them.   Other car-
nivorous animals are also liable to be attacked in the same way,
if they eat of the diseased flesh.   This exclusive liability of the
herbivorous classes, appears to me to favor the hypothesis of  its 
MILK SICKNESS.
49
vegetable origin.  The  cow and  horse  are most frequently its
victims.
  It derives its name  from the fact, that as  occurring in the
human subject, it is  most frequently met with as the conse-
quence of eating milk rendered poisonous by the diseased con-
dition  of the cow from which it was taken.  Butter made from
such milk, is still  more acrid;  and the flesh of  the animal,
evfen when cooked, more strongly poisonous than either.   It is
fortunate  that  the  localities in which it resides, are capable of
being  defined accurately.   Such places are kept carefully fenced
in  from the intrusion of cattle, whose milk  is  then  unhesita-
tingly used.  The  beautiful valley of Jocassa, in the neighbor-
hood of the White-water Falls, in  the  upper  part of this State,
is one of these spots, and cattle are not allowed to range beyond
certain well known limits.  The cultivation  of soil which has
been known to produce it, seems to deprive it of this deleterious
quality.   If animals be kept within their enclosures until late in
the forenoon, when  the dew has  entirely exhaled, and driven
home again early in the evening, it  is said they escape injury,
even although allowed to feed within the known localities of this
 poison.  It usually affects animals as a chronic disease, and  they
 may not, in any way, appear to be suffering from ill-health, but
 sometimes attacks  with great violence  and  rapidly proves fatal.
 My guide to the fine cascade above mentioned, informed me,
 that  a valuable horse, belonging to  a  neighbor, which  had
 strayed upon the dangerous ground and fallen  sick, died before
 he could cross the mountain and return.  He had gone to bring
 a dose of bear's oil, considered there a specific, and lost no time,
 but was too late to save the life of the  poor  creature.   The
 incapacity to bear exercise, is  said to  be so complete a diagnostic,
 that the owners of cattle give them a hard  drive before  killing
 them ; this excites the disease infallibly, if latent in the system.
    The accounts which have been given of  this disorder,  from
 various sources, lead me to the belief, that it is a species of gas-
 tritis  or gastro-duodenitis.  Languor and  lassitude are among
 the earliest symptoms of the attack, soon followed  by nausea
 and vomiting, with great oppression at the epigastrium, and pain
 with  a sense of  heat and burning in  the stomach.  The thirst is
 great__the skin  soon becomes hot and dry—the eyes are red and
        vol. n.—5 
50
MILK SICKNESS.
suffused and glassy, and, as some say, a peculiar odor is exhaled
from the surface.   The pulse  is affirmed by some  to be  little
changed  from *ts  ordinary condition, while others declare that
it presents a  frequency and  tension  resembling that of typhus
fever, to which, indeed, the  whole history of this  remarkable
disease, after  the  first stage is past, presents a striking resem-
blance.   Patients  recover slowly and imperfectly, remaining
long after, and perhaps for life, subject to indigestions and other
complaints of the stomach.
  There is as little agreement among those who have written of
its treatment, as there is in the discussions concerning its cause.
I have already alluded to the  local  prejudices  in favor of the
administration of oil, and especially of bear's oil, to  domestic
animals when attacked.  The same  practice  has  been  tried on
the human subject, and some writers declare that the success of
such management  is remarkable.  The  constipation is singu-
larly obstinate, and purgatives  are with  difficulty retained  on
the stomach.  One physician states, that in a case which  resisted
all his other  remedies, he had used quicksilver  with  success.
Calomel forms the chief dependence of the majority of practi-
tioners, some of whom give it in very large doses and alone,
while others combine it with opium,  and employ  smaller quan-
tities.  It is said to be very difficult  to procure the excitement
of ptyalism.
  If a case of this  nature were to occur under my care, I would
propose to treat it as if the effect of an acrid poison, and one for
which no antidote was known.  If the  stomach were not emp-
tied, by spontaneous vomiting, of the deleterious  food  taken, I
would wash it out with draughts of warm water or ipecacuanha.
I would apply leeches or cups  to the epigastrium or abdomen,
and give the patient ice and cold fluids.   The first stage being
past, and excitement continuing and becoming more general, I
would resort to venaesection, and administer such purgatives as
eould best be borne, perhaps preferring  to  employ castor  oil,
aiding them by proper enemata.  When  the bowels had been
rendered soluble, I would depend, for farther advantage, upon
the mercurials, combining them with moderate doses of opium,
and persisting until  the gums  should become spongy,  and the
 salivary glands be urged to increased secretion.   Many physi- 
COLIC
51
■cians place  their exclusive dependence, we are told, upon the
persevering  employment of active purgatives, which they con-
tinue to exhibit for  many days in succession  I confess, how-
ever, I cannot  understand the  adaptation of the drastics, as
gamboge, aloes, etc.  to  the removal of such  symptoms as they
describe.  Great care should be taken to guard the patient from
improper food, when convalescent, and to protect him from the
effect of  sudden alternations of weather, by  warm  woollen
clothing.
                    CHAPTER XXVL

                           COLIC.

  This distressing affection, in  its various forms, is among the
moat frequent  which  demand the attention of the practitioner,
and is fortunately one of the number of those over which we
may exert the readiest control.   In  no other instance, perhaps,
in the vast catalogue  of diseases, is the  skill of the physician,
as exemplified  in the successful application of the  resources of
our divine  art, so easily appreciable by the most sceptical patient
or observer; and in no other instance will he  obtain, in reward
for his humane and judicious exertions,  a  fuller expression of
unreserved gratitude.
   Colic is sub-divided by writers into a great number-of species,
in reference to the infinite variety of exciting causes capable of
producing it, and the train of symptoms which may or may not
be  developed under  the  diversity of circumstances of constitu-
tion of the patient, and successful or unsuccessful treatment.
Indeed, this sub-division may be almost endless.   Cullen makes
seven species—Good, six; many more might easily be  added.
We have colic arising from many purgatives—from many poi-
sons of specific character—from mechanical obstruction in her-
nia, external and internal—from hemorrhoidal tumors—schirrus
of  the rectum—from enemata, whether  of irritating  quality or 
58
COLIC.
of large quantity.  I have known it produced in great intensity
by an injection of tepid water.  It  arises from crude ingesta—
occurs in  the course of the exanthemata, and  in many fevers.
It may or may not be  attended by stercoraceous vomiting or
intussusception;  but all these modifications, the  enumeration of
which seems to you. no doubt, an announcement of the causes,
remote or exciting, which may give rise to it, have been treated
of as separate species of a  particular genus.  I will yield so far
to the, common custom of American authors,  as to admit and
treat of three varieties of colic, viz.: 1. Simple colic, otherwise
ileus  or wind colic or flatulent colic ; 2.  Colica biliosa;  and,
3. Colica Pictonum; reminding you, that  while I follow this
arrangement for  the  sake  of convenience, I by no  means ac-
knowledge any specific difference to  exist in  the nature of the
proximate or essential cause, which  I hold to be identical and
the same in each  of these and in all other varieties of colic.
   1. Simple colic may be briefly described as presenting the
following symptoms:—Pain  in the  bowels,  with a  sense of
twisting or griping chiefly  about the  navel, with nausea for the
most part, and costiveness.   The pain is  accompanied usually
with a sense of distention  of  the abdomen, and  much general
uneasiness.   At first, there is  no tenderness upon pressure, but
rather a degree of relief is given  by pressure, which is  often
applied forcibly to some  particular part of the belly, frequently
about  the caput  coli.  There are "violent attacks of tormina,
occurring at intervals, like the strong impulse  downwards  from
the  action of a drastic purgative, the action  proceeding down-
ward to a certain point  and there  stopping."   The distention,
from being merely a sensation of the patient, becomes sometimes
very obvious, and a tympanitic inflation of the abdomen ensues,
with great distress in breathing, from the upward protusion, no
doubt, of the diaphragm into the  thoracic cavity.  The nausea
 and vomiting are more and more frequent, following the parox-
 ysms of tormina  above described.   The contents of the stomach
 having been emptied, an inversion of the peristaltic action of the
 intestines is at last brought  on, and stercoraceous matters are
 thrown out of the mouth,  which symptom has given name  to
 an often  recognized variety of colic, known as the iliac passion.
 When there is no  distention, the  muscles of  the  abdominal 
COLIC.
53
parietes occasionally become hard and inelastic, being as flat and
firm as a wooden board.
  At first the pulse is  unaffected, but after a  time increases in
frequency, losing force and volume as the case progresses; cold
sweats break out on the face and become general;  and the patient
if unrelieved, may sink at once, exhausted by the mere intensity
of his sufferings.  More commonly, however, an inflammatory
stage will supervene, and enteritis of exquisite character be de-
veloped, with ulceration or even gangrene of  large  portions of
the intestines.   Post mortem examination, besides these termina;
tions, not unfrequently exhibits a third described as intussuscep-
tion of a portion of the tube within another  portion, the internal
being strangulated by pressure and running  into rapid mortifica-
tion.  The  occurrence of this  terrible accident  has even been
ascertained in some cases before death, by the protrusion of the
lower part of the strangulated bowel at the anus, as affirmed by
Abercrombie.
   Many of the Causes of colic have been  already alluded to;
it arises, perhaps most commonly, from  the presence and irrita-
tion of crude and indigestible articles of food ;  it may be brought
on by fasting for a long or unaccustomed period, and by expo-
sure to cold and wet, especially when applied to the feet;  it may
be occasioned indirectly by any of the passions of the mind, and
in general by the  influence of all  such circumstances, formerly
enumerated, as interfere with  the due performance of the diges-
 tive function.  An extrication of air or gas, which distends the
abdomen  to an enormous extent in certain cases, has been men-
 tioned as  among the ordinary symptoms of the disease, and every
 one who has been the subject of colic, is aware of the great and
 immediate relief which  attends its escape,  whether upwards or
 downwards.  Such gases, the chief part of whose volume seems
 to consist of sulphuretted and carburetted hydrogen, may be the
 product of the chemical  decomposition of crude and undigested
 vegetable aliment.   Dr.  Hales tells us, that an apple, during this
 process, will give up above six hundred times  its bulk of air, and
 there are several vegetables habitually employed as food, which
 are said to evolve even more air than the apple.  But we cannot
 thus account for the tympanitic distention  in all cases.  To the
        5* 
54
COLIC.
number of instances recorded by authors, in which the obvious
evolution of gas was beyond all possible  explanation, by any
reference to any supposable state of the ingesta or their quantity,
I will add a very remarkable case from my own practice.   A pa-
tient laboring  under scarlatina, in  October, 1831,  was affected
with a very irritable state of the stomach and bowels, which ad-
mitted of the  administration of neither food nor medicine, but
in the very mildest form and in the smallest  quantity.   Tran-
quility and costiveness  followed this  expectant treatment, and
after a very quiet day, it was thought advisable, in the evening,
to empty the lower bowels by an enema, prepared in the usual
way.   This produced a severe paroxysm  of colic with great
discharge of air, both upwards and downwards, though no token
of the presence of any had been previously observed.   Twenty-
four hours after, the enema  was repeated, a mere  mucilaginous
solution (strained  gruel) being employed.   This was followed
by the same consequences.   The  experiment was  tried a third
time, with simple  tepid  water, at  the  same interval, with the
same result, so highly aggravated, that the sufferings of the pa-
tient were intolerable, and required to be allayed by free doses of
opium.
   I regard the supposition as therefore entirely plausible, and in-
deed probable that, in such and similar cases, the exhalent ves-
sels opening upon the mucous surface of the stomach and intes-
tines, may throw  out, instead  of their normal and habitual se-
cretions, either gases of various kinds, or a fluid whose affinity
for caloric is such that  it assumes, as soon as evolved, the gase-
 eus form.
   Autopsy.   "The  most uniform morbid  appearance,  in fatal
 cases of colic, is a greater or less extent of the intestinal canal
 in a state of great and uniform distention."  This distended por-
 tion may not be at all altered in structure.  It may be found in
 various stages of inflammation, "from a recent tinge of redness
 to extensive gangrene."  Other portions have been found  con-
 tracted and agglutinated.   I  have already mentioned  the fre-
 quency of intussusception.   Organic  disease  of great diversity
 may be found constituting a part of the description of fatal cases
 of ileus; but these  which have  already  been alluded  to and 
COLIC.
55
some of them enumerated, seem to me entirely incidental and
unessential; you will find a long  list of them in Good, Cullen
and Abercrombie.
  The nature or proximate cause of colic is at present matter of
much dispute.  The last named writer, to whom our profession
is deeply indebted for his valuable contributions to useful know-
ledge, lays down the position, in contradiction to all previous au-
thority, and maintains it with much apparent weight of fact and
much ingenious reasoning, that in colic the distended part of the
intestine is the true seat of the disease, which consists pathologi-
cally in a muscular paralysis of a portion of the muscular coat
in the intestine.  He denies that the contraction (so called) of the
contracted portion of the intestine, is effected by spasm; but sup-
poses it to be  "merely collapsed, because it is empty, its muscu-
lar action being unimpaired."   He endeavors to explain the fami-
liar phenomena of colic, by the supposition that the passage of
the alimentary ingesta or flatus ceases at  the point where the
muscular impairment of the capacity for contraction exists, and
that distention must begin there. To this distention progressively
increasing, he refers the subsequent symptoms.
  After the most impartial consideration of the subject, however,
I must declare myself still disposed to adhere to the ancient doc-
trine, and to regard colic as depending in all cases upon spasmo-
dic constriction of some portion of  the intestinal tube.   I find
no  difficulty in replying to  the  arguments urged  against this
opinion.
   1. It is easy to  explain why the evidences of disease should
be more remarkably exhibited  in the distended part after death,
If death has occurred early, the spasm or constriction may have
entirely disappeared ; muscular contraction, whether natural or
morbid, must cease when life is over.   Nay, such  spasm may
have relaxed occasionally during the continuance of the disease5
and returned again.  The changes occurring as the result of this
spasm are two-fold, being both local and general.  The circula-
 tion is stopped in the mucous tissue of the intestine above, and
 congestion and inflammation and  gangrene thus  brought on.
 The general system is thus  affected, first,  by the  impediment
 offered to the performance of the digestive function, and secondly,
 after a little while, by the inflammation of part of the digestive 
56                         colic,

tube.   This inflammation is rapidly increased if the stricture be
close and obstinate, by the internal pressure of  the accumulated
secretions, which may even rupture the tube, unless carried up-
wards  by an anti-peristaltic motion and vomiting.
  But on the other hand, if the case  is sufficiently protracted to
allow of the occurrence  and extension of inflammation which
shall agglutinate the contracted fibres, permanent and undilata-
ble stricture is detected.
  2. How shall we account for intussusception  upon Abercrom-
bie's view ?  It is difficult to conceive how a distended portion of
intestine should  enter into the  collapsed tube  below it, whose
"tonic  contraction" is not overcome by the regular propulsion of
foeces or flatus.  And if the smaller  portion  above, which is in
a natural state, does descend into the enlarged part of the tube,
this latter cannot contract upon it  to form stricture.  Now, it is
plain, that a strictured part of the  tube will be  smaller than the
part below it, which is collapsed, or in a natural state of tonic
contraction.   The strictured point, then, in relation to the neces-
sarily distended portion above it,  will represent the apex of a
cone, which being pressed downwards, by the violent voluntary
and involuntary  efforts of the patient, will readily enter and
pass along the tube below, even to the anus, as in  one of Aber-
crombie's own cases.
   3. The analogy with hernia may be allowed some weight in
this matter.   All the phenomena of ileus, attend upon  strangu-
lation  of a rupture.
   4. Distensibility is the natural condition of the intestine, and
to be distended its passive function.   The sudden production of
colic, then,  in instances  where the distention  cannot be large
or  inordinate, is not to be accounted for, otherwise  than by  the
supposition of irritation and spasm.   And how, but by the oc.
currence of spasm, can we explain the sudden  stoppage  in the
course of a fluid or  semi-fluid  substance along a  tube,  urged,
too, by a vis a tergo; for the distended portion may not be long,
and the bowels are acting above it.
   5.  I would press lastly,  the argument a posteriori, which, in-
 deed, has been used by our antagonists themselves, in their refer-
ence to galvanism as a valuable remedy in colic.  If colic be not
 owing to spasm, but to muscular paralysis and distension, whence 
COLIC.
57
the utility of venassection, the warm bath, opium, tobacco, reme-
dies which 1 have chosen to mention, as  they are selected and
eulogized by Abercrombie.  "There are cases," he says, "which
yield to a full dose of opium," a fact, he tells us, familiar to every
practical man.  It is no wonder that he should allude to it, as
illustrative of "the peculiar and  intricate character of the dis-
ease."   "The warm bath," he says, "is often beneficial;" is it
by relieving distension?   "The relief," he says, "from venaesec-
tion is often so  immediate, that there is no time to raise the pa-
tient out of bed, before  complete evacuation takes place."  Fi-
nally,  "the tobacco  injection," he  tells  us,  "is,  as far as my
observation extends, the remedy of most general utility in  all
forms and  stages  of ileus."  This is conclusive,  for  tobacco is
our most efficient relaxant, and exhibits here most remarkably,
its valuable power of overcoming spasm.
   It will be perceived, that I also place the disease in the  mus-
cular tissue of  the intestinal tube;  but this,  though  its promi-
nent seat, is not the first acted on, the irritation having been first
excited by the  impression of some agent, directly or indirectly,
on  the mucous surface  within.   This I believe  to be  the true
pathology  of colic; but the  irritation, when transmitted, may
disappear altogether from its first locality,  and  leave no trace
behind.  I do not affirm that it does, for I am rather inclined to
think, that a certain train of morbid  action productive of vitia-
ted secretions is,  to say the least, a general concomitant  of the
iliac spasm.  You will  find cases on record, however, in  which
it is affirmed that the contents of the distended bowel were per-
fectly natural and customary.
  The  Treatment  of simple colic is not  usually a matter of
much doubt or difficulty.  In an infinite  majority of cases, the
domestic management is promptly  successful.  This  consists in
the administration of aromatics, of which the chief are, alcohol,
aether,  mint, camphor,  ginger, etc.   It  is, I suppose,  by their
anti-spasmodic influence that these are useful,  for they possess
no other power in common.   Perhaps they may, as stimulating
the stomach, exert in a certain degree, a revulsive influence.
   Colic which  follows a full meal, or is occasioned by the taking
of indigestible  or deleterious articles, must be  treated by the
quick exhibition  of an emetic, which will very often  give entire 
58
COLIC.
relief.  If from exposure to cold or moisture, we must place our
patient in the warm bath, and afterwards cover him up warmly
in bed, applying large poultices, or other fomentations to his
abdomen, and sinapisms to his feet.  Opium  is  here  specially
serviceable.   Indeed, I resort to it at once,  without delay,  in  a
very large majority of the instances which fall under my  care,
and have rarely any occasion to omit it.  The purgative prac-
tice, as initiatory, or resorted to in the first instance, I condemn
most unequivocally; believing it to be more likely to aggravate
than diminish the  sufferings  of the  sick  man, if depended on
previously to the relaxation of the stricture of the bowel by the
proper means.  A mild cathartic is a secondary measure of great
importance  and utility, and should not often  be neglected.
To prepare the way for the free evacuation of the canal, calomel
may be at once added to the opium prescribed, and this will, of
itself, frequently suffice.  If it  should not, the  gentlest means
which will effect our purpose, are next to be tried.  When the
stomach  will bear it, castor oil is the best of these, and is almost
always preferable for children.   Some adults  will not take it,
who will be pleasantly acted  on by rhubarb.  And although I
do not in general advise  saline purgatives, under these circum-
stances, yet there are  not a few, who  consider  the epsom salt
entirely unobjectionable, in its manner  of operation.   You will
sometimes find a return of the disease follow  the  exhibition of
an unsuccessful purgative.   Do not, in  this case, press  your ca-
thartic, nor hope to move the bowels by increased doses.   Return
to your  relaxants.  If there  be a  sound  constitution, use the
lancet freely.   It must never be neglected, if the pulse rises in
force or frequency, or the belly becomes tender  on pressure, or the
tongue is dry and the skin hot  Repeat the warm bath and fo-
mentations.  Large  poultices with a little mustard  sprinkled
over the surface, are the best of this class of applications, and
should be laid upon the abdomen, and to the  lower extremities.
If nausea prevail to any great extent, abandon the exhibition of
medicines by the mouth, with the exception  of calomel and
opium, which should be freely prescribed, in doses proportioned
 to the urgency of the symptoms.
   In the meanwhile, enemata should be given.   The  ordinary
 mixtures should first be resorted to, and will generally be  found 
COLIC.
59
sufficient for our purposes.   If they fail, we may try the more
energetic formulae, those for example, which contain turpen-
tine, tartarized antimony, and tobacco.  I am not fond of using
any  of these,  and have seen  little of their  effects, but  they
are highly recommended by writers on the disease,  and may,
therefore, be numbered by you among your ultimate resources.
When there is apparent torpor, without inflammatory symptoms,
or obvious febrile action, the turpentine injection is to be pre-
ferred.  Turpentine is  highly stimulating and  irritating, and
ought not to be employed, where there is any  reason  to suspect
an inflammation of the mucous surface, especially of the lower
intestines.  It is usually given  rubbed into an emulsion,  with
mucilage or the yelk of an egg.   When judiciously prescribed,
you will have occasion to be pleased with its powerful cathartic
effect.
  The tartar emetic, administered in this way, is a most impres-
sive relaxant.  I have  made use of it in a very few extremely
difficult cases, to  obviate obstinate constipation; but it is not
unattended with danger to the patient, as it depresses his already
enfeebled functions, and produces the most distressing sickness.
Great caution should, therefore, be observed in its exhibition.   I
dissolve ant: tart: 3i in a pint of water,  throwing  up into the
rectum one half;  if no evident effect be produced after  twenty
or thirty minutes,  the remainder may be given.  The consequent
relaxation of every muscular fibre in the body, rarely fails to be
followed by an alvine evacuation, which  is copious  and offen-
sive, in a degree proportioned  to the previous circumstances of
the case.
  The tobacco injection is attended with very similar dangers
and benefits, as the solution of tartar  emetic.  It is,  however,
more  generally resorted to, and is recommended by many writers
of very high  authority, among  whom,  Abercrombie does not
hesitate to describe it as "the remedy of  most general utility, in
all forms and  stages of  ileus."  All agree, however,  that it  re-
quires to be handled with great  caution.   Not more than fifteen
grains, infused for ten minutes,  in six ounces of boilinc water
should be given at first—to be repeated  in increased quantity
after  waiting from half an hour to an hour,  until  its peculiar
effects are^exhibited in vertigo, and general profound relaxation. 
60
COLIC.
Thus managed, it may  be considered as tolerably safe; but
Earle proposes, as a matter  of still greater security,  the intro-
duction of a half chewed quid into the anus, to be withdrawn,
as the ordinary symptoms of prostration come on.  A moistened
segar may be used in the same manner, as a suppository, and for
the same purpose.  You are aware that the internal  use of to-
bacco smoke, both by the mouth and rectum, is  very common
among old women and nurses, who relieve the colics of infants
veiy frequently, by giving them water to  drink,  in which the
smoke from a pipe has been blown for several minutes, and using
the same as an injection.
  I must not omit to mention to you a mechanical mode of over-
coming the obstinate obstruction of the bowels, forming so prin-
cipal a feature of colic, which was originally  proposed by De
Haen, and has received warm commendation from Cullen,  and
others.  It consists in the gradual and progressive distention of
the lower portion of the intestines, by pumping in large quanti-
ties of simple water.   It is said  that two gallons have been thus
thrown  up successfully.  I cannot but regard this as a useful ad-
dition to our list of remedies.   In one of  my most unfavorable
cases, it was attended with a happy effect, after the failure of all
other means of cure assiduously employed.  A negro fellow of
nearly middle age. was brought to me in  the month of Septem-
ber, 1827. from a plantation a few miles distant.   He had been
ill then  three days, and his sufferings were described as extremely
severe, during the whole of that  time.   They were  intensely
great when I first saw him ; his belly was hard and inelastic as
a board; there were thirst and delirium, with a full and bound-
ing pulse ;  constant vomiting of every thing taken into the sto-
mach, of stercoraceous Kiatter occasionally during  the  fourth,
fifth and sixth days, and occasionally of the component parts of
the ordinary enemata  which  were administered  from time to
time.  He was  bled by  me  largely  and repeatedly, and went
through the usual routine of medicine  in  vain.  On the sixth
day, I pumped  up, with Read's apparatus, (the stomach pump
inverted,) as much water into his  intestines as  he would allow.
.After receiviug  a large portion, (which  I had no  convenient
means of measuring,) he complained  of the distention as abso-
lutely intolerable; his pulse sunk to a thread, and his skin was 
COLIC.
61
bedewed with a cold, clammy sweat.   When I desisted, he felt,
for the first time during his attack, an inclination to stool;  but
the effort was then ineffectual.  Two hours  afterwards,  (the
disposition having continued,) his bowels were freely evacuated,
and he thenceforward recovered, though slowly.  With a view,
I suppose, to a similar mechanical removal of obstruction,  but
from above, large quantities of crude quicksilver  have been fre-
quently  employed, especially by British  practitioners.  Aber-
crombie tells us that he has repeatedly tried it  "in doses of one
or two pounds."  He says, however, that he has  seen  no other
effect from it, than that "it certainly appeared to allay the vomit-
ing."   Pills of solid gold and silver, have also  been adminis-
tered, I presume, with the same mechanical  purpose, for I  can
imagine no other mode in which they can be expected to fulfil
any valuable indication.   But this view is no less unreasonable
than gross.   It is surely overlooked, in this coarse speculation,
that their weight, if it is by this quality they are to prove  effi-
cacious, will be as much opposed to their passage in some of the
turns of the intestines, as favorable to it in others, so as  in  this
way fairly to neutralize their effect.
   2. Bilious Colic, a form of ileus recognized in a great number
of American essays, is a modification of the disease which owes
its characteristic peculiarities to the  cause immediately instru-
mental in  its production,  to the constitutional temperament in
which it exhibits itself, and to the season of the year in which
it is most apt to be met with.
   It occurs during the  summer and  autumnal months, affects
persons of bilious habit of body, and such as  are liable to he-
patic  disorder, and is attributed to the influence of malaria.  The
immediate intestinal excitement may be, not unreasonably, con-
jectured to arise from a morbid secretion from the liver, of an acrid
and irritating fluid.  Many writers have traced its close analogy
with our autumnal remittents.  It arises under the same circum-
stances, follows similar exposure, is sometimes (Rush incorrectly
says,  always,) ushered in with a febrile chill, and is frequently
attended throughout, with the familiar symptoms  of  this  type
of fever, a full and frequent pulse, great thirst, the tongue being
thickly furred, and of a brownish yellow  hue; there  is inces-
sant nausea,  with  frequent vomiting, often  of bilious matter;
       VOL. n.—6 
62                         colic.

pain and heat are felt at the pit of the stomach, with great dis-
tress and oppression of the precordia ;  there is frequently recur-
ring disposition to go to stool, with intolerable griping in the
belly, chiefly about the navel, but  the  constipation is  obstinate
and difficult to overcome.  The patient rolls and tosses himself
in every direction, crying out for  relief from sufferings which
he is unable to describe or sustain.
  Treatment.  The picture which I have drawn, will  give you,
I fear, but an inadequate  idea of the  violence  of the  attack of
this formidable malady, or of the urgency with which the case
demands prompt and judicious management.   Venaesection is
your first remedy.   In no  other instance can  there be a more
evident call for the use of  the lancet, than in this; and there is
none in which its bold and ready employment  is attended with
more satisfactory results.  After opening the vein, let the blood
flow freely from a large orifice, without regard to the quantity,
until some sensible effect is produced;  the patient declaring him-
self relieved completely,  or  falling  into syncope.  Should the
pain return,  and the pulse rise again, repeat the bleeding without
hesitation; it may be necessary  to do this twice or thrice.  Per-
sons liable to be affected with this form of colic,  are  almost al-
ways robust and plethoric, and bear venaesection extremely well.
   Your next object is  the free and  perfect evacuation of the
bowels—of difficult attainment, because of the  spasmodic  ob-
 struction which prevails, and also, because the stomach becomes
 from the commencement of the attack, so irritable as scarcely to
 retain any thing swallowed.  To meet the  complicated  indica-
 tions arising from this state of things, it is  my custom  to pre-
 scribe calomel and opium, in as  large doses as  can  be borne.
 The former is our best cathartic, under the circumstances,  and
 the latter, so far from  delaying its operation,  as has been ob-
 jected, rather promotes it, by  relaxing spasmodic constriction
 and diminishing the hyper-excited sensibility of the stomach
 and bowels.  It is indeed, necessary to relieve, with as little de-
 lay as possible, the extreme anguish of the patient.   Nothing is
 better adapted to do this than opium.  A  dose of from three to
 five grains  may  be administered at once, with  ten grains to
  3i of calomel, to be repeated  in an hour  or  two,  if required.
 In the meanwhile,  place the patient in a warm bath,  and when 
colic.
63
lie is taken out of it, cover the abdomen with warm  poultices,
containing a small proportion of mustard.
  Enemata should also be promptly used.   The ordinary forms
may be at first tried.  If these  fail, resort  may be had to  the
turpentine, tobacco or tartar emetic, or distention by large quan-
tities of water.  The cold bath generally, the shower bath,  the
dashing of cold water on the abdomen, feet and legs ; the pla-
cing cloths moistened with iced water, or lumps of ice upon the
belly, have been recommended, and there are authentic testimo-
nials  to the success of these remedial  means.  I have  not  yet
found it necessary to resort to them, and am disposed, upon my
views of the pathology of the disease, to prefer relaxants of the
opposite class.  I must not be understood to object to the internal
use of ice and cold  fluids ; these, I believe to be, not only plea-
sant and palliative of suffering,  but directly remedial.  Indeed,
I have always allowed them in the treatment of febrile disease,
and have never, so far as I recollect, had occasion to regret the
indulgence.
   To assist or continue the  cathartic  effect of the combination
above advised,  other purgatives may be substituted, when the
stomach is calm  enough to bear them.   Of these, the least  irri-
tating in  general  deserve a  preference; castor  oil will  answer
the purpose well in most cases.   In  some,  the epsom salt is un-
objectionable.  I employ the latter very frequently, in  mixture
with rhubarb and some aromatic.  A  loose state of the bowels
must be kept up for some days ;  the patient generally requiring
to be treated very nearly as if ill of bilious remittent.
   The same observation will apply to the state of convalescence;
 recollecting that peculiar caution is to be observed in the man-
agement of the  diet of the patient, which,  for a long time, must
 be extremely plain and abstemious.
   3.  Colica Pictonum—Colic of Poitou—of Devonshire—Pain-
 ter's  Colic.  This  form of intestinal disease has received these
several denominations, from the localities in which it has been
 most frequently  met with, and the trade or occupation which
 renders men most liable to its attack.  It has been pretty clearly
 proved, I think, to be in all cases attributable to the poisonous in-
 fluence of lead and  its salts.  These agents are used for so many
 different purposes in the arts, and even, I might almost say, in do- 
64
COLIC.
mestic economy, that any one may readily become subject, una-
wares, to its deleterious impression.   Thus, in Devonshire and
Poitou, above referred to, it has been long and much employed,
to diminish the acidity of the weak wines and ciders for which
they were noted.  Much of the ardent spirits (gin  especially,)
and malt liquor, used  by the lower classes in our own country,
are more or  less strongly impregnated with it, either by  direct
admixture, or by being passed through tubes or pipes construct-
ed of it, at least in part.
  House-painters,  glaziers,  plumbers and printers are likely to
be seized by this species of colic.  It has been known to affect
those who sleep in newly painted houses ; nay, what is most of
all strange and unaccountable,  it is alleged to have been produ-
ced and kept up by the effluvia thrown off from the clothes of
those who make much use of it in their  daily occupations, as
plumbers and painters.  This statement,  which would be abso-
lutely incredible upon any other than the best authority, comes
to us  supported by the respectable names of Sir G. Baker, Dr.
Reynolds, Sentin and Good.  If these exhalations,  so impalpa-
ble and so minutely diffused, can exert  so impressive an influ-
ence as is thus asserted, we can surely find no difficulty in re-
ferring all the cases which  have hitherto been ascribed to other
causes than the  absorption  of lead, as the use of acids, mineral
and vegetable, to slight impregnation of these fluids  with this
common and useful metal.   Thus, Thomas, who maintains the
possibility of Colica  Pictonum originating from other causes
than the use of lead, and founds his  objection to the doctrine of
the exclusiveness of this cause, upon the fact that the disease is
frequent in the West Indies, goes on to observe, in the very same
sentence, " that there is only a very small quantity of lead in the
mills employed to  extract the juice from the sugar cane."  It is
remarked to be of very common occurrence among animals in
the neighborhood of smelting houses, and I have known it  fatal
to dogs, &c, belonging to  painters,  from their drinking out of
the vessels  in  which  the  brushes were occasionally kept in
water.
  Colica pictonum may be  considered as belonging,  for the most
part,  to the catalogue of chronic diseases.  It commences  with
a dull pain  at or near the pit of the stomach, extending  down- 
COLIC.
65
ward to the navel, where it fixes and increases to extreme se-
verity.  The abdominal muscles become sore to the touch, and
are drawn backwards to the spine, with much pain in the loins
and back, whence the name Rachialgia.
   There is obstinate  constipation, with  occasional but ineffec-
tual desire to evacuate the bowels.  There is often, but not in-
variably, nausea and  retching, and a green porraceous bile is
thrown up with mucus.  The pulse is small  and not particu-
larly tense, but rather preternaturally  frequent.  Dimness of
sight, double vision, and even total blindness, have been known to
occur in the progress of the case.  The patient becomes  feeble
and much emaciated,  and prefers a bent posture, leaning forward
on his knees.  Hiccup is troublesome in the last stage, and deg-
lutition difficult and painful.
   The duration of the disease in this, its peculiar and character-
istic form, is various,  extending  from days to weeks.   Under
proper management and in favorable circumstances, it  may yield
readily and  terminate in perfect recovery ; but it is apt to recur?
and still more apt to leave behind it, a train of obstinate and
troublesome effects.   Among these, epilepsy is not uncommonly
met with ; but the  most frequent of the consequences of colica
pictonum, is a remarkable paralysis of the  upper extremities^
sometimes affecting but  one, sometimes  both hands.   In this
local palsy,  the joint  at the wrist becomes loose and flaccid, and
there arises  a tumor on the back of the hand, with wasting of
the muscles of the forearm and arm.
   Autopsy  presents  nothing  satisfactory or uniform;  bowels
generally pale; sometimes appearances  of  inflammation, but
rare;  intestines  contracted in some places, in others irregularly
distended.
   The Treatment of colica pictonum was formerly a matter of
warm discussion among physicians, but  at the present day, there
exists but little difference of opinion as to the  indications of
cure.
   Opium is by almost all regarded as a  principal remedy, and is
employed largely and freely.  Its efficacy is by no means limited
to its  immediate benefit in relieving pain, in  which  it excels ;
but by the relaxation  of spasm, and the subdual of irritation, it
       6* 
66
COLIC.
paves the way for the successful exhibition of cathartics, which
indeed operate most gently and perfectly, when  given in combi-
nation with it.  Pemberton  highly eulogizes a formula contain-
ing castor oil with tinct: opi:  and some aromatic ; while others
substitute epsom salt as a preferable purgative.  Either of them
will answer our purpose generally.
  Irritability of stomach  presents, in some instances, a very
great  difficulty in the management of the case, the nausea and
vomiting being so  readily excited, that nothing is retained for a
moment.  Here we must  administer our opiate in an enema, or
by persevering friction, as recommended by Ward, who speaks
very highly of the  tranquilizing effects of its application to the
surface. We may introduce it into warm poultices, which should
be laid upon  the abdomen, while  sinapisms are applied to the
extremities.  If the pulse be tense and chorded, or the strength
of the patient admit, the lancet will be found useful, though we
cannot, generally, bleed largely  or frequently the subject of col-
ica pictonum.  In these most severe attacks, the preferable ca-
thartic will perhaps be calomel, which will remain on the stomach
more readily than  any other, and which it will often be proper
to continue in  smaller doses until ptyalism is  induced.  Com-
bined with opium, it forms one  of our most certain and useful
resources in the most obstinate cases, and will often effect a cure
without any farther prescription.
  If,  after the  use of these  means, however, the patient should
still suffer from protraction  or return of his intestinal disorder,
epispastics should be  applied over  the abdominal surface and
upon the inner part of the thighs ; and the bowels kept soluble
by the occasional use of ol:  ricini or sal: epsom.  The sulphate
of alumine, common alum,  is affirmed to exert a favorable influ-
ence  in these circumstances.  The  high  names  of Grashuys,
Richter and Percival unite in its praise.  It is given in a dose of
from six to fifteen grains every three, four or five hours.  Nutmeg
also has been recommended as possessing no little efficacy here.
   During convalesence from colica pictonum,  great  caution is
necessary in the diet  allowed to the  patient, which should be
light, nourishing and rather laxative.  Flannel  should be worn
next  the skin generally, and a flannel  roller round  the trunk of 
CHOLERA.
67
the body, and  the feet carefully kept warm and dry.  A return   <■
to former occupations, if they  necessarily  exposed him  to  the
influence of lead, should be avoided.
   You will be much embarrassed in the treatment of the paraly-
sis of the arms and hands, so  frequently met with as a conse-
quence of this disease.   I have been accustomed to resort to the
combination of opium and calomel in small  doses, while I kept
the hand and arm  constantly supported by the carved splint re-
commended by Pemberton.   It  is a remark of  DeHaen, which
I believe to be true, and which will encourage the fearless use of
opium, "that paralysis succeeds less frequently when the cure is
effected by this remedy than any other."  The gentle catharsis
that will be kept up under the plan advised, will  be found useful;
and a slight ptyalism, maintained for some  time, will do much
towards the restoration of the power  of the muscles paralyzed.
   Strychnine  has been  experimented with, and as is affirmed,
with  gratifying results.  Veratrine,  also, we are told, has been
successfully used.  Two cases of cure, by the  nitrate of silver
in large doses, have  been reported.  Cold affusion has been of
obvious service, in some instances, with stimulating frictions and
bandaging.   Electricity and  galvanism have not yet received a
sufficiently fair and persevering  trial.   I cannot account for this
neglect; these agents seem to me to be clearly indicated, and I
indulge much favorable  expectation from  their energetic  em-
ployment.
                    CHAPTER XXV1L

                         CHOLERA,

  Sydenham has given of this  disease—commonly called by a
strange pleonasm, (perhaps emphatically, as "morbus," "the dis-
ease," par excellence,) Cholera Morbus—a description at once so
vivid and so faithful, that it is copied by most writers, as admit-
ting scarcely of amendment or addition.  "Vehement vomitings, 
m
CHOLERA.
and difficult and painful dejections of ill-conditioned  fluids;
agony and inflammation of the intestines and abdomen, cardial-
gia, thirst, a quick pulse often small and unequal, heat and anxi-
ety, nausea and colliquative sweats, spasms of the arms and legs,
fainting,  coldness of the extremities, and  other symptoms of
great danger, which  terrify the by-standers, and kill the patient
in twenty-four hours."
   The picture thus drawn, is truly fearful to contemplate ; but,
far from being in any degree  overstrained, it rather falls short of
the real horrors which attend the disease in  its worst and most
aggravated forms.  I have  myself  seen fatal terminations, in
common or sporadic  cholera, in eight, and twelve, and  twenty
hours.  And in  the malignant cholera, which  originated  in
India,  but with which the whole civilized world has now, alas!
become but too familiar, death  has not unfrequently happened
in from four to seven hours, or even in a shorter period of time;
the constitution being  at  once struck down or paralyzed by the
causative  agent, and deprived  of  all powers of resistance, as
from the  effect of the  more intense poisons.
   Yet, while we consider the history  of  this  justly-dreaded
malady, and read with shuddering, the gloomy records of its
ravages in the East and elsewhere, we cannot but reflect, with
high gratulation, on the  resources of our divine art, and  the
triumphs which it. has  obtained even over  this  fell destroyer.
In the report of the Secretary of the Medical Board at Bombay,
published   in the second  or third year of  the  prevalence of
epidemic  cholera in that  region, it  is asserted,  that "there is
melancholy reason to  believe, that every individual unblessed
with professional  aid perished,  twelve hundred and ninety-four
such instances having occurred in this single district;  no case
having recovered in  which  medicine  was  not  administered,
while,  on  the  other  hand, the  proportion of mortality  was, by
the treatment  generally resorted to, reduced to less than seven
per cent."
   Let us,  then,  hear no more of the alleged inefficiency of  our
science, so sneeringly spoken of by sciolists  and sceptics,  nor
of the highly-boasted restorative influences of the vis  medica-
trix naturae—alas! how vain  and futile.
   It will be perceived, from these remarks, that I am not unwilling 
CHOLERA.
69
to recognize or acknowledge, for convenience sake, this common
appellation of the two forms of Cholera, so constantly distin-
guished, in speaking of this subject.   But, indeed, no  one can
hesitate to admit the  necessity  of such a distinction.  The
ordinary sporadic cholera is one of our most familiar maladies.
Although  not without its alarming appearances and real terrors,
yet its proportional  mortality is  certainly within  the  average
limits of other serious  disorders  of the same season  and cli-
mate.  Its  causes are  for  the  most  part  obvious, definitely
known and easily avoided.
  Not so, however, the malignant or epidemic  cholera, which is
easily traced through a brief but  most extraordinary existence.
Its  history presents  some of the most impressive phenomena
that have ever been recorded.  No  form of pestilence has ever
exceeded  it in mortality.  Its causes are unknown,  undefined,
and present topics of angry and unremitting discussion.
  Whether or not, therefore, we assume the  identity of these
two modifications of cholera in nature  and pathology, we must
allow that the question of cause  is still  unsettled.   I  shall
proceed,  on that account chiefly, to  treat of them  under the
separate heads of Common or Sporadic, and Malignant Cholera.

  I. Sporadic Cholera—the cholera morbus of vulgar lan-
guage, generally makes its  attack at night.  It comes on with
restlessness and  oppression at the stomach, which  rapidly in-
creases to  nausea, and brings on violent and repeated vomiting.
A griping attends early, with a feeling of distention and  twist-
ing of  the bowels ; the  retching produces an irresistible propen-
sity to  stool, and the contents of the alvine  canal  being dis-
charged,  large and thin evacuations are thrown out with  great
force, and  extreme  severity of intestinal pain. The pulse  be-
comes weak and frequent—the skin is bedewed with sweat, and
soon becomes  cool  and relaxed; there is great prostration  of
muscular strength, with remarkable depression of spirits.  This
anxiety and dejection  are followed by  a  light wandering  or
delirium.    The  painful  and involuntary contractions of the
stomach, give rise to similar cramps of the abdominal and other
muscles, adding infinitely to the agonies of the sufferer. 
70
CHOLERA.
   These symptoms, if progressing unrelieved, may so far debili-
tate the patient, that death may occur at once from the sinking
produced by the  immoderate evacuations  upwards and down-
wards.   Yet, even  when  these are checked,  or  have subsided
spontaneously,  another train of circumstances  will  often  be
pressed upon  our attention.   The patient, after a  short sleep,
perhaps, which seems, in  some measure, to have  restored his
exhausted energies, recovers  the  usual temperature of his sur-
face, and loses  the haggard  and ghastly expression of counte-
nance so often a trait, even of the milder forms  of this violent
malady.  His  skin regains  its warmth and  becomes dry and
ruddy;  but the re-action thus exhibited, does not stop at this
proper point.  The cheek flushes darkly—the eyes sparkle, and
are suffused—the surface  is  harsh  and hot—the abdomen is a
little tender on pressure, and  fuller than natural;  there is pro-
pensity to  stool, but without evacuations, or  only a very small
quantity of mucus is discharged.  The epigastrium also betrays
some soreness, with heat and thirst, and, in  the course of a few
hours, a well marked gastro-enteritis is fairly developed.   The
attendant fever generally assumes a low typhous type, with red
lips and mouth, and dry tongue, with gloomy muttering delirium
and jactitation.
   Causes.   A large majority of the cases  of sporadic cholera
which we  meet with, may be traced directly to proceed from
crude ingesta, such as indigestible and  undigested articles of
food, which irritate the stomach and  intestines.   This is most
likely to occur, when any  improper aliment  is taken at  supper
and just before going to bed;  hence the  great proportion of
attacks  at  night or early in  the morning.   There are  certain
kinds of food which  seem particularly apt  to disturb the sto-
mach in this manner, as shell-fish, and, indeed, all fish, to those
who use them rarely as diet—unripe fruits—vegetables insuffi-
ciently prepared by cooking—meats which have commenced to
decay—vegetables in a similar condition.  Fruits  brought to
market  in  cities  for  sale, are generally plucked immature, and
undergo an imperfect maceration or softening, instead  of ripen-
ing properly; hence it is, perhaps, that fruit so often produces
cholera, especially when taken in any large quantity.  Occasion- 
CHOLERA.
71
ally a transient cholera  follows  the  administration of many of
our medicines, as gamboge, colchicum in free doses, sulph: sodae,
and the antimonials, etc.
  It arises also under circumstances which forbid us to refer it
to any thing taken into the stomach,  being undoubtedly attribu-
table to a morbid impression sympathetically transferred to that
susceptible organ.  Exposure to  sudden changes of atmospheric
temperature—to cold  and  moisture—sitting in a current of air
at night—getting the feet wet—remaining in damp clothes—are
among its  causes.  It  often supervenes upon repelled eruptions
of whatever character, and  follows  sudden  and careless expo-
sures  after the  subsidence of the exanthemata, measles espe-
cially.  Of this last mentioned  kind, was  the  most promptly
fatal case I ever witnessed in an  adult.
  Dissections  show various  conditions of the stomach  and in-
testines,  in accordance with the duration and  violence of the
attack.   If it  terminate  rapidly, the  fatal  issue seems to  be
brought  about simply by  prostration  of the  strength of the
patient and exhaustion of the vital energies ; and here, we  can
find  no  trace of any lesion.  I  have  examined subjects dying
under these  circumstances, and have found all the viscera in
an  entirely natural  and  sound state,  the  villous coat of the
stomach and small intestines being just tinged with the slightest
imaginable blush, not  more  than  one would readily believe to
be altogether consistent with perfect  health.
  Where the case has been protracted, all the changes which
follow inflammation of the mucous surface in its several stages,
are detected.   The abdomen is often greatly distended, and the
peritoneum sometimes found to  contain a considerable secretion
of a curdy or purulent fluid.  Unequivocal  marks, too, of  cere-
bral  congestion, and  inflammation  of the brain and  its mem-
branes,  are not  unfrequently met  with, especially  when the
irritative fever has existed  for  any length of time, or has been
more than ordinarily  developed.
   From time immemorial, it has been the  fashion to attribute
attacks of  cholera to disturbance of  the stomach from bile secre-
ted in inordinate quantities  or variously vitiated in quality, and
the practice every where  resorted to, was in general accordance
with  this view of the  etiology.   The offending fluid must be 
72
CHOLERA.
dislodged from whatever portion of the alimentary canal where
it  might be  imagined to be  lurking—must  be got rid of by
whatever means were most efficient, and the poor patient, already
exhausted by the repeated evacuations  upward and downward,
was still urged with emetics and diluents  and cathartics, until
he sank too often (as might have  been  expected) into the repose
of death.  It is hardly necessary to remind  you, that such gra-
tuitous  assumptions no longer guide  us in these later days of
more enlightened pathology;  we no longer set ourselves impor-
tunately to solicit bilious discharges.   The hepatic secretion, so
far from being  the  exciting cause of the alvine irritation here,
either by its undue abundance or its morbid properties, is for the
most part obstructed in a greater  or less  degree, nay, it would
seem, in many instances, entirely suspended; the  evacuations
being thin and colorless, consisting generally of serous and mu-
cous effusions  mingled at first with the  contents of the  canal,
and afterwards unmixed.  Yet, I would  not  go with Johnson,
to  the opposite extreme.  I would not affirm this obstruction or
deficiency of  bile to be a matter of regular  and uniform occur-
rence, nor consent to regard it, as he seems disposed to maintain,
as  a constant attendant, or an  essential constituent, if not abso-
lutely the cause of the attack.   On the contrary, we meet, not
unfrequently,  with  violent cases  in  miasmatic  regions and
through the hot months of summer and of autumn, during the
prevalence of  what are styled  bilious disorders ; nor can I con-
ceive any reason why a vitiated secretion from the liver, poured
into the duodenum, should not prove by its acrimony, like other
irritating contents of the  abdominal canal, a  cause of cholera.
Indeed,  I have been satisfied,  in  more than  one instance, that
this was the actual state of the facts, and that the cases deserved
the appellation which  has been assigned to designate one spe-
cies or variety of  the disease, bilious cholera.
  The general Prognosis in  sporadic  cholera is, as has been
already  hinted, favorable rather than  otherwise.  The  cause
which produces it is, for the most part, transient.  Irritating in-
gesta  of whatever  nature  or  quality  can scarcely fail  to be
promptly removed  by  the vomiting and purging which  they
have  excited, and the  irritation to  which  they have given rise
gradually subsides.  The patient sleeps and  awakes refreshed 
CHOLERA.
73
and restored.  In feeble constitutions, the poisonous  influence
exerted by the causative agent, is however sometimes so intense
as to prove immediately fatal.   I  have seen  a child sink thus
from an  over-dose of emetic tartar, and  another vomited  and
purged to death in a few hours after eating an orange.  Yet,
this is  not the ordinary mode in which the unfortunate result is
brought about.  As I have already stated, it is by the superven-
tion  of gastric or enteric inflammation, and  sometimes by a
similar affection of the brain and its  membranes.   Any symp-
toms, therefore, which  indicate these tendencies, augur unfavor-
ably for the patient.  Tenderness on  pressure, or  tumefaction
of the  abdomen—a  return  of  vomiting, accompanied with fe-
brile excitement—redness or  soreness of the tongue, lips and
mouth—headache—a dark flushing of the cheek—a  low mut-
tering  delirium, with great thirst; these  are all tokens of immi-
nent danger,  and require special care and assiduity.
   The Treatment  of  cholera  requires  to  be  modified  by the
cause which  has brought  it on, as well as by the condition and
circumstances of the patient.   If you are present  at the very
commencement of an attack, preceded by a full meal or by the
use of articles of diet of difficult  digestion  or improper and
dangerous quality, it will be best  to empty the stomach at once
of its deleterious contents, by a mild but efficient emetic.  Ipe-
cacuanha, I think,  deserves an unhesitating preference, on ac-
count of the  gentleness of its operation, its well known relaxant
or anti-spasmodic influence, and  its diaphoretic powers.   If it
fail to  act, or  act slowly, the  sulphate of zinc may be substituted.
Should  any  alvine  uneasiness remain  after  the vomiting, an
enema may be given,  or  a very mild cathartic administered, as
castor  oil to those who bear it  well, or a proper dose of calomel
with opium.
   These observations, and this practice, it is  evident, will not
apply in cases originating from any other cause than irritating
ingesta, as exposures to cold  and moisture, or malaria, or from
mental emotion and the like.  Besides this, attacks of ordinary
cholera are not generally alarming at their onset, and the physi-
cian will seldom be sent for, or if sent for, will hardly reach his
patient before he has  been pretty  thoroughly evacuated both
upward and downward.  In addition  to  the oppressive nausea
       VOL n.—7 
74                       CHOLERA.

and propensity to stool, he  now labors under severe spasmodic
pains, not only in the stomach and bowels, but in the abdominal
muscles—nay, even those of the legs and arms, the hands  and
feet, are affected with annoying and distressing cramps.  He is
sensible of the utmost degree of weakness, and disposed to syn-
cope—perhaps faints outright after an evacuation ;  and mutters
indistinctly and incoherently.
  Here, we are  presented with  two  plain indications, which
require to be fulfilled with the utmost promptness and decision.
We must  subdue irritation, which has  not only brought  on
profuse  secretion from the vascular surfaces affected, but  has
also excited spasmodic contractions of the muscular structure of
the digestive tube  in the first instance, and,  secondarily  by
sympathetic association in all the sets of muscles over the whole
body, both voluntary and involuntary; and we must support the
strength  and vital energies of the sick man, now in the  most
Imminent danger of being exhausted, as well by the intolerable
pain he endures, as by the loss of fluids effused from the vessels.
  Happily these  our objects are  not only perfectly compatible
with  each other, but the accomplishment  of the  one, is best
promoted, by the very means which we must resort to, to effect
the other.  Opium—magnum Dei donum, is here our chief reli-
ance, and a remedy of inestimable value, perfectly efficient alone
to remove the disease in a large majority of cases.  I prefer, as
Sydenham did, "liquid laudanum," to any other of its prepara-
tions.  It is true, as  is affirmed by writers, that a pill (from its
form) will sometimes be  retained when any fluid is promptly
rejected; yet, nevertheless, the  tincture, even when thrown  up,
will  often be found to exert  a more  soothing influence than a
pill retained.  And this apparent paradox  is easily explained.
The nerves of  the disturbed stomach are at once impressed by,
and admit, the anodyne influence of the fluid opiate, as it comes
in contact with  and washes  over their sentient  extremities;
while the pill remaining- undissolved, or dissolving slowly, in
the fluid contained in the  cavity (corpora non agunt nisi soluta)
produces an effect proportionally slow and  imperfect,  perhaps
acting in the meanwhile, by its bulk  and hardness, as an addi-
tional cause of uneasiness and  disturbance  to a  surface whose
sensibilities are excited to the highest degree of morbid intensity.- 
CHOLERA.
75
With these views, I do not confine myself to measured doses of
the opiate, nor restrict myself to any limit of regular interval in
its administration.  To an adult, I usually give at once a  tea-
spoonful of laudanum in a little  water, and repeat this quantity
with a frequency proportioned to  the urgency of the pain  and
vomiting.   If, as will sometimes happen, the expulsive action of
the stomach is so  stormy and incessant, as not to allow of  any
thing being taken, the effort to vomit being consentaneous with,
and absolutely overcoming, the attempt to swallow—administer
your opium by the rectum, throw up an  enema composed  of a
small quantity, not more  than an ounce  or two of  some cold
mucilaginous fluid—starch, gum arabic water, or the like, with
two or three teaspoonfuls or a tablespoonful of the tinct:  opii,
and let this also  be repeated with a frequency proportioned to
the urgency of the symptoms.  In the meanwhile, apply warm
poultices with mustard to the  epigastrium and extremities, and
let the belly be well fomented with hot spirits and laudanum-
bladders or bottles of hot water, or hot bricks, being  kept to the
soles of the feet and the thighs.  If the  strength yield, add to
your opiate  some stimulant  and  nutritious  fluid—arrow-root
with brandy, or, if this be not retained, small doses of aether or
camphor may possibly be less  likely to be rejected on account of
their smaller bulk.
   In some cases, all stimulants will be  refused by the patient, .as
adding to the uneasiness and discomfort which he suffers at the
stomach.  His thirst will lead  him to ask for cold fluids and ice,
the latter of which  is  not  only a  most grateful and pleasant
indulgence, but  is actually, in a high degree, remedial occasion-
ally, and, as  far  as I  can judge, unlikely to do injury.   I am in
the habit of allowing its use almost ad libitum, and  have never
yet seen any evil result from it.
   By these means, as above recited, we shall  generally succeed
in allaying  the  particular irritation of the  stomach  and  intes-
tines, in which cholera consists, and having thus checked the
inordinate secretions, which were poured out from the immense
mucous surface affected, and obtained a suspension  of the con-
vulsive and spasmodic  actions which  threatened the immediate
destruction of life, we may, in common cases, consider our task
accomplished, and leave the patient to the enjoyment of quiet 
76
CHOLERA.
and repose, advising  him  to remain at rest, and enjoining, for
some time, strict  abstinence from everything but the  smallest
portions of some mild,  light, nutritive fluid, at proper intervals.
  We  are  not  always, however, thus  fortunate, and will occa-
sionally meet with instances in which our success will  prove to
be less complete.  Whether from a more than ordinary intensity
of cause or peculiar susceptibility 0f constitution, or from other
circumstances more or  less obvious, we shall sometimes find our
patient, instead of continuing  to  improve, begin or persist to
complain of uneasiness and weight  at  the pit of the stomach,
with a sense of  heat  and tenderness  upon  pressure.    He is
thirsty—the  skin becomes harsh and hot—there is restlessness
and  tossing, and the abdomen feels  sore and distended.  The
case has now assumed a new character.   A sub-acute gastro-
enteritis has obviously  supervened, and requires appropriate
management.  It is not necessary or proper  to consume your
time, by repeating here,  what has been already  said,  of the
treatment of  that modification of disease.  I will  only add, that
my principal reliance is placed unhesitatingly upon the combi-
nation of calomel with opium, so often and so justly eulogized.
"Calomel," says  James Johnson, "must never be  omitted, be-
cause it answers here a triple purpose; it  allays the inordinate
gastric irritability—it excites the action of the  liver, and it cor-
rects the  constipating  effects  of the opium, so that, when the
spasmodic orgasm is  over, some gentle  laxative may with  it
carry off the diseased secretions."
   When the brain becomes affected prominently in this conse-
cutive manner, I would diminish or.subtract  the opium, and
rely upon calomel in small doses, with cold applications to the
head, and  sinapisms and blisters  to the  extremities.   I scarce
 need remind you, of  the importance of blood-letting  from the
 arm if the pulse and  strength admit, and at any rate, from the
 epigastrium  and temples and behind the ears, by the employ-
 ment of the  proper number of leeches, from time to time, as the
 protraction and  other exigencies of each individual case  may
 seem to require.

   II.  Cholera  Maligna—Epidemica—Asphyxia—Asia-
 tica—Indica. Hyper anthraxis. Having thus briefly spoken 
CHOLERA.
77
  of the history and treatment of cholera as under ordinary cir-
  cumstances it occurs sporadically every where, and has been for
  ages familiar  to the profession, it is requisite in the  next place
  that I should  go on to offer you  some account of that more ma-
  lignant and terribly destructive  malady, known under the same
  name, which  showing itself in Hindostan in 1817, spread with
  fearful rapidity over the whole of Asia, depopulating  many of
  the most flourishing and thickly inhabited  districts of that most
  ancient quarter of the globe.   What countries has it not since
  then invaded  !—what  favored portions of  the human race have
  escaped its dark  dominion !   Africa, Europe and America have
  in turn  groaned  under its unchecked ravages ; its progress has
  extended over every ocean  and continent, embracing in its un-
  limited range by sea and land, every variety of surface of country,
|  of soil, and of temperature.   Of all  the devouring pestilences
  that have in ancient or in modern times devastated the nations,
  it has been the most fatal.   Neither the black death of  the four-
1  teenth century, nor the sweating sickness  of the sixteenth, nor
  the gloomy plagues of Eygpt, of the Levant, or of London, have
  equalled it in mortality.  Several years since the number of its
  victims  was calculated (by  Moreau  de Johnes) at upwards of
  fifty millions.
    It made its appearance as an epidemic, and diffused  itself with
•  a progress more appalling, a sway more potent, and an influence
  more extensive than had ever been known in any former exam-
  ple.  It  has prevailed  to a degree equally violent in all climates,
  and in every season of the  year;  in regard to temperature—
  from the frosty atmosphere  of Moscow, (from  September to Ja-
  nuary inclusive,) when the thermometer had sunk below zero,
  to the burning plains of British India, when the mercury stood
  above 100 of Fahrenheit; "in regard to moisture—during  the
  continuance of rain for months, to that dry state of the air which
  scarcely leaves a vestige of vegetation on the  surface  of the
  earth."—Sir G. Blane. It has  not been observed to  follow the
  course of prevailing winds or currents, but in this, as in  all other
  respects, seems independent of  all  sensible influences.  It often
  selects for peculiar prevalence, portions of country of high repute
  for salubrity, and  passes by low and unhealthy regions.  Not
  the least impressive of its features  is the unaccountable  sudden
        7* 
7$
CHOLERA.
' ness of its appearance  and disappearance.  In  one of the En-
 glish regiments of Bombay, it showed itself on  the 21st of Sep-
 tember,  and committed dreadful ravages before night; on the
 25th it had abated remarkably, and in three days more, had van-
 ished  entirely.   As a general  rule, however, it seems slow to
 leave altogether  a position which it has once  occupied;  occa-
 sional cases continuing to recur from time to time.
   Symptoms.   In the history of malignant cholera, we are pre-
 sented with certain prominent phenomena which deserve special
 attention.  It is alleged, plausibly, that none  of these are new
 features; nor do they indeed afford us such lines of regular or
 exact division as may seem clearly to distinguish in all cases the
 Asiatic or epidemic, in  its early stages, from  ordinary sporadic
 cholera.   Nay, it is probable that each  of them may have been
 now and then met  with in an  insulated and severe  example of
 cholera  morbus, popularly so called.  But  here they occur  in
 masses, and present themselves with great uniformity during the
 reign of the epidemic.   In  deference to the views  of the best
 authorities, I will describe the disease as offering three stadia  or
 periods,  separable without difficulty, and  demanding a notable
 difference in the treatment properly adapted to each.
   1. The  Incipient, by some  called the premonitory stage.  In
 an immense majority of instances, a diarrhoea precedes the other
 symptoms of cholera.  It is  attended with  languor and some-
 times nausea.   The discharges at first consist  of the common
 contents of the bowels, then become thin and watery, and finally
 assume the serous appearance regarded as characteristic.  They
 are apt from the beginning to be very copious,  and  pass easily
 without  much griping, and are followed by great weakness, the
 pulse being slow and feeble.  This condition of things lasts, in
 different individuals, from a few hours to four or  five days.
   2. The purging is now attended  with oppressive  nausea and
 frequent vomiting of a similar thin or serous fluid.  The patient
 is apt to  be thus attacked at night, or towards morning.  Cramps
 first of the stomach and intestines, and  afterwards  of the mus-
 cles of the body and limbs, come on at brief  intervals, and are
 productive of intolerable anguish to the  unhappy sufferer. After
 this spasmodic  or convulsive vomiting and  purging have  con-
 tinued a short time, not often beyond eight to  twelve hours, the 
CHOLERA.
79
evacuations are less frequent and profuse, and the patient sinks
into the state of collapse.   His pulse, which has become gradu*
ally more and more feeble, is now scarcely if at all perceptible.
The skin is cold and pale, or even livid, bronzed or blue, and
covered with a clammy sweat; while a sense of distressing heat,
and of thirst, is  often complained  of.  The hands are icy cold,
and the skin of the fingers is sodden and  wrinkled, as  if long
soaked in water.  The tongue is moist, pale, and colder than na-
tural.   There is a  feeling of weight and oppression at the prae-
cordia.  The voice  is husky and feeble, and this whispering
tone is considered by some as characteristic, the "vox cholerica."
The face is haggard  and hippocratic ; the  features shrunk and
wan;  the eye hollow.  A peculiar appearance  of this organ is
described by Magendie, who has laid greater stress upon  it, than
any other writer.  The sclerotica, he says, becomes transparent,
as in bodies sometime dead, giving a most ghastly and  corpse-
like appearance to the person of the sick ; the respiration is slow ;
the mind  usually clear throughout; the secretion of urine is
often absolutely suspended, and also that of bile.  Few  survive
who have fallen into this extreme condition.  In milder cases,
whether from the  inferior vehemence of the attack, the  greater
energy of the constitution, or the  success of the remedies em-
ployed, the vomiting and purging subside ; the diarrhoea  ceases;
the cramps abate; the tongue and skin grow warm ;  the pulse
rises;  the  secretion of urine is resumed ;  bile is discharged by
vomiting or purging, and the patient recovers.  But he does not
at once pass into a state of perfect health.
  3. A third stage of this  dreadful  malady  ensues, which has
been differently  regarded  by  different writers.   The  majority
consider and style  it a consecutive fever, excited  by  the vehe-
ment irritation of so many organs or tissues as have been affected,
or perhaps, (like the  febrile disorder  so often consequent  upon
large losses of blood,) as the result of an inordinate  and ill di-
rected re-action, after the prostration  and exhaustion  from the
discharges that have taken place.   Others, however,  regard
cholera as properly a distinct type of fever, of which the former
symptoms  are merely the initial or cold stage, and this the hot
or principal stadium.   And this is the view,  which,  upon ma-
turest consideration,  I am myself disposed  to entertain.   But I 
 80                      CHOLERA.          '

 will admit that it is not indisputably  established.  The  patient
 now complains, perhaps, of headache;  his  eyes are suffused
 and intolerant of light; the skin becomes dry  and hot;  the pulse
 is contracted, but evidently more voluminous than  before, and
 assumes some tension and frequency ;  the  tongue is clean and
 red, and hard and dry;  afterwards with  the  teeth and lips be-
 coming incrusted with sordes; there  is  often a low, muttering
 delirium.  In short,  the description  of typhus mitior applies,
 with certain modifications, to these cases, which it should be re-
 marked, occur more frequently in some of the localities invaded by
 cholera,  and in some  seasons than in others.  Nay, a few writers
 declare,  that they have failed to meet with  any examples of this
 sort.   It was certainly rare in India,  the  original  seat of this
 pestilence, so much so,  that after it had invaded  Europe, Dr.
 Russell,  one of the physicians  sent by the British  government
 to Russia, to acquire  information concerning its existence and
 history there, remarks, that this consecutive  fever was "a new
 feature to him;" while he nevertheless,  asserts  most  promptly
 and positively, the identity of the epidemic, with that  known to
 him familiarly on the banks of the  Ganges.  It was, perhaps,
 most general in France and Russia, less  so in England, (though
 Brown asserts that he always  met with it,) and  still less so  in
 this country.   Instead of it, we meet not very unfrequently, with
 a strange and peculiar condition  of the sensorial system.  The
 patient is drowsy, but not comatose,  dull, but  not incoherent.
   'I feel no pain nor sickness," said a negro  patient to me, "I am
 only sleepy, and I'm  afraid I shall die that way;" as, indeed, he
 did.   The pulse is slow and full, but not hard;  the pupil some-
 what  dilated;  the tongue and mouth  dry, with thirst.  The
 breathing generally easy, but sometimes stertorous, with occa-
  sional moaning and muttering.  Respiration is always very slow.
  The patient requires to be spoken loudly to,  or shaken, to rouse
 him, but when awaked, speaks clearly, and sometimes promptly
 and with alacrity.  The stomach and bowels are tranquil, gene-
  rally,  in this stage;  the strength is almost  gone, so that if the
  body is  raised from the recumbent  posture,  the  pulse fails, the
/ jaw falls, and the skin becomes covered with sweat, with every
  other  sign of extreme prostration.  Blood,  when drawn, is very
 \ dark, coagulating slowly, with little or no serum. This condition 
CHOLERA.
81
 is not described, so far as I know, by more than one writer—Dr.
 Keir, of Moscow, who regards it as a "congestive, sub-inflamma-
 tory state of the brain and spinal cord."
   It cannot be expected that I should attempt to  describe the
 frequent anomalies which are exhibited during the course of so
 horrid a pestilence, or point out the  numerous varieties of mode
 in which the malady makes its dreaded assault, or in which death
 seizes on his devoted victim.  Some die at once, probably  from
 spasm, without either vomiting or purging;  their torments end-
i ing in less than an hour.   Others sink gently exhausted by pain-
 less diarrhoea.
   Convalescence  is  usually  slow  and  tedious,  and irregular.
 Great irritability of the digestive tube remains for a long while.
 The hair falls off.   The voice continues  rough and weak, the
 whole body is feeble and emaciated, and in many instances, the
 patient seems to have rapidly grown older by many years.
   Prognosis.  In no disease is the proportional mortality greater,
 on the whole.   It is true, that in particular localities it has as-
 sumed,  comparatively, a less murderous aspect.  It is true, that
 by proper attention to the wants of the  sick, and  prompt, and
 skilful,  and assiduous employment of  remedies, many lives are
 saved.  It is true also, that many physicians claim to have en-
 joyed, in their peculiar modes of treatment, a degree of  success,
 that would be utterly incredible, even if affirmed of the most
 common and slightest ailments, a mere  cold,  a colic,  an  inter-
 mittent fever.  Yet, notwithstanding all this, the ratio of deaths
 in epidemic cholera, is truly frightful, varying  from seven  to
 fifty, and even seventy per cent., if we select as the basis of our
 calculation, documents not totally  inadmissible from exaggera-
 tion.  Well then, might the French physiologist  have  applied
 to it, when he first examined its appalling features, the phrase
 which has since become so familiar.  After his visit to  Suther-
 land, Magendie being asked what he thought  of cholera, de-
 clared that "it began where all other diseases end—in the death
 and cadaverization of the patient."
    The  individual prognosis seems  to be drawn,  most  clearly,
 from the degree of collapse.   This  condition, (which I regard as
 a mode of capillary paralysis,) is, when  exquisitely formed, an
 absolutely hopeless state, and the degree of its intensity is a very 
82
CHOLERA-
 accurate measure of the danger.  Even if the patient do not die
 in collapse, he is likely to fall  into a secondary or consecutive
 fever,  of proportional violence and  risk;  or  emerge  into the
 strange condition of sensorial torpor,  attempted to be described
 above.   The vomiting and purging are not  so much to be dread-
 ed, it would seem, as was at first  imagined.  The  suppression
 of urine is a very bad symptom; so also is a marked  coldness
 of the tongue and  mouth, and the sodden appearance of the
 hands and feet.   Vascular re-action, and the return of  deficient
 secretions and excretions, as  of bile in the  evacuations, and of
 the urine, afford us  the best hope of recovery.
    The Diagnosis can only refer to the line of distinction, which
 we may be called on to  draw  between  sporadic and epidemic
 cholera.   In the earlier cases of invasion, this may be  attended
 with some  difficulty.   The  characteristic  circumstances  have
 been dwelt on.  The prompt tendency to immediate failure of
 the circulation, whence the phrase cholera asphyxia;  the col-
 lapse or capillary paralysis, shown by coldness and shrinking of
 the surface,  coldness of the tongue, and blueness or lividness of
 the  skin; the total absence of bile  from the  evacuations, and
 their peculiar character as albuminous, resembling  so remarka-
 bly, thin gruel or  rice water ;  the violence of the spasms ; the
 rapid emaciation; all these form a picture which can never fail
 to be immediately and clearly recognized.
    Autopsy.   The external  appearance of the body is striking.
 The solids are shrunk with seeming  emaciation, not so much
 attributable  to absorption of the fat, as to the previous  draining
 of the fluids.  The surface is livid, bronzed or blue;  the skin
 of the hands and feet corrugated;  the nails purple ; the fingers
 often rigidly contracted by spasm, which may, indeed, continue
 to affect the various muscles, several hours after death,  in  cases
 of short duration.  The arteries are empty,  nay, this is the fact
 in some instances, even before death ; the radial, and even the
j carotid, having been eut open without the  escape of a drop of
 blood from their gaping orifices. The  cutaneous veins not unfre-
^quently  refuse  to  bleed, when pierced.  The mass  of blood
 seems to be collected in the large veins of the trunk and viscera.
 The blood has undergone some remarkable changes.   It is black
 and viseid;  if it coagulate at all,  it does not  separate into its 
CHOLERA,
83
   usual constituents, having lost, by the inordinate serous evacua-
I   tions,  much of its water and its peculiar salts.
     The morbid appearances of the viscera differ, relatively to the
   duration of the case.   The vessels of the brain are usually found
   full, though  not  uniformly  so.   In  the  thorax, the lungs are
   much congested or loaded with blood.  The heart is generally
   distended with blood on the right side, sometimes on both, and
   sometimes even the aorta is thus filled.  The veins in the neigh-
   borhood of the heart, are uniformly much engorged.  The veins
   of the abdomen, of the liver and  mesentery, especially, are dis-
   tended.
     If the fatal event have occurred early, we shall discover few
   or no marked changes ; a slight redness of both the serous and
   mucous surfaces, has been noticed, but in general, it is stated by
   writers, that there is  presented very little  trace of disease.  On
   the contrary, in  protracted  instances,  notable  alterations are
   found to have taken  place.  The  brain shows its vessels filled
   and turgid, in cases that have exhibited the symptoms of con-
   secutive  fever ; sometimes with serous effusions  between the
   membranes.  The lungs are  rarely  altered in structure, even
   where respiration  has  been  much affected during  life.  They
   are. however, sometimes hepatized, and sometimes unaccounta-
   bly collapsed.  In the  abdomen, a certain degree of redness and
   turgidity is perceived, over the peritoneal covering of the intes-
   tines ; they sometimes adhere from inflammation.  The stomach
   is (rarely) found empty or contracted.  The mucous coat is so
   variously changed as to offer a great diversity of appearances.
   There are tokens of congestion,  and of active inflammation in
   different parts ;  it appears softened, thickened, friable, and Scott
   says, sphacelated.  The intestinal tube is  sometimes collapsed,
   but more generally filled with air, or with the rice water fluid
   described as forming the principal portion  of the evacuations;
   its internal surface sometimes shews the marks of active inflam-
   mation.  The urinary bladder is found empty  and much con-
   tracted, but not diseased.  Buere  de Boismont affirms the spinal
   marrow to be uniformly affected; sometimes, he  says, there  is
   effusion of blood, sometimes of serum, and  sometimes of gela-
   tine in the canal.  Dr. Schnurrer notices a peculiar  feel  of the
   bowels.  "They have  lost," he says,  "their usual polish, they 
S4
CHOLERA.
are flaccid and yielding;  the mucous membrane is doughy, and
the submucous tissue congested."  Although, for the most part,
cholera corpses are rigid, yet Dr. Davy has, in some cases, found
the muscles extremely flaccid, as in animals  killed by fatigue or
electricity.
  It is a very curious fact, however, that after the disease had
prevailed in numerous portions of the civilized world for seven-
teen years; after it had engaged the  most  earnest attention of
the physicians and pathologists of the old world ;  after the per-
formance of almost innumerable autopsies  in  the hospitals  of
Russia, Germany, England and France, by Jahnicker, Searle,
Craigie, Louis and Andral,  it was reserved for an American to
discover the specific lesions produced by this modern pestilence.
Dr. Horner, Prof: Anat: in the Pennsyl: University, published in
the May number of the American Journal, 1835, a paper "the ob-
ject of which is to prove,  that  in Asiatic cholera, the following
morbid anatomical characters are found in the alimentary canal:
1. A copious vesicular eruption, entirely distinct from the tume-
faction  of villi, muciparous  follicles  or glands, and which per-
vades  the whole canal;  2.  A  lining  membrane of coagulated
lymph, which exists in the small intestines at least, if not in the
stomach and colon also, and resembles, in texture and mode  of
adhesion, the membrane  of  croup; 3. Vascular  derangements
and phenomena, which  are  confined  almost exclusively, if not
entirely so, to the venous system ;  4. An exfoliation of the epi-
dermic and venous lining of the alimentary canal, whereby the
extremities of the venous system  are denuded and left  patu-
lous."   For his cases, and the observations and reasoning upon
them, I refer you to his essay with but one  remark, viz.:  that
statements so  definitely made as these, must ultimately receive
definite confirmation  or confutation.  I cannot wish that any of
you should have the opportunity to  examine the matter  for
yourselves; but, if you should, I  hope that it will not. be suf-
fered to pass by unimproved.  In the meanwhile,  I  am unable
to yield an unhesitating  credence to  details differing in their
alleged uniformity from, and thus contradicting, all  former  ac-
counts, which, until now,  agreed in  the ascription  of extreme
irregularity to the local affections in cholera.
  Pathology and History.  The nature and origin of this terri- 
CHOLERA.
85
ble pestilence, have  formed the theme of innumerable  essays.
It  is a question adhuc sub judice and still most warmly contested,
whether we are to regard it as identical  in character and seat,
with our common and familiar cholera.  No one can deny, that
in their modes of access, their  symptoms,  and the manner of
termination, there is, to say the least, a great similarity; while
even in violence and rapidity, some of our accustomed sporadic
attacks approximate closely, if they do not fully  rival  their for-
eign congener.   The difficulty of drawing a precise line of dis-
tinction, has been noticed every where,  when the invasion oc-
curred.   At Orenburg, (in Russia,) the physicians did not pro-
nounce upon it for several days, as offering any thing peculiar;
and  in Sunderland, (England,) opinions were  for some time
divided upon the question,  whether it was endemic or Asiatic
cholera.   It is said to have been, in many localities, foreshown
by cases  of ordinary cholera of remarkable malignity;  although
I would receive  such accounts always, with large allowance.
Ever since the attention of the medical world has been drawn
to this pestilence, bad and rapidly fatal cases of sporadic charac-
ter have been much talked of whenever they occurred, and have
given rise to occasional panics,  which, when  they died away,
left upon the minds of those who had participated in them, ob-
scure impressions extremely unfavorable to the drawing of accu-
rate distinctions  in future.  Hence those who had not partaken
of the alarm, became affected with a degree of scepticism likely
to prevent their ready acknowledgment of the true nature of an
actual  invasion.   Thus the periodicals teemed with histories of
severe sporadic cases, which had been met with in Great Britain,
during the few months previous to its irruption there as an epi-
demic.  It is singular that  these were so little dwelt on at the
time, though  so well  remembered afterwards.   Thus, every
where in our interior country, instances  are  seen from  time to
time, which are  pronounced to be malignant or Asiatic in their
aspect.   I am inclined to believe,  however, that  such  have al-
ways occurred at intervals, in all places,  but failed to attract
special notice until  they assumed a new importance, as predict
ing or forerunning the arrival of a dreaded plague.
   Some contend that this is not the first instance on record of
the epidemic prevalence of cholera, although from its vehemence
       VOL. II.—8 
86                       CHOLERA,
its pestilential mortality, its wide extension and long protracted
duration, it stands prominent in the history of the world.   It is
said to have diffused itself in every  part  of Europe, in 1600;
(Bontius, physician to the Dutch settlement  of Batavia, states
that) it was  extremely prevalent in Asia, in 1629.   It prevailed
thus in London, in 1669 and 1676 ; in Switzerland m 1696, and
in Paris, in 1750,  Sonnerat, who travelled in  Hindostan, be-
tween 1774 and 1781, describes  it as epidemic  on the coast of
Coromandel, and affirms that more than sixty thousand persons
perished, during one of its  visitations in the country  between
Cherigam and Pondicherry.  Paisley mentions it as an epidemic,
in 1774, and Curtis, as ravaging the southern provinces of India,
in 1782.   It seems to have been unnoticed, from this period un-
til Aug., 1817, when it attracted attention in the town of Jessore,
about sixty miles  from Calcutta,  which city of palaces it inva-
ded before the end of the month, raging there with great violence.
  From this its origin, in the Delta of the Ganges, it is not in-
appropriately called Indian cholera;  to distinguish it,  by refer-
ence to its wide and rapidly extending sway,  (as influenza is
separated from  common catarrhal  fever,) it is entitled epidemic
cholera; and from the remarkable prostration or stagnation of
the vascular function, it is proposed to denominate it cholera
asphyxia.   It would be useless to enumerate  the  several other
names by  which it has been designated.
   A brief sketch  of its progress  to the present  time, may inter-
est you.   In about a yearafter its appearance in Bengal, it reached
Bombay and Madras; invaded Ceylon in January, and the  Isle
of France in November, 1819 ;  in 1820;  the Isle of Bourbon,
Bankok, the capital of the kingdom  of Siam, where  it proved
widely mortal; and Canton, in China.   In 1S21, it appeared at
Muscat, in Arabia, and extended to Shiraz and Ispahan, in  Per-
sia, and to Bagdad;  in 1822, spread  into Palestine; in 1S23, ac-
companied the British army into Burma, with which kingdom the
English masters of India were then at war, and committed dread-
ful ravages in China, especially in the cities of  Nankin and Pe-
kin;  in 1825, it crossed the great wall of the Celestial  Empire,
attacking the trading place or mart of the inland  commerce of
the Russians and Chinese, Kiachta;  and in 1827 reached  Cocu
Choton, in Tartary.   In 1829, it prevailed in Russia,  at Oren- 
CHOLERA.
87
burg, near the Tartar frontier;  in 1830, at Astrachan; from this
town, which lies at the embouchure of the Volga into the Caspian
Sea, it disseminated itself over all the eastern and northern parts of
Europe.  It attended the Russian armies in their march over un-
happy and trampled Poland, adding to the almost unexampled
wretchedness of that devoted  people, and  almost depopulating
her war-worn and starving metropolis,  (Warsaw.)  In 1831, it
showed itself in prompt succession at Moscow, Constantinople,
Vienna, Berlin and Hamburg, crossing the German sea to Sun-
derland, and thence spreading over Great Britain.  Paris was
not attacked until March, 1832.  In that fatal year, it passed across
the wide  Atlantic, with the stream  of British emigrants to Mon-
treal and Quebec, in less than a month, appearing also at New-
York. From these central positions,  it can readily  be traced
along our sea coast  to Philadelphia, New-Haven, Boston, Balti-
more, Richmond, Edenton, (N. C.,) Mobile  and New-Orleans,
and along the St. Lawrence and the Lakes, to the upper Missis-
sippi.  In  the  fertile valley  of that  father  of rivers,  and his
tributary streams, it found a congenial and favorite  abode, and
long  prevailed  in many of the towns and villages of the great
West, with potent sway.   It had not, until the summer of 1836,
placed its dreaded footstep within our city, except in a transient
visit, which shall be noticed particularly.  The nearest points
of prevalence to us, had been, on the north, Edenton, and Sa-
vannah river, on the south, where it attacked several plantations
near the city of Savannah.  During 1835 and  1836,  it spread
over  the West  Indian Islands, and seems to have  fixed  itself
tenaciously at Havana.  It committed the most dreadful ravages
in Italy in  1837—Rome and Naples, and in Sicily, Palermo ex-
periencing  its worst terrors.  I was shown a letter from an offi-
cial person in the latter city, stating that upwards of one thou-
sand  persons died of it daily, and that, such were the panic and
distress of the people, the corpses would have remained unburied,
but that their interment was made  part of  the duty of the  large
body of government troops garrisoned there.
   The westward progress of this dread malady, has been calcu-
lated to average about eighteen miles a day, or  as others say, a
degree in a month.   What can check  its career ?  Where may
this plague be stayed ?  Nor climate, nor season, nor soil, nor 
88
CHOLERA.
locality, nor  national habits,  nor commercial restrictions,  nor
military nor municipal regulations, have availed  to repel its ad-
vances, or protect against its  invasion.   Nor  seas, nor  deserts
interpose  an effectual barrier.   The actual  mortality of cholera
has been estimated at considerably more than fifty millions.  Its
proportional mortality varies much in different  situations, and,
let it be regarded as one of the proudest triumphs of our divine
art, it has uniformly observed an inverse ratio,  to the facility
with which medical aid can be obtained.   Of the barbarous and
semi-civilized tribes, over whom it has swept with its dark wings,
more than half have probably perished, and in  many instances
a larger proportion even than  this.   Its horrid features have
seemed less appalling, when  intruded  amidst the  enlightened
and well ordered among the  nations.   Yet even  here,  its ap-
proach  is calculated to excite the most impressive  terror.   The
extreme muscular debility, the syncopic  state of  the  circulation
and sudden loss of genial animal heat, the exhausting and painful
evacuations, the cold, blue, clammy skin, and the torturing cramps
of the limbs and trunk, form a picture of intense agony, which
all must regard  with the  deepest sympathy and  dismay;  the
only mitigated feature,  indeed,  of this  pestilence,  is the brief
limit of its inflictions, and the prompt arrival of  death.
   In the investigation of the  Etiology of epidemic cholera,  the
question of its contagiousness  is truly one of fearful and pressing
interest, and demands from every philanthropist in the profession,
a deliberate and careful consideration.
   Cholera, if contagious, can  be in some measure restrained in
one of its  modes of propagation.   If non-contagious, but merely
endemic and epidemic, whether we refer it to atmospheric or tel-
lunic sources, there is no human probability of arresting or check-
ing it in its course, and we must submit with sullen passiveness
to the  decrees of an irresistible  fate; decrees more terrible, be-
cause, though like  other epidemics, it has its periods of  increase
and  diminution, yet it does not, like these its congeners, subside
and disappear.   The evil of its  introduction is not only incalcu-
lable in extent, but as far as we yet know, unlimited in duration;
"it takes deep root," "says a  writer," in the soil  which it has
once possessed.
   If we come to the first conclusion, and believe  that it is within 
CHOLERA.
89
our power, however partially and  imperfectly, to restrain the
progress of this pestilential disease, we shall at once adopt and
institute the measures best adapted to this purpose.   We shall
recommend commercial restrictions, careful and despotic quaran-
tines, cordons sanitaires, and other military and munipical regula-
tions.  These  measures fall heavily upon mercantile men, and
distress and embarrass all civilized communities.  Business must
languish  or die,  and national as well as individual prosperity
receive a severe shock.   A view of these consequences, however,
should only  have the effect  to stimulate us to enquire with
the utmost patience and caution ; to investigate conscienciously,
and weigh well the offered testimony ; it must not be allowed
in any degree to influence our decision.  This must be  frankly
and fairly deduced from  the  premises.   Truth alone must be
sought for.  At her feet we must,  like the Magi guided by the
star to the stable of Bethlehem, cast  away our  prejudices and
lay down our wealth, our myrrh, our frankincense, our treasures
of gold and silver.  Her only must we worship.
  We must not allow ourselves to be embarrassed by the false yet
prevailing notion, that there is any incompatibility in the posses-
sion of the two properties of epidemic extension and contagious
communication.   I have had occasion, more than once, to allude
to the epidemic prevalence of contagious disease,  and I am fully
persuaded that an impartial review of the facts  in the case before
us,  will prove that this  remarkable pestilence, like the  plague
itself, offers a striking instance  of this mode of propagation.   It
would  be well  to  lay down, in a  definite  way, the kind and
amount of evidence required to prove its  contagiousness.
  1st.  It is true, we cannot here apply the experimentum crusis;
there is no palpable secreted matter with which we may inocu-
late, as in small pox.  But we cannot inoculate for typhus, nor
mumps, nor hooping cough.   This test, therefore, is  not of es-
sential force.
  2d. Cholera does not affect every one who approaches the sick,
nor even a majority; nay, it may fail  to attack any one of those
who surround a patient.   But the same is true of small pox and
every  other contagious  disease: how else could they ever pass
away, or suspend their ravages? "During nine months," says Dr.
Haygarth, "while the small pox prevailed epidemically in Chester,
       8* 
90
CHOLERA.
I attentively marked its progress.  At the beginning, two or three
families were seized, not immediate neighbors, but in the same
quarter of the town ; then the children of a neighborhood, com-
prehending an entry ; but it did not  spread from thence as from
a centre ; in no part of the town has it spread uniformly from a
centre."  I challenge any one to show the transmission of small
pox, in any instance of its prevalence any where, from house to
house, and from person to person, as is required of us to do in
regard to cholera.  These remarks  will  of  course apply more
forcibly in the  instance of the plague, hooping cough, measles,
etc.   Writers omit to consider, or choose to forget, that diseases
acknowledged  to be contagious, differ very much in  the degree
or  intensity  of this power.   Nay, the same contagion spreads
more rapidly at one time than another, under the influence of
causes utterly unknown to us.   Small pox is probably the most
powerful of the contagions, and  depends  least for its extension
 upon extraneous  contingencies.   Yet even this spreads  often
 feebly and irregularly, and soon  dies out after  its introduction
 into a neighborhood.   Now in the argument on this question, the
 anti-contagionists unfairly require—not only that cholera should
 be equally communicable with the most forcible  of known con-
 tagions, but that it should be communicable in all the different
 modes and under all the various circumstances predicable of each
 of this diversified class of maladies.
   I have already suggested  that  the most contagious diseases,
 are  not capable of propagating themselves during  all the se-
 veral  stages of their  duration, but only at certain  periods or
 points of time and condition.  Drs. Russel and Barry state that
 the consecutive fever, so common in Russia, was  scarcely known
 in India.  They also  say that the number of medical men and
 hospital attendants attacked with cholera was also beyond com-
 parison greater in  Russia than in India.   Hence it would seem
 logical to infer, that  this  consecutive fever is  the contagious
 stage emphatically, though perhaps not exclusively, of cholera.
   3d. We must here allow the usual and logical preponderance
 of positive over negative testimony.  From  "want of susceptibi-
 lity," a great variety of unknown protective  circumstances being
 included under that phrase, thousands escape the influence of
 all the causes of disease,  and of  contagion among  the rest, 
CHOLERA.
91
Whose experience and  observation do not furnish him with ex-
amples of this sort ?  Who has not escaped measles or pertussis
at one time, to fall into them at another ? Cobbett mentions that
his  wife nursed all her  children, eight in number, when succes-
sively inoculated for  the small pox, being herself unprotected,
yet never took it.   I  have both vaccinated and inoculated, many
times, a young lady of  this city in vain.  Her family have suf-
fered  extremely from varioloid,  and she nursed  assiduously a
sister who died of small pox.   Yet she never received it.   The
argument that cholera  cannot be contagious, because it fails to
affect the physician,  nurses and friends who surround the sick,
proves too much, if it prove anything.   The disease exists about
and among them ;  some cause or causes  must  be efficient in the
production of new cases; it  is, they say, epidemic.  But these
persons are not only  exposed to contagion, but to atmospheric and
telluric  vitiation, and to all causes whatsoever.  If their escape
prove cholera to be not contagious, it proves also that it is not
epidemic.  Such  examples, after all, only go  to show that no
cause of disease is universally or omnipotently efficient. "Thus
far  and no farther shalt thou go !" is the providential fiat; and
our feeble  and miserable race is thus  preserved from utter ex-
tinction.
  4th. In the examination of alleged facts, we must rather dwell
upon the obvious and  concurrent inferences to be fairly drawn
from  them, than the  minute difficulties which may be suggested
by  the ingenious special pleader.  A ship, bringing persons ill
of cholera, or recently  convalescent from it, arrives at a certain
sea port  town, and in a short time afterward, the disease makes
its  appearance there.  Similar examples occur  again and again,
and the opinion arises that cholera has been propagated by trans-
portation and contagion.  But no! exclaims a philosophic doubter.
I must have proof that the first who was taken ill, in the speci-
fied town,  had direct intercourse with a patient from on board
the suspected vessel, and from him you must trace it to the next,
and so on.  This test,  however, I hold to be inapplicable in any
case,  even  of the most undoubtedly contagious malady, and
maintain the satisfactory  nature of that evidence,  which  shall
establish a repeated coincidence in point of time,  between the 
92
CHOLERA.
 approach of a source of contagion, and the infection of  a region
 or community previously healthy.
   Let us now proceed to apply the  above rules to the case
 immediately under discussion.  1st. Cholera, since  its  eruption
 in 1817, in the Delta of the Ganges, has made regular, but not
 very rapid progress, over  the  world.   In this  point, it shows
 striking correspondence with the movements of  a known conta-
 gion.—Influenza, whether contagious or not, travels, in  some of
 its visitations, infinitely faster.   2nd. Cholera has followed, in
 thus extending itself, the  usual  channels  of  commerce—the
 great lines of human intercourse, by sea and land.  It accompa-
 nies armies, attends  the march of caravans, and is  transported
 in ships.  Whenever it has reached an island, or crossed the
 sea,  the first place of its appearance has been, uniformly, on the
 sea-coast, a  fact of itself, sufficient to  render  probable, if not
 establish, its contagiousness.
   Among the statements offered in proof of the doctrine I have
 advocated, the following has seemed to me to be specially striking
 and  conclusive.—On the  31st  October, 1832, the  brig  Amelia,
 bound to New-Orleans from New-York, was wrecked on Folly
 Island, about twenty miles from our city.   Some of  the passen-
 gers labored under cholera, which prevailed at New-York when
 she sailed.  They were all landed safely, and lived in the few
 buildings on the island and in tents.  There they continued  to
 sicken with the disease.  A boat's crew of wreckers had gone
 to the stranded vessel  to  save her cargo, and on their return to
 town, one was seized with cholera, and died.  The rest of the
 crew were ordered to the island to perform quarantine with the
 persons  landed from  the  brig, and one Was taken on his way
 and died in the boat.  There were four negroes on the island.
 Three physicians were sent from the city to attend the sick, and
 a detachment of the  city-guard  was detailed to enforce the quar-
 antine.  Let us see what was the result of this intercourse, upon
neutral ground, between healthy and sick men.   Of  the wreck-
 ers,  thirteen in  number, several were  sick, and eight  died  of
 cholera.   One of the physicians, Dr. H.,  was  ill of it, but re-
covered.   The nurse of the wrecker above mentioned as dying
 in the city, himself sickened  and  died  after being sent to the 
CHOLERA.
93
 island.  Of the four negroes residing  there, three died ;  of the
 guard sent down, eighteen in  number, ten were sick and one
 died.  Such are the undenied facts, and all the ingenuity of the
 most practised sophist, cannot impair the force of the inferences
 to be deduced from them—That cholera is communicable—that
 it can be transported by sick bodies to healthy localities, there
 to infect healthy bodies—and that quarantine institutions, how-
 ever imperfect, may yet avail to  protect maritime cities.  I do
 not  doubt that Charleston owed her exemption from cholera, at
 that time, under Providence, to the energy and  wisdom  of her
 Intendant and Council.
   Much has  been written upon the subject of  the assignable
 causes of cholera, besides those  included under the  heads of
 epidemic distemperature of the air, and contagion and infection;
 for  some, offering  at  a  distinction without a difference, have
 been willing to  speak of  it as infectious who denied its conta-
 giousness.   Malaria reigns in  Bengal, the low and swampy
 region where it first  appeared,  with  perennial  and despotic
 sway.  But we  must  affix a new meaning to the word, when
 we employ it to  refer to an agency powerful in all climates and
 at all seasons, and in every district of country.   There can be
 no identity between the malaria of the  alluvial coast of Hindos-
 tan, under  the  influence  of the burning  sun  of August and
 September, and that which may be supposed to exist during the
 frosty winter  of Poland  and Moscow.   Telluric emanations
 have been much talked of;. but  nothing can be  more  absurd,
 that the notion of an alleged  similarity between the exhalations
 of the marshy soil of India, the arid plains of Tartary, and the
 paved streets of London, Paris and Boston. Animalculae have
 been considered the generators of this pestilence by Hahneman,
 Neale, Monjon, and others.   Some who hold this opinion, ac-
 knowledge that their existence cannot be exhibited or detected—
 it must be inferred; while  others tell us, that, notwithstanding
 their minuteness, these little creatures can be traced by their
immense numbers, and they talk of clouds, "darkening the air
and  making the sunbeams dim," as  having  accompanied or
preceded cholera on its march in India  and elsewhere.
  Food.  The discussions first entered  into in relation  to the
effects of improper  food as a cause of cholera, have been re- 
94
CHOLERA.
 vived by Dr. Tytler.   In 1818, he pressed his sentiments upon
 the  authorities in India, but they were not generally received.
 He professed to trace the disease every where to the use of rice,
 whether in Asia,  Europe or America.   We feel here the ridicu-
 lousness of this notion.  Moorshadabad in  Bengal, and Charles-
 ton, in South-Carolina, until 1836, have reason for grateful exul-
 tation at their escape from  cholera, though surrounded by it
 and threatened in every direction.  It cannot be proved, that we
 eat better rice than our less fortunate neighbors, while it is
 obvious, that in both cities we consume more of the grain in its
 various qualities than is eaten either  in Paris or London, Vienna
 or Moscow.   Damaged rice, however, ranks with the  improper
 articles of food which  have been among the most influential of
 exciting causes,  and  hence the  disease has always  prevailed
 most extensively and fatally in  the  lower  ranks and  poorer
 classes of every community.  Excesses of all kinds increase the
 susceptibility to it, and enhance its violence.  This  is especially
 true, as is stated  by every writer, of intemperance in the use of
 ardent spirits.  During its prevalence, the employment of acrid
 and irritating  ingesta should  be avoided—flatulent vegetables—
 shell-fish—unripe fruits, and all  aliments which tend to bring
 on attacks of sporadic cholera.    Exposure to  alternations of
 temperature,  dampness and  cold, must  be shunned.  Flannel
 should  be worn  next  the  skin,  with  thick, warm shoes and
 stockings.   The  apartments  of  the sick  should be  carefully
 ventilated, and their excretions immediately removed.
  Of the Treatment, I cannot, even now, venture to speak with
 much  confidence.   The accounts of  the results  of different
 modes of management, are  so various  and conflicting, that it is
exceedingly difficult to decide where truth  and accuracy are to
be found.  The  English East-Indian  surgeons, whose reports
stand first in point of time, and  exhibit  great skill, ability and
success, if they saw the patient early in the attack, bled freely
and largely,  and then administered calomel and opium in full
doses, applying warmth and counter-irritation, in every form, to
the surface of the body and limbs.  A  similar mode of practice
has been very generally followed  in Russia, Great  Britain, and
in our  own  country.  But it may be  as well to speak of the
various remedies  proposed  in succession.  The lancet has had 
CHOLERA.
95
many advocates, and its employment  is, by some practitioners,
urged under circumstances the most  forbidding, even during
collapse.   I should prefer to follow the general rule here.   I
would shrink from the attempt to bleed a patient in this condi-
tion of vascular debility;  in truth, the blood will often refuse to
flow, whether from vein or artery when cut.  The temporal has
been divided—the radial, nay, the carotid, and from its gaping
diameter, not one drop has issued.  "The fluids are stagnant,"
says Magendie, pithily and truly.  When there were spasms or
gastric or intestinal uneasiness, with a pulse that would bear it,
I would resort freely to V. S., and would  not hesitate to repeat
it, the same circumstances  requiring and permitting.  Topical
blood-letting is an  unobjectionable remedy.  I would use  the
cups in preference, applying them to the epigastrium, spine and
temples, pro re nata.   Opium  I  regard as of indispensable
utility.  In mild cases, and in the early stage, it is often found
to be the only medicine required.  It has lost reputation  in  the
hands of some practitioners, because,  1st. Too much was  ex-
pected from it; and, 2nd.  It was misapplied.  It was believed
capable of  curing  all  forms of the disease.  It is not indicated
in those attacks in which  the  stomach, struck torpid, fails to
empty itself of its  irritating and poisonous secretions.  It is not
sufficient  in itself for the  removal of the collapsed condition;
nor is it adapted to the  secondary stages of gastro-enterite and
choleric fever, as  it has been called.   But in  a vast majority of
ordinary invasions, it is most useful.   It allays spasm;  it soothes
irritation and diminishes the frequency and amount of the  eva-
cuations ;  it tranquillizes  spinal  and  cerebral  disturbance, and
brings on quiet and refreshing  and restorative sleep.  Calomel
is the article  of the Materia  Medica  perhaps most  universally
exhibited.   In all the stages of the attack, this drug  has been
prescribed, and in  every varied  quantity—from  Ayre, of En-
gland, who gives repeated small doses of a grain or two every
five or ten minutes, to Cooke, of Lexington, who, aiming at the
maximum  dose, offers a tablespoonful pro  re  nata; all  but the
followers  of Broussais,  Hahneman and Thompson, advocate
and resort to it.  The preponderance of evidence in its favor is
immense.   I would administer from 5 to 20 grains at  intervals,
as circumstances might indicate. 
96                       CHOLERA.
  The acetate of lead, recommended by Graves, has been eulo-
gized by several practitioners.   I have certainly seen it  do good
service.  I combined it sometimes with opium, and occasionally
dissolved  it in the mist: camphorata. It requires to be given in
free doses to make any definite impression.   It  is useful  as an
astringent enema, when the discharges  are frequent as well  as
profuse.
  Emetics cannot be often applicable to ordinary cases.   If the
circulation became feeble early in  the attack, with coldness and
blueness of the skin, and collapse impended without great pre-
vious exhaustion  from discharges, I would follow  the  authori-
ties which advise a  stimulant emetic.  Mustard  seems to be
generally  preferred.  Half  an  ounce  to  an  omice may be given
diffused in warm  water.  Common  salt is much used for the
same  purpose;  other emetics, as  sulph: zinci, ipecac:, etc. are
occasionally combined with them.  Cathartics are employed by
few physicians in the early stages of cholera.  In certain pro-
longed cases, when  a species of inflammatory affection  of the
stomach and bowels is developed,  the milder articles of this class
are occasionally beneficial.   If calomel  does  not suffice,  castor
oil, magnesia or rhubarb may  be  added in  moderate doses.  Of
stimulants, properly so called, I should wish to avoid the admin-
istration,, if possible.  If they  become  absolutely necessary, be-
yond opium, which is,  incidentally, the  very  best of them, I
would use capsicum, camphor and ammonia, in quantities pro-
portioned to the urgency of the case.
  Heat is almost uniformly applied  to  the surface, though dis-
putes have run high, whether  it ought to be in the  dry  or moist
form.  Hot,  dry  air, is extolled by  one; vapour  baths by an-
other, or hot water; and by  still another, the  whole body is
directed to be enveloped in poultices, of as  great warmth as can
be borne.   If the skin is relaxed,  I prefer the dry form, and lay
about my patient bags of hot  salt, hot bran, etc.   Mustard may
be advantageously  applied, in poultices or by  dry friction, to
irritate the suface.  Nitric  acid and capsicum, and a great varie-
ty of irritants are used also, as ointments and embrocations.  In
protracted cases, epispastics are of unquestionable  service, both
as stimulant and revulsive.  Some practitioners,  finding that
these heating formulae are  so  often  complained  of by patients, 
CHOLERA.
97
as adding to their sufferings, have gone to an opposite extreme,
and have advised cold affusion, and even frictions with ice, upon
the blue or bronzed skin, covered as it is, with a chill and clam-
my perspiration.
   Camphor has been proposed by Hahneman, upon homoiopathic
principles, as "the true and only  remedy for  cholera," and he
ventures to assure any one, who will "take it in sufficient quan-
tity,  and  proper zeal  and perseverance,  that he will not die."
The remedy has gained much celebrity even in  our own coun-
try, and is much employed every where as prophylactic.   Large
draughts of tepid water have been recommended, on  the  one
hand, and on the other, a Dr. Hardwicke Shute, has reported a
prodigious success from the drinking of indefinite quantities of
cold water exclusively. Broussais gives pellets of ice—Magen-
die hot punch—Baird, of Newcastle, relaxes with  the tobacco
enema—Fyfe, (of same place,) stimulates with glysters of mus-
tard  and of brandy.   Sulph: quinine, nux vomica, galvanism,
electricity, and acupuncture, have their  advocates.  Sir  James
Murray suggests  the  placing of the body in an  exhausted re-
ceiver, to  determine  to the surface in  collapse.   The idea is
plausible and ingenious—it is dry cupping  on a  large scale.
The blackness of choleric blood has  induced the  exhibition of
oxygen, and its mixtures, as nitrous oxyde, etc.;  but the reports
of the results of the experiments, are not favorable.  Dr.  Latta,
and  others, have injected into  the  veins, warm water in large
quantities, holding in solution the salts drawn off in the serous
discharges peculiar to  this disease.   The attempt is a total  fail-
ure.   Dr. Stevens, who entertains peculiar views of the chemi-
cal changes of the fluids  in  disease, and  of  the paramount
importance of saline  remedies  in fevers, has extended his treat-
ment also to cholera; and the reports of  the success of his plan
in the management of the epidemic  in  the Cold-Baths-Fields
Prison, London, were highly flattering.   They have not, how-
ever, received any farther confirmation from any quarter.
   The highest degree  of success, in the encounter with  this
terrible malady, that has yet been attained in this or any other
country, is claimed for Dr. Cartwright, of Natchez.  His  state-
ments are supported by a  mass of collateral evidence, and  the
most flattering testimony borne to his merits  by the community
       VOL. II.—9 
98                       CHOLERA.
among whom he resides.  The newspapers tell us, that a silver
vase, of great value, has been presented to him by his neighbors
and patients, bearing  an inscription, which affirms, that he has
had under treatment more than  three hundred patients without
a single death.  His plan, as described in his publication, con-
sists in the free exhibition of calomel, capsicum and camphor.
  It may be observed, generally, that in the doubtful and tenta-
tive management of this terrible pestilence, to which even the
most sagacious and scientific  physicians were  driven, those
prescriptions have obtained most  reputation which  contained
some or all the articles thus mentioned.   Of these, perhaps, the
capsicum  was,  at least  in  the  Southern and South-Western
parts of our own country, the most relied  on, and has been
combined  with morphine, quininer aether,  etc.  I was much
pleased with the effeet of a formula, which I frequently exhibi-
ted, differing from Cartwright's chiefly in the addition of opium
or morphine.   The quantities of  camphor, calomel, capsicum,
and morphine, were carefully adapted to  the age of  the patient
and the apparent urgency of the  case.   If any symptoms of
narcotism presented themselves,  I omitted the opiate  and substi-
tuted ammonia.
  Some writers have fallen  into the error of attributing the
cerebral torpor or comatose condition of the latter stages of
cholera, to the  previous use of  narcotics.  The  fallacy of this
notion is evident, from the fact, that these tokens of sensorial
disturbance have been most strikingly  notable,  and  of most
frequent occurrence, in  those parts of the world where opiates
were  least confided in, as among the Broussaians  of France,
and the Homoiopathists of Germany.  But it is  easy to satisfy
ourselves  on the  subject by experiment.  I saw this condition
exquisitely  developed  in several  patients who  had taken no
stimulant, and  to whom I had  suffered  no  anodyne to be ad-
ministered.
  I repeat, that I  regard this pathological  state, as a part of the
full  history of cholera—as  one,  indeed, of its  characteristic
stages.  It is not  shown, of course, when the patient dies in the
first or congestive stadium, or sinks, under the exhausting dis-
charge of fluids, into  collapse or promptly  fatal  prostration, or
is suddenly put an end to by vehement  and universal spasm* 
DIARRHOEA.
99
Nor do we  meet with it when we  have been successful in ar-
resting  the  progress of disease, and substituting remedial and
healthy re-action and excitement for the series of irritations and
inflammatory lesions and obstructions to which its current tends.
So, to compare small things with great, we may put a stop to a
paroxysm of intermittent fever, in the cold stage—the stage of
incubation which ushers it in, or in  the hot stage; by bringing
on, in the first, a recuperative re-action, and,  in the hot stage, a
remedial instead of the impending  morbid cutaneous determi-
nation and relaxation.
                    CHAPTER X  vVIIL

                         DIARRH05A.

   That disorder of the bowels  which has received this signifi-
cant  title, is so frequent an attendant  upon other diseases, that
 many writers, with the great Cullen  at their  head,  have ex-
 pressed  considerable reluctance  to give it place as a distinct
 malady in systems of nosology.  I have not hesitated a moment,
 on this point.  Diseases are not palpable to us, unless as a series
 of cognizable symptoms, effects of certain definite causes; and
 it is  in  this combination of cause with regular and uniform
effect, that each disease, practically considered, must be allowed
to consist.  In the case now before us, there is doubtless present
some peculiar and characteristic  condition of  the mucous mem-
brane lining the  intestinal tube,  as exhibited by the  increased
secretion from its exhalent vessels,  and the consequent or symp-
tomatic  increase  of peristaltic  action of the muscular tunic of
the same tube.
   Diarrhoea, then, may be defined to consist in morbid frequency,
fluidity and vehemence of the  alvine evacuations.   These cir-
cumstances  are usually connected  with pain  and griping pre-
ceding each motion, and  more or less relieved by it.  For the
most  part,  there  is  loss  of  appetite and  gastric  uneasiness, 
100
DIARRH03A.
 amounting occasionally to nausea and vomiting, perhaps.  The
 tongue is furred and whitish—the  pulse small and rather fre-
 quent, but  free from  febrile irritation;  there  is  early loss  of
 strength, and when the discharges are abundant, or the attack is
 protracted, emaciation  goes on to a striking degree.
   Nosologists have made a variety of distinctions in diarrhoea,
 founded upon  the  causes by which it is brought on, and upon
 the nature of the fluids voided;  thus, we have mucous, serous,
 lienteric, bilious and gypseous  diarrhoeas.   These phrases ex-
 plain themselves with two exceptions.  Lientery is an old word,
 referring to  that looseness of the bowels connected with almost
 total  defect of digestion of the food taken, which passes un-
 changed, or nearly so,  though mixed with fluid.  Gypseous di-
 arrhoea is a  phrase of Good, who takes for granted the calcare-
 ous nature of the white or chalky discharges sometimes passed.
 This assumption is, as  far as we know, unfounded, for no chemi-
 cal proof is offered, that a secretion so improbable and unnatural
 has taken place from the intestinal vessels ;  and the color may
 be owing  to defect of  bile, or the presence of much  albumen.
 The same writer speaks also of  a variety which he denominates
 tubular diarrhoea—membranous flakes,  of different shape and
 size, coming away, some of them moulded upon the inner surface
 of the alimentary tube.  This is a  rare phenomenon.  I have
 never met with  it, unless following or connected with a high
 degree of  inflammation of the  membrane, as in enteritis proper
 and  in dysentery.   I  cannot regard it either as correctly con-
 sidered, a  form of diarrhoea, or even  as one of the symptoms of
 that affection.
  The Causes of diarrhoea are numerous and diversified.  In a
 general way, we may affirm, that it  is likely to follow the en-
 trance into  the bowels of anything which has bid defiance to
the solvent and assimilating powers of the gastric fluids. Thus,
the husks and seeds of fruits, rarely fail  to  promote the alvine
evacuations, and  are used,  figs for  example,  and  unbruised
mustard seed, as laxatives, by many invalids.  Undigested food,
under whatever circumstances, whether the failure  be  owing to
weakness  of the stomach, permanent or  temporary, if not got
rid of by  vomiting, is  apt to excite diarrhoea, and thus  promote
its own expulsion.   Not only the husk and seeds, but the juices 
DIARRH03A.
101
of many fruits, and the  substance of many vegetables, are irri-
tating and laxative to those unaccustomed to  their use as diet.
Indian  corn, cabbage, the  sweet potato, the  beet, apples, pears
and berries, may be enumerated as showing  this quality.   The
waters of many sections of country are purgative to strangers.
I need not do more than allude to the long catalogue of cathar-
tics to be found in treatises of Materia Medica.
  It usually occurs, that diarrhoea excited by these modes of
irritation, terminates promptly;  the morbid causes having  pro-
cured their own expulsion, by the peristaltic action  which they
have excited,  the  disturbance  and ailment  gradually  subside,
health being at once restored.   On the  principles of revulsive
derivation, with which you are all familiar, and which  you can
readily apply here, many slight indispositions of which the pa-
tient had complained previously, are found to be  thus  relieved,
and he enjoys better  health  than he  did  before  the attack.
Hence diarrhoea, in its milder form, has come to  be  regarded as
a salutary sort of malady,  and its spontaneous appearance  often
looked  upon as critical.  It was easy, and not  irrational to rea-
son a little farther,  and infer  that its artificial  production by
cathartics, was likely to prove beneficial  in  disease generally,
and thus the extensive  employment of this  class of medicines
is accounted for.  Hence also, the use of cathartics as preventive
of certain ailments—the habitual use of "spring physic," and
other domestic prescriptions, and the currency of the maxim so
pithily expressed by a Scotch physician,  that to live comfortably
in  this  world, and prepare  thoroughly for the next, it was  only
necessary to "keep the conscience clear  and  the bowels open."
 Against the whole  tissue of these ancient  opinions,  the modern
school of Broussais and his followers, has set  itself with a zeal
worthy of a better cause, and with  great ingenuity and  equal
bitterness, has endeavored to prove, that  the mucous surface of
the intestines,  instead of being  the best  outlet of disease,  is the
readiest of all its points of entrance and invasion.  But truth is
a rock  against which the  waves of error and innovation  dash
themselves in vain.
   There are other causes of diarrhoea besides those which direct-
ly affect the alimentary tube.   The ready reciprocity of action or
impression which connects the cutaneous surface and the abdo-
        9* 
102
DIARRHOEA.
minal viscera  is matter of familiar  attention, and  we  are here
presented with a striking  example  in  illustration of it.  The
skin, when in  a moist and perspirable state, being exposed to the
influence  of a damp  or cold atmosphere, its  vessels undergo a
severe constriction, the fluid  that filled them being expelled;
the cutaneous transpiration is obstructed  or checked, and often
obviously vitiated in  quality, and determination of blood neces-
sarily takes place to the internal organs and surfaces.  Particular
predispositions,original and accidental, permanent and temporary.
decide the current of  these internal determinations.   If the bow-
els receive the full shock of the morbid impression, we may have
either enteritis or diarrhoea, or dysentery or  colic,  according to
the various modes of  morbid action which may be excited. The
irritation affecting the mucous surface expends itself sometimes
on the  secretory vessels, and  there is an  inordinate effusion of
somewhat vitiated mucus,  perhaps  mingled  with serum;  this
excites, by its presence and distention,  the peristaltic movement
of the muscular  structure  of the tube, and is  expelled.  The
discharge  is often so  acrid as to  occasion a burning pain with
tormina, as it passes  along the alimentary canal, and give rise to
annoying tenesmus.   Nay, as the  upper lip is inflamed  by the
coryza of catarrh, so the anus and  neighboring surface may be
inflamed by this discharge.   From a supposed analogy referring
to  the similarity of  cause, of suiface affected,  and of effused
fluid, some have entitled this catarrhal or rheumatic diarrhoea.
   Morbid impressions made upon the liver, whether mediately or
immediately,  sometimes occasion a large  secretion of vitiated
bile, which either by  its  inordinate amount, or some change in its
qualities, becomes  a  source of irritation  to  the intestines, and
produce what is not  improperly distinguished by many writers
as a bilious diarrhoea.  This variety of the disease, it is evident,
may  occur under a great diversity of circumstances, and show
itself during the existence of many maladies, sometimes adding
to the danger, and sometimes regarded as critical and salutary.
 Sympathetic or symptomatic diarrhoea is of frequent occurrence
 whether from extension or metastatic transference of morbid irri-
 tation.  We meet with  it as the result of repelled eruptions; at
 the subsidence of the exanthemata, as  when measles are drying
 away  upon the skin;  in  irregular gout,  and occasionally  in 
DIARRHCEJU                     103
rheumatism.  It supervenes also pretty regularly during the last
stages of certain diseases, as in phthisis pulmonalis, and consti-
tutes, so to speak, the "initiatory stage" of others, as in epidemic
or malignant cholera, and sometimes of dysentery.
   Diarrhoea, I have said,  exhibits  in a very great majority of
cases, a disposition  to  spontaneous  subsidence, either from the
expulsion by alvine  discharges of the crude and irritating mat-
ters which had given rise to it, or from the relief, to the disorder-
ed vessels  of the mucous surface, by the effusions  which they
pour forth.  This relief, however, does not always attend;  the
irritating cause is not always got rid of in this summary manner,
but sometimes originates a degree of irritation which progresses
from one step  to another, until inflammation being  lighted up.
we have, on the one hand, dysentery; or, on the other, a tenacious
habit of morbid action is acquired, and the disease  runs into a
chronic form.   This is a singularly obstinate and unmanageable
affection, bidding defiance to  our best remedies, and enduring,
through an indefinite protraction, from a few weeks or months
to several years.  Under these  circumstances, the condition of
the patient is truly to be pitied, all capacity of comfort or enjoy-
ment being totally destroyed,  and a gradual and prolonged atro-
phy and exhaustion  leading him  downwards   to a  lingering
death.
   Prognosis.   In its early stages, diarrhoea is very rarely diffi-
cult of cure.
   Treatment.   In  general, perhaps, it  might suffice to put the
patient in a recumbent posture, and at rest, for muscular motion
and an erect attitude favor, as all nurses know, the disposition
to inordinate frequency of alvine discharges, and to inculcate
abstinence from every thing but fluids adapted to quench thirst
if it be present, and even these should be  taken in very mode-
rate amount.   A mild anodyne diaphoretic will seldom fail to
remove at once every unpleasant symptom ; a small dose of the
elix: paregoric or tinct: camphor is often used.
   Few rules in practice have been more generally received than
that which advises the exhibition  of some  gentle cathartic in
incipient diarrhoea; and this homoiopathic maxim is applied in
 all instances, from whatever  cause arising, and with whatever
symptoms attended.  The object avowed is here two-fold ; the 
104
DIARRH02A.
purgative is supposed, on the one hand, to carry off all crude ov
feculent  matters which may be  present within the  canal  and
acting on any part of its  surface, as  a source of irritation ;  and
on the other, by soliciting a free effusion from the excited secre-
taries to diminish the irritation present^ whether primary or sym-
pathetic.  Now, although I will not deny the propriety  and  effi-
cacy of the cathartic in particular instances, yet I cannot recon-
cile  myself to its general  or  promiscuous  administration.   A
distinction may, for  the most part, be drawn, without difficulty,
between those cases in which it is indicated, and those in which
it is  not  admissible.  Where indigestible or improper articles of
food had  been takers, and there was  reason to believe they  had
not  been expelled, but remained within  the  digestive tube, I
would not withhold a mild  laxative.   So also, if on inspection
of the evacuations, they were found  to contain no feculent mat-
ter from the first, or to present no trace of bile naturally  mingled
with them, being white or clay colored, I  would prescribe a ca-
thartic.  Some care is necessary in the selection of a proper ar-
ticle or formula.  The  drastics should be avoided, and the least
irritating laxatives employed.  Rhubarb has been long consider-
ed entitled to  a preference.   I usually select, when  the  stomach
will  bear it, castor oil, which operates at once mildly and freely.
If it be offensive, I combine rhubarb  either with the sal: epsom,
adding a little aromatic, or  with calomel.  This latter combina-
tion  is specially adapted to cases  in which the liver is torpid  and
the stools clay colored, from defect of the hepatic secretion.  A
few  grains of the mercurial, with a proper dose of opium, gives
quickest relief under the opposite condition  of that large  and
important gland, when it is pouring out an inordinate amount of
its secretion, or gives it  forth vitiated in  any manner in its
qualities.
  Experience has long since proved  the value of the aromatics,
in attacks of diarrhoea.  Mint, aniseed, ginger, etc., may be  em-
ployed in mucilaginous solutions ;  with the addition  of a slight
opiate, they relieve the gripings  which attend, and  frequently
put an end  to all complaint  on the part of the patient.  These
remedies having been prescribed during  the  day, if bed time
should arrive and find him  still annoyed with his looseness, let
him take a full dose of Dover's powder—ten, twelve,  or fifteen 
DIARRHCEA.
105
 trains, applying for an hour or two, warm flannels wrung out
 of brandy and laudanum, or a warm mustard poultice to his ab-
 domen.  A hot pediluvium will be a useful adjuvant,  especially
 if the skin be harsh and dry, or the  temperature of the surface
 unequal.  The warm or hot bath, if convenient, may be resorted
 to with great advantage.  I employ occasionally, in cases which
 seem disposed to protract themselves, the Dover's powder com-
 bined with a small amount of rhubarb, at proper intervals through-
 out the day.   Under the use of this formula, the stools will
 assume a degree of consistence, and be passed in  diminished
 number,  without pain or  inconvenience.
   Many  practitioners are in the habit of commencing the treat-
 ment of  diarrhoea with an emetic,  which they  occasionally re-
 peat, if necessary; they assert that the morbid train of associated
 actions, in which the disease consists, being thus early broken
 in upon,  health is at once or very  readily restored.   I have no
 objection to this method,  but that it is, in relation to the majority
 of cases, unnecessarily harsh, and that the  exercise of a little
 forbearance, or the employment of the gentler  remedies, above
 pointed out, will answer every purpose.   The emetic is indica-
 ted, if from the commencement of the attack the tongue is thickly
 furred, with gastric oppression and  anxiety, and  ineffectual at-
 tempts to vomit.  Ipecacuanha should,  I think, be preferred, as
 least irritating, and yet  thoroughly effectual in  its  operation.
 The emetic may be prescribed at any period, during a protracted
 and obstinate case,  for the purpose of exciting  new  and revul-
 sive action, by the sudden impression or shock which it gives to
 the system.   Some more active and harsher article must be here
 added  to, or substituted for  the ipecac:,  as  the  tart:  antimony,
 sulph:  cupri and sulph: zinci.  This last is highly recommended
by Mosely,  whose  well  known "solution" will  be frequently
found useful.
  In all cases of prolonged diarrhoea, the use of absorbents and
astringents will be absolutely demanded.  The prepared chalk
may  be mingled with our mucilaginous  solutions, and made the
basis of our formulae.   To this may be added the tinct: kino, in
sufficient quantity.  An extensive experience enables me to con-
firm all that its eulogists  have said,  in  praise of this valuable
article.   Pemberton in England, and Bally in France, have writ- 
106
DIARRHOEA.
ten much concerning it.  The former believed it to be possessed
of some  specific  virtues,  and  thought it  an astringent, only
when diarrhoea is present,  not universally.   He prescribed it
in substance, and combined it with opiates.  Bally has given us
in detail,  the result of numerous experiments made with it, at
La Pitie, in Paris.  In recent cases,  it almost invariably effected
a cure promptly.   He succeeded with it in one case, of not less
than three years'  standing.   In chronic  diarrhoeas,  it  seems to
have been equally beneficial, whether they were  or were  not
attended with febrile and inflammatory symptoms.   The writers
of the new school, without venturing to impugn the statements,
^'confess their surprise at such results."   Other astringents have
also their advocates.  Catechu, the  rind  of pomegranate,  the
decoction of blackberry root,  logwood and galls, are among vege-
tables, the most generally trusted to.  It is well to be aware that
a change from one  to  another  of these, is useful  in  obstinate
cases, the first losing its influence  by habit.  Alum is highly
commended, among others, by Cullen; some prefer to  adminis-
ter it in substance, combining it with nutmeg or any other aro-
matic ; but in general, the whey is preferred.   The acetate of
lead, is a very favorite prescription  with  me.  Combined with
opium, it will scarcely ever  fail in any ordinary case,  and even
when we have to contend with the most tenacious protraction
of the disease, it is our best resort.   The doses may  be  increased
from one to five grains, adding opium pro re nata.   The sulph:
cupri is highly recommended by Elliotson and some other Bri-
tish practitioners.  They combine it often with  opium, and re-
gard it as best adapted to cases of long standing.  I have not often
seen it beneficial.  The nitrat: of silver is more serviceable in
my hands;  it is indicated, and will do good service, when there
is  deep  fiery redness of the  lining  membrane of the mouth,
tongue and fauces, or aphthous ulceration of the mucous surface.
   In the meanwhile, we shall derive much advantage from the
exhibition of our astringents as enemata.  Opium and the acet
 plumb: are here best adapted, and are best given in small quan-
 tities of starch, or any other glutinous or mucilaginous solution
 gently thrown up into the rectum.   On the principle of revulsive
 determination by counter irritation, some  apply blisters to the
 abdomen in troublesome cases, and others to the extremities, the 
DIARRHOEA,
107
wrists and ankles.  With similar  views,  perhaps, or it may be
merely as a powerful alterative, a few of our American physi-
cians, as well Northern  as Southern, have  strongly  urged a
resort to the mercurial treatment, carried to the extent of a mode-
rate salivation.  I have not, in any instance,  perceived from it
the beneficial effects which they have  promised us, but on the
contrary, have found it productive of a great degree of suffering
and inconvenience, which was not  compensated for.   1 do not
now speak, you will observe, of its exhibition in those examples
of diarrhoea, which are complicated with, or  depend upon  vis-
ceral obstruction and derangement;  in these,  it  may be indica-
ted, and may prove indirectly advantageous.
  The mineral acids have  also been proposed  here, partly as
alteratives and partly as astringents, and  it is affirmed, have been
occasionally of great service.  The  nitric,  sulphuric and  mu-
riatic are used.  I have,  now and  then, seen a patient derive
some benefit from the sulphuric, the vitriolic elixir a combina-
tion with some aromatic, being the  formula generally chosen.
I have thought it succeeded best, when administered with a light
tonic, as cinchona or quassia.
  In chronic diarrhoea, the general management of the patient is of
great importance.   His diet should be light, but nourishing, and
even gently stimulating, consisting, when the stomach will bear it,
of solid food, such as biscuit, toast, soft boiled eggs, poultry and
tender beefsteak.   If he cannot take these, give him broths pretty
well seasoned, jellies,  sago, arrow root, or  rice  gruel, rendered
cordial by spices.  Nothing acescent should be allowed him; fruits
and crude vegetables must  be altogether  forbidden.   His drinks
should be in small amount, no more fluid being  taken at any
time than is absolutely necessary to quench thirst, all  superflu-
ous fluid being laxative.  A little sound madeira or sherry  may
be permitted, or perhaps, in preference, port wine.
   Great advantage has attended the use of the flannel  compress
on the abdomen, and the roller, as advised by Dewar.
   Your patient should guard himself carefully  against all vicis-
situdes of weather, and avoid  every exposure to cold and mois-
ture.   Let  him exercise much in the open air, if he is able • let
him leave his home and go through a long  journey, on  horse-
back, should his strength permit, seeking a warm and dry cli- 
108
DYSENTERY.
mate;  finally, if all these means fail to restore him, send him on
a long sea voyage.  However we may explain the fact, no one
doubts that the general effect of confinemement on board  ship
is, in a healthy man, to render the bowels costive ; so  in diarr-
hoea merely habitual, the very first access of sea sickness is often
perfectly effectual in putting an end to the diseased propensity,
and restoring tranquillity, or even inducing torpor of the bowels.
                     CHAPTER XXIX.

                        DYSENTERY.

   Althouch at the present day, the  seat and nature of this
painful malady are well known  and understood, yet there has
been much dispute among  pathological writers of past times
concerning  its proper classification.  Akenside, Richter, Stoll
and Parr, no  inferior names among our moderns, agree with
Coelius Aurelianus, and other ancient authors, in regarding it as
a rheumatic affection of the intestines.   Sydenham viewed it as
"a fever," to use his own coarse but  significant phrase,  "turned
in upon the guts;" Cullen also admits it among fevers, but adds
contagiousness, as an  essential characteristic ;  Linnaeus  and his
followers, ascribe it to the irritation of a specific  animalcule, the
acarus dysenteries ;  Sir G. Ballingall treats of it as mere colitis;
Chapman and Caldwell, of our own country, look upon it as
primarily a gastric affection ;  while James Johnson attributes it
to cutaneous and hepatic derangement and disorder.  Syden-
ham, notwithstanding his pithy definition given above, describes
two forms of dysentery; the first,  simple dysentery without fe-
ver ; the second, of a  more violent nature with fever ; and this
distinction is received  by Good, and  incorporated into his sys-
tem.  Eberle differs little from Ballingall, except  that he con-
siders it a mere diffused inflammation of the intestines.  Let me
call your attention for  a moment, to the  inaccuracy and want of
correct diagnosis implied in these  definitions,  which  confound 
DYSENTERY.
109
dysentery,  on the one hand, with diarrhoea, and on the other,
with enteritis.  It is true,  as I  have already stated, that diar-
rhoea is the initiatory state of many  dysenteries; but some at-
tacks come on without  any previous diarrhoea, and diarrhoea
may and does  exist,  without  inflammation  of the  intestines;
nay, according to my  views, it ceases to be simple diarrhoea,
when this has supervened.  It is therefore true, that inflamma-
tion of the mucous  coat of the  bowels is' an essential element
of dysentery; but there are other elements equally essential,
without which, it would not be dysentery, but  mere enteritis, a
confusion which  no physician is likely to make at the bedside.
  The violent  peristaltic  movements of the bowels, irregular
and spasmodic; the peculiar secretions  and  foul discharges of
mucous, sanguinolent and purulent matter; the shifting pains and
urgent tenesmus; these are as  uniform parts of the history of
dysentery,  as the mucous  inflammation, and they surely do not
belong to the description of enteritis.  Like enteritis, dysentery
is essentially pyrectic also;  but the constitutional  derangement
differs exceedingly, in the two  cases.  Writers dwell upon the
small, oppressed, sinking pulse of intestinal inflammation, so
usually connected with true gastritis.   "Animal life  is hurt and
lessened," says Hunter.  In dysentery, on the  other hand, the
pulse is full and bounding,  and the general excitement,  for the
most part,  is of open character  and high  grade.
  Sydenham, Good, and  such others as  treat of a dysentery
simple, and without fever, have committed  an  error, according
to my views, in mistaking for it an unmanageable form of  diar-
rhoea, as even Elliotson speaks of diarrhoea, with  ulceration of
the intestines.   The  nature of the  morbid  alvine  discharges,
and the great variety of appearances presented  by the evacua-
tions, have  led  them  astray,  and  occasioned the confusion
among authors, who assert that  it is a  matter of difficulty to
distinguish between diarrhoea and dysentery.   In practice, it is
true that we shall meet with cases of a transitive character, par-
taking of  the symptoms of both, and it  may be,  that we shall
doubt for a short period, as to  the proper designation of such
cases ; but our doubtful or erroneous nomenclature,  will  by no
means lead us to error in the treatment, nor perhaps  even in the
general diagnosis.  *When the symptoms  are thus mingled,, there
      vol. n.—10 
no
DYSENTERY.
must in all likelihood, be some complication in the nature of the
attack, requiring a corresponding  modification in  our plan of
management.  Theoretically,  the diagnosis is easy.  Diarrhcea
consists in morbid secretion  and vehement  peristaltic action,
the results of irritation of the mucous digestive surface.  Dysen-
tery implies  inflammation,  with its  consequences—ulceration,
hemorrhage and  morbid secretion, with spasmodic action; an
interruption of peristaltic movement by constriction  of, or in
some part of  the intestinal tube, being a frequent attendant.
  Symptoms.  Dysentery is a painful affection of the bowels',
with fever; there  is a feeling of soreness in the abdomen, with
occasional griping and tenesmus;  there  is strong propensity to
stool, recurring at short intervals, the dejections being mucous
and bloody;  foeculent matter is discharged seldom and  in small
quantities, sometimes not at all.
  The attack sometimes commences with a chill;  at others, the
pains in  the  abdomen  precede; not  unfrequently,  there is no
rigor, but after an uncertain period, the  skin  becomes  hot and
dry ; the pulse is frequent, hard, and full and  tense ; the tongue
is covered with a thick  yellowish or whitish fur; there is thirst
with restlessness  and jactitation ; dejection of  spirits and loss of
strength,  and great  anxiety and distress about the praecordia.
As  the disease progresses,  the alvine discharges  become very
frequent  and offensive, attended  with excessive  tormina and
tenesmus, unrelieved by the evacuations, which consist as above
described, of  a thick mucus, resembling jelly colored with blood,
or in the  latter  stages,  of a watery serous fluid highly fetid,
resembling the washings of putrid flesh ; pure blood is sometimes
passed in  considerable quantity.  Small round lumps, sometimes
consisting of hardened foecal matter, and sometimes  of fatty
and of fibrinous substance,  which have obtained  the  technical
name of scybala, are occasionally voided, and generally to the
relief of the patient.  The  presence of these  scybala,  is, how-
ever, by no means so common an occurrence as you would infer
from the mention of them in your books.
  The intestinal  pains  are, in many cases, intolerably severe,
inducing  great  debility  of body, and  light  delirium;  the stom-
ach sometimes  becomes very  irritable.   Mortification  occasion-
ally ensues, the pain ceasing suddenly, offensive stools flowing, 
DYSENTERY.
Ill
almost without interval, from the anus, unnoticed by the sick;
and death soon relieves  the sufferer from his torments, and  the
attendants from an object, now loathsome to look upon.
  Such is the usual course of the symptoms, but the various
cases met with, present, from time to time,  many irregularities.
Thus,  I have seen fatal  dysentery, with very little abdominal
pain, the patient seeming to sink  merely under the debilitating
effect of the large and frequent discharges of blood and  mucus.
  Necroscopy.   Autopsic examination uniformly reveals to us
all the appearances of high inflammation of the intestinal mu-
cous surface ; patches of this tissue are deeply injected and soft-
ened, and if the  case have been of any duration, ulcers are founds
of various size and shape,  extensively  diffused.   It is to their
erosion, that we  attribute the free hemorrhage,  most generally
venous, but in rare instances arterial also, that occur.  The ca-
nal is sometimes found constricted,  especially  at  some  part of
the colon.  Gangrene and sphacelus,  sometimes separating con-
siderable lengths of the tube, are known to have taken place.
  Causes.  Dysentery occurs sporadically, and as  an epidemic ;
in the  latter form, its ravages  have at times been dreadful in-
deed.  Cullen, as  I have told you, asserts it to be uniformly and
essentially contagious, and the doctrine has received very able
and extensive support from  others.   I myself have never  met
with a single instance, which I could attribute  fairly  to  this
source.  I cannot  consent, however,  to set aside the recorded in-
stances and proofs of this opinion,  coming from  the best au-
thority, and derived  from a most extended observation.  And
even among those who refuse to consider dysentery as in itself,
uniformly or essentially contagious,  there  are few who doubt
that it may assume this character or quality,  under particular
circumstances—as when  in camps,  jails,  hospitals, and other
crowded and ill ventilated places, the attendant fever takes the
typhoid type.   Indeed, we find that it is chiefly under such con-
tingencies, that  this contagious  property  is contended to have
been active in spreading the infection.
   In this climate, dysentery belongs to the list of autumnal mal-
adies,  and is produced by all the agents  which give rise to bili-
ous attacks, as the phrase  is—cholera, bilious remittent, inter- 
112
DYSENTERY.
mittent and cholic;  malaria,  for  example, exposure  to  sudden
and unexpected alternations of temperature, to cold and moist-
ure ; the chilliness of a dewy night, after a hot day; wet cloth-
ing, damp beds, sleeping on wet ground, as when troops bivouack
in the  fields.  It developes  itself, occasionally, in combination
with our malaria fevers, both remittent and intermittent,  adding
very much to the suffering and danger of the patient.  The most
malignant and rapidly fatal  case of country  fever, which has
ever fallen  under my care, was of this nature.
  A strong predisposition to dysentery, is generated by continued
fatigue;  by long use of bad  and innutritious diet; by confine-
ment to bad air, whether vitiated by putrid animal or vegetable
effluvia.  Under the influence of these causes, arise those dys
enteries which prevail with fatal sway in particular localities,
as in ships  and prisons, depopulate whole communities, and drive
armies from the field.
  I have not known it, in this city, so rife as to deserve the title
of epidemic, though in particular seasons, the  attacks have been
both frequent and severe.  Malaria is now universally regarded
as one of the causes of dysentery.   In all hot climates, it origi-
nates so evidently, from the same contingencies that produce the
endemic fevers, connected with hepatic derangement, as  to have
received from  writers  on the  subject, titles expressive  of this
obvious connection; as bilious  fever,  with flux; hepatic flux,
etc.  Careless examination of the alvine  discharges,  has led to
the belief of a frequent combination of dysenteries with vitiated
secretion of abundant bile;  but this, I agree with James John-
son, is not  likely often to happen.   I am not certain that I have
ever met with it, though I will not deny the possibility of its
occurrence.
  Dysenteric evacuations are, as I have said, exceedingly diver-
sified  in their appearance.   Mortification has frequently been
inferred, but too rashly, from the peculiar fetor and offensiveness
of the sanious and ichorous fluids poured out; and the membra-
nous films thrown off are assumed toconsist of sloughing portions
of the  villous coat of the intestines.  But recoveries happen after
both these  phenomena  have  been noticed, and so readily and
perfectly, as to be altogether inconsistent with the  idea  of gan- 
DYSENTERY.                     113
grene of the alimentary tube,  The films, I suppose to be simi-
lar to the membranous or fibrinous deposites met with in trachitis.
and in the tubular diarrhoea of Good.
  It is not easy to understand how  the sebaceous lumps found
in dysenteric stools, are generated,  Sir  Edward Home has  en-
deavored, it is true, to prove that it is  among the ordinary func-
tions of the intestines to secrete fat; but here the  healthy func-
tions and secretions are all interrupted and obstructed.  I told
you that the presence of scybala  is not, by any means,  so uni-
form or frequent a circumstance, as you would infer from  a
perusal of the books on the subject  In a considerable majority
of the cases which have come under  my care, they  have  not
been  observed, though it is my  constant  habit to inspect  the
alvine discharges, and. to enforce the same attention upon the
nurses employed.  Ulceration and  erosion of the intestinal tu-
nics, give rise, at times, to proper  hemorrhage, from the lesion of
some large vessel.   Mosely affirms  pure arterial blood  to have
been voided in a stream, at brief intervals, from  such  lesions,'
and the patients to have thus bled to death.  I have myself seen,
more than once, considerable venous hemorrhage.  The ordi-
nary mixture of blood with  mucus, seems  to be  the result of
the yielding of the vessels upon  the villous surface, to the in-
tense inflammatory congestion,  by diapedesis or  transudation,
without ulceration, in the  first instance, or  breach  of continuity
by rupture.  In one  fatal case, in which I took  great interest,
fallacious hopes were frequently  aroused  by the  alternation of
bright yellow fluid and feculent stools, interposed among the
foulest sanious and muco-sanguinolent evacuations.
  Prognosis.  The prognosis in dysentery is in the  greater
number of instances readily drawn, depending, for the most part,
upon obvious conditions evidenced by unequivocal symptoms.
   In the sporadic cases which so frequently occur in all seasons
and in every climate from the application of transient causes, such
as exposure to cold and moisture, and the use of articles of food
of indigestible and irritating character, the prognosis is generally
favorable.   Allowance  however  must be made for the constitu-
tional peculiarities of the patient, who  is likely to suffer much
and run not  a little risk, if subject to frequent attacks of diarr-
hoea or other bowel complaints,
       10* 
114                     DYSENTERY.
  Epidemic dysentery may be  pronounced to be always a seri-
ous and dangerous malady, and in  low, damp situations is fatal
in pretty large proportion.   The autumnal epidemic dysenteries
of hot climates are always  dreaded, and with just cause.
  The greatest amount of mortality, however, is met with in
the typhous form, which is  generated in crowded and ill-ventila-
ted places, as  in jails and prison  ships, and spreads itself in
camps, where  the sick are  of necessity deprived of the proper
solace and  comfort of good shelter and  careful nursing.  It is
under these circumstances that it has exhibited the most obvious
proofs of a contagious character and property, a character which
I am disposed to think almost always results from typhoid com-
bination with  every other form of  disease.  But of this I have
spoken before.
  Among  the most  important  of the  symptoms to which we
look as affording us a  test of the true state  and probable pros-
pects  of our patient, I am inclined to regard the degree of tenes-
mus present, and the frequency of the calls to stool.  From the
latter, indeed,  we draw our least fallacious conclusions.   Tenes-
mus,  when peculiarly urgent, and  it is sometimes ceaseless and
intolerable, gives a similarly unfavorable  impression, as to the
condition of the bowels. The occurrence of apththoe in the mouth,
or a deep redness with smooth and dry state of the lining mem-
brane of the cheek,  and gums, and the  tongue,  offer a gloomy
presage.  Hiccup, a low delirium and  a relaxed state  of the
sphincter ani,  are, for the most part, immediate precursors of a
fatal issue.
   In  a gentleman of this city,  who died some years since, this
 total  relaxaton of the  sphincter occurred as long  as  four days
 before his  death, the orifice being permanently dilated to the ex-
 tent of one-half or three-quarters of an inch.  From the begin-
 ning of the attack, I was led to entertain a gloomy presentiment
 in  this case, on account of the urgent and ceaseless desire to go
 to  stool, which so annoyed him, that during  his whole illness he
 had not an interval of more than five to ten minutes.   Notwith-
 standing which, he never conceived himself  to be very ill, as he
 suffered very  little pain, speaking comparatively, had very little
 fever, with a tongue and pulse not strikingly altered, and retain- 
DYSENTERY.
115
ed his  muscular strength, and  a certain degree of cheerfulness
and hope to the very last.
   On the  other hand, we  infer a  favorable change in the pros-
pects of our patient, when we observe a diminution in the degree
of tenesmus, and  the urgency  and frequency of the returns of
the propensity to  stool, the intervals  being attended with more
notable relief  of the abdominal uneasiness, the bowels becoming
less tender on pressure, the lining membrane of the mouth and
tongue less red, and moister, with a more natural coating on the
latter, the  evacuations  improving  in  appearance, by assuming
the feculent aspect  and odor, the surface of the body becoming
of a more regular and uniform temperature, with general perspi-
ration  and refreshing slumbers.
   I think  we may safely pronounce  dysentery to have become,
of late  years, a far  less formidable  and fatal  malady, than in
times past, thanks to the zeal  and talent of the British medical
officers of the  army and navy, especially, who deserve, for the
important  additions which they have made to our knowledge
of, and power over this, as  indeed, many other  diseases also, the
abiding respect and gratitude  of the profession.  Among these
writers, I  would  notice here the names of Pringle, Ballingall
and James Johnson; the  brief treatise from the pen of the last
of whom, ought to be carefully studied by all of you.
   Treatment.  The indications which are to-guide us  in the
treatment of  ordinary dysentery, whether sporadic or epidemic,
are clear and undisputed.   Our object is primarily, to  effect as
promptly as possible, the removal of  spasm  and the reduction of
inflammation, two parts of  the description of this disease, which
I have maintained to be uniformly and essentially characteristic.
As besides this inflammation and spasmodic state of irritation,
we have also almost constantly, a species of entonic hemorrhage
from  the intestines, there  cannot be  a reasonable doubt of the
necessity of venaesection.   Some physicians, indeed, have trust-
ed the management of dysentery entirely to the lancet, carrying
to an enormous extent their detractions of blood.  Among those
who  have spoken highly of this extreme venaesection,  and
boasted of their success with it, under the present circumstances,
are Dr. Whyte who treated the disease in Egypt, and Dr. Somers
on the European  peninsula.  But although I believe there is no 
116
DYSENTERY.
case in which the remedy is more distinctly called for, and in
which, when judiciously employed, it will do more obvious ser-
vice, I cannot advocate the indiscriminate and copious blood let-
tings thus extolled.  Consider in each case the actual condition
of the patient;  calculate not only the force of local inflammatory
excitement, but  the tone, the resiliency  of his system ; the re-
sources of his constitution.  Reflect upon the danger of general
and irremediable prostration to which you may subject him, if
without  regard  to his capacity of enduring them, you  resort
rashly to impressive measures of inordinate  depletion,—nor
must you forget that if the morbid action prove too tenacious to
be thus unseated, and the disease goes on while the patient is in
this condition of artificial  debility, his prospects are gloomy in-
deed,  if not altogether hopeless.  Some obvious distinction may
however be noted.  Sporadic and vernal  dysenteries bear venae-
section infinitely better  than the epidemic  and autumnal  forms.
When of typhous character, and  spreading  by contagion, the
lancet is most clearly contra-indicated, and can do nothing but
injury.
  If you determine  in favor of the  propriety  of venaesection,
open  a large vein, and  do not check the flow of blood until it
has produced some sensible effect upon the patient, removing the
pain in the abdomen, and reducing  the vascular excitement.  In
autumnal attacks at least, you will seldom enjoy opportunity for
a repetition of the remedy.  The influence of our hot season on
the body, is such as to predispose the system to sink with readi-
ness under all modes of active depletion,  and you will often find
the strength  decline with great and frightful rapidity.   I do not
mention this to deter you  from the operation, but merely to in-
spire you with just and prudent caution.
  A great deal  of stress  is laid, by some modern writers, upon
the means of topical blood-letting, and they  are, no doubt, very
often  of great benefit, besides  that they are attended with little
risk of any coincident injury.  A large  number of leeches may
be laid to the abdomen, or, if these are not at hand, cups  should
be  applied pretty extensively  over the  surface.   The flow of
blood from the leech bites and  scarifications, should be promoted
by the employment of warm stupes, which also tend very much
to sooth and comfort the patient, and may, therefore, be perse- 
DYSENTERY.
117
vered in throughout the whole duration of the case.   I have
often had occasion to see very great relief to the tormina and
tenesmus given, by the  application of these warm fomentations
and poultices, which may, after a while, be rendered somewhat
stimulating by the addition of mustard or of hot spirits.
  Emetics  have been esteemed, from  the earliest times, among
our most valuable remedies in dysentery, and many physicians
advise their early administration in the incipient stages of the
attack, and repeated resort  to  them throughout its whole pro-
gress.  With those who regard the disease as a gastric  affection
primarily, the reasonings which have led to this practice, must
be irrefragable ; but, I will confess, that I have not  been satis-
fied  either with  their  pathology  or  therapeutics, having met
with frequent  disappointment, in  my hope of benefit from the
class of medicines thus highly recommended.   Wherever there
is present any considerable degree of gastric oppression, with
nausea or retching, and  a foul tongue, or the patient has been
living on a bad diet, or has eaten any thing acrid or indigestible,
which has not been evacuated, it may be proper to  unload the
stomach of such irritating crudities.   This is, however, so far as
I have seen, all that we can gain from the exhibition  of emetics;
the patient is rendered less uneasy, but no strong impression is
made upon his tormenting disease.  With a view  to procure
complete evacuation of  the alimentary canal, a  combination  of
some cathartic with the emetic, is a very  common domestic
formula,  such as  the mixture of sulph:  magnes: or sulph: sodas
with tart: antimon.  This rough  treatment is  sometimes suc-
cessful, when the case is attributable  to improper ingesta; and
sometimes, by the excitement  of an artificial cholera, the train of
morbid action is  interrupted, and by  the substitution of a new
disease, the first is put an end to.   Yet,  I  cannot advocate this
coarse method of cure, as it is sometimes unsafe, and occasion-
ally aggravates the intestinal irritation in a very serious degree.
  Purgatives, either alone, or in combination, are employed  by
a very large majority of  practitioners, without scruple; but  all
acknowledge the  necessity of making among them  a judicious
selection, and the risk of doing grave injury, by inattention  or
unskillfulness in this matter.   The purpose to  be aimed at,  is
the free  and  complete evacuation  of  the annoying  ingesta; (if 
IIS
DYSENTERY.
there be any,) and the foul secretions of the alimentary tube, by
means that shall not add to, but diminish, as far as possible, the
inflammatory and spasmodic  irritation present, and productive
of painful and often obstinate constriction, wThich, to overcome,
has  been considered as of great  importance.   To accomplish
these purposes, a great diversity of medicines and formulae are
proposed.  Calomel alone, is  prescribed by one ; another con-
joins it with opium, as an anti-spasmodic and anodyne ;  a third
objects to this  union, and prefers to  substitute hyosciamus as
free  from astringency, and therefore more likely to remove con-
stipation.   Antimonials are  highly  extolled  by Cullen, who
advises them to  be given in small doses, and at such intervals,
as to determine their operation by stool, and  not by vomiting.
With  this view, both  Dr. Young and Sir John Pringle, have
given  the weight of their powerful sanction to the exhibition of
the vit: cerat: ant.   Rhubarb, so unhesitatingly condemned by
Cullen, has nevertheless  its advocates, and is  very frequently
used, though chiefly in  combination.  Cleghorn, whose opin-
ions are  always  entitled  to  respect, speaks, without reserve, of
ipecac: as useful both by its emetic and purgative effects.  Play-
fair  administered it in  much larger  doses than we are accus-
tomed to employ, and, as he informs us, with very great success.
He gave the dose of 3SS. to  ~i., adding from 30 to 60 drops of
tinct: opii, keeping the patient for some  time at rest in a hori-
zontal posture.  He tells us, that  though  the  first portion was
sometimes rejected, the second was  almost invariably retained,
and proved gently and beneficially cathartic.   Clark exhibits
the  same  article  in the form of enema, and  bestows a warm
encomium upon its virtues as displayed in this  mode of admin-
 istration.  He orders 3iii. of the  bruised root  to be boiled in a
 quart  of water down to a pint, which injection may be repeated
 twice or thrice in twenty-four hours.  In both these last formulas;
 ipecac: is singularly effectual, we  are  told, in  relieving  spasm,
 and procuring free and feculent stools.   To this beneficial  ope-
 ration of ipecacuanha in dysentery, I  can indeed bear, from my
 own experience, the most decided testimony.   I combine it with
 ol: ricini, and can safely aver, that 1 know no purgative formula
 gifted with  equal, efficacy in the case before us.  In the  propor-
 tion of a grain or two grains of the  powder, mingled with  one 
DYSENTERY.
119*
or two tablespoonsful of castor oil, it will  rarely fail to relieve
the intolerable  tormina and tenesmus, and  obtain, what  is so
much  desired,  a free evacuation of feculent  matter, bringing
away from the bowels masses of scybala, and other contents that
have the appearance of having been long retained, to the  great
solace and comfort of  the  patient.
   Among the documents offered us, from time to time, by the
medical officers of the British army and navy, a highly intelli-
gent and useful body of men, none  do them more  credit, as I
have already said, than the papers which treat of this disease.
In the ships and armies under their care, they meet with it fre-
quently in all parts of the world, and especially, perhaps, in the
East and West  Indies, whose climates so  nearly resemble ours.
These  gentlemen agree almost universally in the recommenda-
tion of the mercurial  treatment  of dysentery, and display a  re-
markable  unanimity in speaking, in the warmest terms, of its
astonishing power over the disease, when  urged with sufficient
energy.  It has not been unusual, as I before stated, to prefer to
all others, the mercurial purgative, in the early stages of dysen-
tery, and many practitioners have continued to prescribe  it, at
intervals,  throughout  the  whole course of the  attack, either
alone or in combination with opium, with a view to its cathartic
operation and its ultimate alterative influence.   But, by the very
respectable authority to which I  am now referring, it is exalted
to the eminence of being designated as  our  principal and most
important remedy, capable of fulfilling,  alone,  most  or  all the
indications of cure, though certainly aided very much  by the
judicious application of auxiliary means.  They represent it as
a matter of much consequence, however, to prescribe it in the
proper  and effective dose.  If offered in  too  small amount, it
will often disappoint you by its inertness, or  vex you by giving
rise to  some irritation or uneasiness of the stomach or bowels.
We must administer it  largely and freely, so  as  to  produce a
prompt and forcible impression upon the system.  For this pur-
pose, scruple doses are recommended by Johnson and Cunning-
ham, who speak  of  this  as the  maximum,  and  caution  us   *
against any farther augmentation, as likely, in some manner, to
prove a source of injury.   We smile at this attempt at precision.
It is not permitted, at  the present day, to talk of a definite limit 
120
DYSENTERY.
in the exhibition of any article of the Materia Medica,  or  to
venture to predict the effect of whatever additions to the estab-
lished doses of ancient formulae.  Rasori, and his contra-stimu-
lant  followers in Italy, and  Cooke with  his Western school of
practitioners, in our own country, have been prescribing, every
day,  as familiar draughts  and  boluses, quantities of our  most
heroic  medicines, which, a  few years  ago, would have been
thought absolutely poisonous, and would have  rendered them
liable to indictment and trial for intent to murder.   But to re-
turn.  It is affirmed, that calomel, administered in this free and
bold manner, will, in the worst forms of dysentery, almost at
once alleviate the sufferings of the patient and  arrest the pro-
gress of the distemper, diminishing the tormina and tenesmus,
and lessening the propensity to go to  stool—that within a short
interval, that is from twenty-four to seventy hours, it will bring
on ptyalism, and that with the occurrence of sore mouth, there
will  coincide a striking and permanent subsidence of all the bad
symptoms—in fact, a removal of the disease.
  To  test  the correctness  of these strong statements,  and to
ascertain clearly the powers of the  remedy thus  eulogized, I
have repeatedly  selected, among our most threatening autumnal
attacks, cases in which I have prescribed nothing but calomel
in the  scruple dose, as above directed;  and thus far,  I may aver,
that  I have found the accounts given, of the proportional success
of this mode of treatment, faithfully true, having as  yet lost but
a single patient  among a  considerable  number thus managed
exclusively.   By the  mercurial, the  bowels  were  gently but
fully moved—the vitiated  condition  of the alvine discharges
corrected, and bilious and feculent evacuations substituted; and
ptyalism supervening  with its attendant influences, the sick
became convalescent  in  shorter time  than  I  have witnessed
under  any other course.
   But, gratified  as  1 have been, with the strikingly beneficial
action of mercurials, and their frequent adaptation to the neces-
sities of the case under discussion, I would, by no means, fall into
the rude, unscientific error of maintaining either the uniform or
the exclusive efficacy of any remedy in any disease.   You will,
without doubt, meet occasionally with cases in  which the plan,
so justly extolled, will be inapplicable, either altogether, or so far 
DYSENTERY.
121
as to render it an  unsafe reliance.  Certain constitutions bear
mercurials badly.   In some  stomachs, they produce oppressive
nausea; their purgative action upon some  persons, is  attended
by griping  and cramp, accompanied with  spasmodic affection,
perhaps, of distant muscles.   Some suffer  from an immediate
salivation, which, when the result of this sort of predisposition,
and arising from the first dose or doses, seems to be a merely
local evil, and unconnected with those general  changes in  the
state of the system which we consider alterative  and  thera-
peutic. Nay, you would not subject a patient to the sufferings
of ptyalism, in any instance, rashly or mechanically, without  a
due  regard  to the  exigencies of his  situation, and considering
conscientiously the question, whether  you may not relieve him
by easier methods.  Besides all this, we find the remedial action
of mercury on the system totally lost  by repetition, nothing of
its agency remaining but its cathartic and sialagogue effects.
  The employment of opium, in  some form of preparation and
combination, for the relief of the torments  of this harrassing
disorder, is almost universal; but I am disposed to regard it as
of higher value than a mere  palliative.   I have, perhaps,  ex-
pressed too  strongly the sentiment of its general reception  in
practice, some physicians having gone so far, on  the opposite
side  of the question, as to denounce  it.   Cullen, for example,
affirms opiates to be worse than  useless, "by occasioning an in-
terruption of the action of the small guts, and thus favoring the
constriction  of the colon,"—neither the fact, nor the speculative
explanation, being consistent with the real condition of things.
It is true, that opium may be useless, or even injurious, if admin-
istered before any effort has been made to  diminish the general
febrile and local  inflammatory excitement  by venaesection, etc.
Premising these necessary measures, however, or combining our
opiate with a well selected cathartic, as calomel or castor oil, we
shall derive from it unequalled advantage and comfort.  No less
beneficial is its action as a diaphoretic,  and, to give it this effect,
we unite  with it  ipecacuanha, an article  already noticed with
due commendation.  The Dovers' powder may be prescribed in
moderate quantity, at intervals, through the day, and at night in
as large a dose as the  stomach will  bear.  If the ipecac: disa-
grees in this way, we may offer it in form of pill, increasing the
       VOL n.—11 
122
DYSENTERY.
proportion of opium pro re nata.   This medicine does not seem
to me to interfere with, but  rather, indeed, to promote, the good
effect of whatever other medicines we are pursuing.
  I would gladly impress on your minds, the unhesitating con-
viction which I feel, and upon which I never fail to  act, that it
is our  professional duty, always to  relieve pain  and suffering
when it is in our power, and that, in all diseases  in which pain
is one of the elements or uniform conditions, its relief or pallia-
tion is  so  far curative.  Pain enhances irritation, and urges  it
on  to  its  worst  results—excites  spasm—aggravates  inflamma-
tion—deprives the patient of slumber or  repose—and thus, by
its  direct  and indirect influences, prostrates  his  strength and
exhausts his vital powers.   Opium, if its  exhibition be properly
timed, will never fail to subtract from the  intensity of pain, if  it
does not subdue it altogether ; it relaxes the harsh surface into
a soft,  warm perspiration, and procures the inestimable blessing
of  refreshing  sleep—a respite to the  worn  out sufferer, how
unspeakably grateful, how restorative !
  Of the  diaphoretic plan of treatment, so vehemently extolled
by those who, with Richter, have advocated  the rheumatic or
catarrhal  pathology of dysentery, I would say,  that while  it
offers us  many  valuable auxiliaries, it does not  deserve  to be
confided in exclusively.  It is  true, that  the relaxation of cuta-
neous constriction, and the return of natural softness  and moist-
ure of  the surface, are among the most favorable symptoms, yet
these tokens of  recovery are found, not only in dysentery, but
in all other inflammatory affections of internal viseera, to follow
much more  readily, and with far greater certainty, the judicious
employment of the general  anti-phlogistic regimen,  including
venaesection, and the gentle cathartics above  enumerated, than
the exhibition of the mere diaphoretics.  In fact,  I  am not
inclined to  repose any special  confidence in  remedies  chiefly
adapted to procure sweating, unless as in  the instances of opium
and ipecacuanha, and  perhaps  the  antimonials, there  be also
conjoined with this sudorific property, an anti-spasmodic, purga-
tive or anodyne effect.
  It ought  to be noticed, too, that  it  is in the dysenteries  of
winter and  spring, rather than those of the summer and autum-
nal season,  that we shall be able most clearly to trace the imme- 
DYSENTERY.
123
diate benefits of the diaphoretics.   Here, we shall derive great
advantage from the use of the warm bath ; and after the patient
has been put to bed, the assiduous  application of warm fomen-
tations  to  the abdomen.   Under  these circumstances, many
advise the exhibition of camphor as  an aromatic and sudorific ;  I
would not trust to it alone, but have seen good effects follow its
combination with opium, ipecac: and calomel.  From  the  em-
ployment of the more stimulating articles of this class at least in
the early stages  of dysentery, so commonly depended  upon in
domestic practice, not only in this but in all other affections of
the bowels, nothing but evil can result.
  The hemorrhagic character of the dysenteric discharges, does
not, for  the most  part, deserve or require  any special notice.
Sometimes, however,  the  flow of blood is  so  profuse, as to
threaten speedy and permanent loss of strength, if  not  checked.
This may be owing to ulceration and erosion of some vessel or
vessels  of notable  size.  Various astringents are employed to
restrain  such hemorrhage;  kino, catechu, pomegranate  rind,
among vegetable articles, are  to be preferred.  Kino, especially
as combined in the cretaceous julap, is well adapted to instances
in which the evacuations are composed chiefly of serous  and
mucous  secretions,  mingled  as  they   often are with bloody
transudation, and thus highly colored ;  but in the true hemorrh-
ages, of  which I am now speaking, I am not willing to trust to
any astringent less impressive than  the acetate of lead.   This
may be  prescribed alone, but  is generally  and advantageously
combined with opium and ipecac.  Its dose  must be proportioned
to the urgency of the case; from one grain to five, every two or
three hours, will usually answer every purpose.
   In the earlier  stages of dysentery, the annoyance and suffer-
ing to which the patient is subjected,  are  plausibly attributed,
at least in part, to  the presence of feculent and acrid matters in
the intestinal tube ; but surely, after free evacuations  from the
bowels have been procured, we are  to  regard the morbid and
acrimonious  excretions as the consequences, rather than the
causes, of diseased action.  Hence, though it is still incumbent
on us to provide for  the  expulsion of such irritating accumula-
tions, it  is yet a  far more important object to correct  that unna-
tural condition of the affected tissue upon which depends their 
124                    DYSENTERY.
formation.  Now, I am well  satisfied, that the acetate  of lead
has no feeble tendency to influence, in this beneficial way, these
mucous surfaces, diminishing inflammatory irritation, constring-
ing the distended vessels, and correcting the vitiated  character
of the secretions  effused.   I  am in the habit of prescribing it
whenever these are poured out  in inordinate quantity, without
regard to their nature and composition, and whenever the degree
of pain and distress is particularly severe.
  In the relief of these  symptoms, much aid may be procured
from the judicious use of the proper enemata.  In the very first
stages of the attack, tepid water thrown up alone or mingled
with some oil or mucilage, promotes the full and easy evacua-
tion of the contents  of the lower  intestines.   When this has
been accomplished, a proper  amount of  opium may be added to
the mucilaginous fluids employed, and will be found effectual in
relieving the tormina and tenesmus complained of.  Cold water
alone is, in this second stage,  a very grateful and soothing appli-
cation, and often very eagerly desired by patients ; when they
are thus  too frequently indulged, however, I have suspected it
of inducing  a degree of debility in the  sphincter  ani, which
renders them incapable of retaining the alvine discharges, and
occasions  some inconvenience, if not more serious evil.  The
acetate of  lead has been found useful here, in restraining both  the
frequency and  abundance of the discharges, and  quieting  the
annoying  irritation of tenesmus.  This  is a symptom so griev-
ously  complained of by the sick, that  physicians  have, every
where, with  praiseworthy zeal and benevolence, busied them-
selves in efforts for its removal.  We must remember, that it is
prominently a sympathetic, not a local affection, and refuses to
yield to any local remedies, subsiding when the internal mucous
inflammation and vehement  peristaltic  excitement upon which
it depends, are subdued, and not  until then.  It is very liable to
be increased by the very measures suggested for its  palliation,
and this, indeed, will certainly happen,  if the  parts  at  the  ex-
tremity of the rectum are injured by too much handling, or sub-
jected to the rude manipulation of an unskilful  nurse.
   Abercrombie proposes for the relief of this tormenting annoy-
ance, injections of limewater diluted with milk or thin, arrow
root,  some opiate being added.  Opium, indeed, deserves your 
DYSENTERY.
125
^chief reliance, and besides being  thrown up in these mucilagi-
nous solutions, may be introduced in  pill  or powder, mingled
with fresh butter or lard.   Some recommend fresh melted butter
to be injected in considerable quantities—half a pint at intervals.
   Leeches applied  at the margin of the anus, are  occasionally
very efficient in  subduing  pain and  diminishing  the restless
urgency of the tenesmus, and I have seen  similar palliation
obtained by fomentation with a soft, tepid poultice of chamomile,
or of hops or poppy-heads.
   In the earlier stages of the attack, you will derive benefit, as
I have said, from the use of stupes  and  poultices, warm  and
somewhat  irritating, laid assiduously on the abdomen ; and,  per-
haps, if convenient, at the same period, the warm or hot bath
would be found still more impressively derivative and sudorific.
But, as the case progresses, we  shall  find it necessary, to have
recourse to measures  of  more active  and  energetic revulsion.
Epispastics may be  laid, in succession, to  the upper part of the
thighs, and to the sacrum.  Should these fail of sufficient effect,
the whole  abdomen  may be covered  with a vesicatory, which, if
necessary,  may be replaced  again and  again, when it heals so as
to admit of the repetition.
   There are certain general rules for the  management of your
dysenteric  patients, which it may be  of much importance to  you
to follow.  "In no disease," says James Johnson, "is patience, on
the part of the sick, a greater virtue,  or more calculated to for-
ward the good effect of medicine.  If obedience be paid to every
call of nature, the straining which ensues, is highly detrimental,
and  augments, in many  cases,  the  discharge of blood; every
motion of  the body, indeed, increases  the desire  for an evacua-
tion."   You  should strongly urge upon the  sufferer, therefore
the necessity of resisting,  with fortitude, the urgent and almost
ceaseless desire to rise to  stool.  Among the best means of con-
trol, in this respect, you will find the substitution of the bed pan
for the easy chair;  in the reclining or half-supported position in
which the  first is used, there  is much less opportunity for  the
muscular exertion in bearing down, to which he feels too strong
a propensity.  And  we thus gain, also, two farther points__his
strength is better husbanded, and he is  less exposed to sudden
changes of temperature.  To guard against this  latter evil it
       11* 
126
DYSENTERY'.
will be proper, in all exposed situations, as in army and navy
practice, and in some hospitals, and  the imperfect dwellings of
the poor, to envelope the trunk of the body in folds of flannel,
We should remember, in regard to this matter, that although the
temperature of an apartment may be to healthy sensation suffi-
ciently regular and comfortable, yet, we shall  find, in many dis-
eases, and particularly in abdominal affections, a morbid sensibi-
lity to very slight changes.   When fomentations are ordered, and
when medicines are administered with a view to their diaphore-
tic action,  very special  caution will be requisite to prevent the
occurrence of a chill on changing the clothes, or permitting the
patient to rise.  Care should  always be taken,  too, to  keep the
extremities as warm as the trunk of the body.
   Every evacuation should be immediately removed, and the
strictest possible attention paid to cleanliness of the apartment,
bed, and person of  the sick.  No one can doubt the propriety of
this rule, whatever opinion he may entertain of the contagious-
ness of the malady under discussion, which, if  admitted, would
be felt to make its observance doubly incumbent upon us.  Full
and free ventilation  must be insisted on, whether the season be
cold or warm, while pains should be taken to guard the patient
from all direct draughts or currents of air.
   The drinks  allowed during the progress of the  case,  should
be of the mildest and least stimulating  kind, although the old
notion, not yet, indeed, entirely obsolete, of giving  mucilages
for the purpose of sheathing the inflamed surfaces, as the phrase
was, from  the  irritation of the acrid matter contained  in the
bowels, is too mechanical to be worthy your consideration. The
tormenting thirst which distresses the sick man, may be quench-
ed with toast-water, strained gruel, arrow root, etc., which hold
 in solution small proportions of nutritious matter.  These and
 the aromatic infusions, and herb teas, which he may be using as
 drink, are supposed to be beneficially acidulated  with some one
 of the mineral acids, of which the nitrous is selected as  deserv-
 ing a preference.   It is alleged, that besides being grateful to the
 taste,  and  more serviceable  in quenching thirst, they tend to
 diminish the sense of uneasiness and gastric oppression so much
 complained of.
   I repeat, here, an observation made in treating  of  diarrhoea, 
dysentery;.
m
that large  quantities  of fluid, taken at once,  are apt to excite
the peristaltic movements of the intestines.   You must, there-
fore, limit your indulgence  by spoonsful, which, however, may
be accorded frequently enough to  prevent any unnecessary suf-
fering from thirst.
   During  convalescence, the  lighter bitter infusions have been
much relied  on as tonics.  Simarouba or common quassia, and
colomba, are often employed.   An astringent may be occasion-
ally added with advantage, the kino being the best, and a little
alkali, the carbonate of soda or of potass will be found useful,
Generally speaking, I trust rather to the mineral, than the vege-
table  tonics, here, and prescribe  the acetate or muriate of iron,
The prussiate, also, has been highly recommended.
   Where dysentery is obviously of malarious origin, or has been
connected with fever of remittent or intermittent type, it will be
well to resort, as early as possible, to some preparation of cincho-
na.   I would  chose  to administer the  infusion, combining it
With  serpentaria, or small  doses of camphor.  The sulphate of
quinine  is generally  preferred.  In either formula, the addition
of proper  quantities  of opium, may be required, to check or
control the abdominal irritation and disorder.
   The diet of the convalescent should  be nutritious, but light
and  unstimulating.   Arrow root,  tapioca, rice properly boiled,
chicken  water, mutton  broths, and unseasoned jellies, will fur-
nish,  at  first, sufficient  variety,  while great attention must be
paid  to  the observance of  strict moderation  in quantity.   He
may be gradually allowed an extending license in the use of the
digestible meats—beefsteak, poultry, etc., but  he should be cau-
tioned, for some time, to  avoid vegetables, especially those of
acescent or flatulent tendency.
   Gentle exercise, such  as sailing, and riding in an easy carriage
may be resorted to as soon as his strength will allow.  He should
wear  flannel next  his  skin, and observe the most  scrupulous
care in avoiding every exposure to night dews, damp air, and all
abrupt changes.  His feet should be guarded particularly from
cold and moisture.
   There are few disorders which exhibit so pertinacious a dispo-
sition to  recurrence or  relapse,  and the  difficulties of cure are
indefinitely multiplied in every successive  attack, until the un; 
129
CHRONIC DYSENTERY*
fortunate  sufferer sinks exhausted, or  the chronic form oi the
disease  fixes itself  upon him—than which, there is no morbid
condition  more  tedious, tenacious,  or distressing;  poisoning,
while it lasts, every source  of enjoyment, and rendering even
life itself an intolerable burden.

  Chronic Dysentery is usually the consequence of the acute
attack imperfectly  cured, or  protracted indefinitely, until the
immediate or more vehement constitutional sympathies have, in
some measure, subsided; and  the local affection of the  mucous
lining membrane of the  intestinal tube becomes  of prominent
and paramount importance, in the disturbing  influences exerted
directly, upon the structure and  functions of that part of the
digestive system.  It sometimes happens as the result of violent
and unmanageable diarrhoea—a transition which, however natu-
ral  and easily explained, has tended still farther  to increase the
confusion so often made between the two varieties of disease.
  It may  be described  as presenting nearly the same  train of
symptoms, already enumerated as constituting the history of the
acute form,  but in greatly diminished  intensity.  There is less
soreness and pain in the abdomen ; the calls to stool are less fre-
quent and somewhat less urgent; yet the  alvine movements are
attended with sharp pangs and severe griping, and the discharges
are mucous and bloody, or ichorous, or mucopurulent, or sero-
sanguinolent, mingled  occasionally  with more or less  feculent
matter.  There may be little fever, but an exacerbation is per-
ceptible in the evening, and the nights are restless and uncom-
fortable : there is some appetite, variable usually, and capricious,
and indulgence in taking food, is apt to  occasion pain in the
stomach and  bowels,  and  to be followed by  a call to stool.
There is an annoying  and constant thirst, and the tongue and
mouth are of a deep red hue, and disposed to dryness*  Emacia-
tion goes  on steadily, with  loss of strength;  oedematous swell-
ing of the feet is noticed, first in the evenings,  afterwards con-
tinuing through the day, with some puffiness of the face ; the
surface is harsh and dry, and of unequal temperature, the trunk
being hot and the extremities cold; an unpleasant odour is ex-
haled from the body, and  the  breath is foetid; the abdomen
becomes  hard,  and painful  on  pressure; apththoe  cover  the 
chronic dysentery.
129
 tongue and cheeks, and the unhappy patient, after weeks, months,
 or as the case may be, years of protracted torment, dies  worn
 out with suffering.
   Autopsy.  On examination, the mucous membrane  is found
 extensively inflamed and ulcerated, the colon being  generally
 the seat of such lesions.  I have seen these ulcers  as  large as
 from a fourth to half an inch in diameter, and in great number.
 Coincident with this  state of the alimentary tube internally,
 there are often found spreading inflammations of all the  abdo-
 minal viscera,  whose  vessels are deeply  injected, and whose
 external surfaces are agglutinated by deposition  of organized
 lymph.
  Some have doubted whether intestinal ulcers ever heal; but
 on this subject,  as I before  said of the  stomach, there can no
 longer remain any reasonable  question.   Latham,  Troilet, and
 others, have collected abundant evidence to establish the affirma-
 tive ;  and I have myself seen the process of reparation, in seve-
 ral  of its stages, and  inspected the eschars of ulcers entirely
 healed.
  The Prognosis in chronic dysentery is, on the whole,  unfa-
 vorable ; although we are not permitted to despond.  Few mala-
 dies are so intractable; few so likely to  return, after a seeming
 cure has taken place.  The favorable symptoms are obvious;
 such as show, on the one hand, a subsidence of the local irrita-
 tion and inflammation, and on the other, a progressive  resump-
 tion  of  the  natural  and  physiological  functions  of the  parts
 affected.   The diminution of the urgency and frequency of the
 tormina and tenesmus,  the substitution of fecal for sanguinolent
 discharges, and the improvement in weight, by proper filling up
 of the emaciated frame, will give fair reason for hope of ulti-
 mate, though probably irregular  and distant convalescence.
  In the Treament, we must lay principal stress upon the gene-
 ral management of the case.  A careful  avoidance of all causes
 of irritation is to be enjoined, whether affecting directly the ali-
mentary canal, as in  the use of improper ingesta; or indirectly,
through their influence upon the general system, as in exposure
to moisture or atmospheric  vicissitudes,  or residence  in  mala-
rious districts.  The patient should be kept very much at rest,
and in a recumbent posture, and spend  most  of his time in a 
130
CHRONIC DYSENTERY,
warm and well ventilated chamber.  When the atmosphere is
dry and genial, he may be  indulged in a sailing excursion, or a
ride in an easy carriage.  He should wear the flannel roller over
his abdomen, and take pains to keep  his extremities  warm and
dry.   His food should be light and nourishing; and as far as
the stomach will bear it, consist chiefly of solids.
   There is no very great certainty in the exhibition of any of
our formulas of medicine.  I would advise a mercurial course,
combining small doses of calomel or of blue mass, with cret: pp:
or Dover's powder, repeating at proper intervals throughout the
day, and administering full doses of anodyne at night.  I would
endeavor to procure the  alterative effect of mercury,  with  as
little of its irritative influence upon the salivary glands as possi-
ble, and when ptyalism supervened, I would desist from it at once.
Some of the diaphoretics are alleged to  exert beneficial powers
here.  James' powder, or the pulv: antimon: of the  shops, and
ipecac in minute quantities, are thus employed.  I have derived
advantage from the use of the infus: serpentariae, with camphor
and opium.
   The astringents, both mineral and  vegetable, are constantly
recommended and much prescribed.   Yet their efficacy is apt to
be transient, and if not promptly serviceable, they will  be apt to
disappoint you.  The kino stands pre-eminent among them, and
may be given alone,  or  with some alkali merely, as the carb:
soda  and potass,  or  combined,  as in the ordinary cretaceous
julap.  The other vegetable astringents—the catechu, pomegran-
ate, etc., are not much relied on.  Elliotson and Granville have
highly eulogized the efficacy of the sulphate of copper, in these
protracted cases.   On their authority, I mention it to you, though
I have not succeeded with it. I am much better pleased with the ef-
fect of the acet: of lead. It may be combined with ipecac and opium.
If the stomach be irritable, the most  inoffensive of all formulse
will be found to be the addition of the requisite amount  of acet:
plumbi  to a mucilaginous solution of the acetate of morphine.
 This may be persisted in for a considerable length of  time, too,
 without losing its influence,  or annoying in any way.
   The nitrate of silver deserves special mention here.   It seems
 to be very generally applicable, and a patient perseverence in its
administration, will seldom fail to palliate the symptoms present, 
CHRONIC DYSENTERY.
131
 in a notable degree, if it does not  effect an absolute  removal of
 them.
   Some of the inter-tropical practitioners praise loudly the nitric
 and nitrous acids, for their influence over chronic affections of
 the bowels generally—chronic  dysentery among the rest.   The
 former is combined with opium, in requisite amount, and advised
 to be taken for a considerable length of time.  Like  the salts of
 copper and silver, just  spoken  of, it is supposed to  exert some
 specific power locally, upon the numerous intestinal ulcerations,
 disposing them to heal, and at any rate, correcting the foul secre-
 tions from the diseased surfaces.   With similar views, charcoal
 finely levigated is offered, and is unquestionably  useful  to a
 certain extent.  Abercrombie mingled it with pulv: doveri, and
 thought  it  of service.
   In  attacks of long standing,  it has been  customary to resort
 to some of the terebinthinate or balsamic  preparations.   Pem-
 berton and Cheyne unite  in speaking favorably of the copaiva
 rubbed with some mucilage. Pemberton also recommends it as
 enema, for the relief of tenesmus.
   I have seen the spirits terebinth: used in both ways, and  in
 acute, as well  as chronic dysentery; and  though  a certain de-
 gree of diminution of suffering was obtained for a time, yet I
 cannot help suspecting it of ultimately  injurious irritating  con-
 sequences.   I  am unwilling to advise or trust to it.
   I ought to mention, however, that in the histories of this most
 obstinate and unmanageable disease, we have  authentically re-
 corded, many  strange stories of direct and unequivocal benefit,
 resulting from the most unpromising and capricious treatment.
 Such statements are worth preserving among '-'the curiosities of
 medical experience,"  although we  cannot venture to guide our-
 selves by the  analogies which  they seem  to suggest.   Thus
 there  is often quoted in  the books, a case given by Forestus  of
 cure effected by indulgence in eating unripe apples; and the
 medlar and other harsh varieties of this very flatulent fruit are
 affirmed by others, to  have been similarly beneficial.   I knew a
gentleman, who, while suffering under chronic dysentery, which
terminated  fatally after many years' protraction, resorted by the
advice of a farmer, to the free  use of hard sour cider.  This
remedy, which he did not employ  until the most extensive  and 
132
CHRONIC DYSENTERY'.
 faithful trial of all regular medical  resources had resulted in a
 total failure—acutally suspended for some time his  tormenting
 disease; but even this lost at last its efficacy.  Thus also, you
 frequently meet in the newspapers and journals, with wonderful
 relations of recoveries from  chronic  intestinal disorders,  appa-
 rently promoted by  indulgence of some morbid  or whimsical
 appetite felt by the patient, who desires odd and revolting articles
 of food, such as cheese parings, raw onions, rancid bacon, etc.
   The best expectation of a permanent cure, is to be founded, I
 think, upon a change  of  residence—a removal, indeed, if it be
 in the power of the patient, to another and distant climate.  All
 changes of place  and of habit, seem to promise somewhat.  All
 modes of travelling are  serviceable, but if the  saddle can be
 borne, a journey on  horseback should be advised.  A  long sea
 voyage often makes a decided and  favorable  impression  upon
 the constitution, by breaking up suddenly  and thoroughly  all
 established habits, and substituting for them a new train  of move-
 ments.  The direct and immediate effect of the tossing of a ship
 on the ocean, is, as every  one knows, to interrupt  the regular
 custom of daily alvine evacuation, and check the peristaltic ac-
 tion of the bowels, thus giving rise to costiveness, sometimes of
 long duration.  This state of things is particularly favorable to
 invalids, who have suffered from undue determination to, and
 morbid irritability of the intestinal tube,  with too  frequent pro-
 pensity to stool.  Such torpor is  not only a condition  of great
comparative comfort to them, but occasionally,  the harbinger of
a complete recovery; and even if ulceration  have taken place,
it gives the best possible opportunity for the supervention of the
healing process and the formation of eschars. 
CHOLERA INFANTUM.
133
                     CHAPTER XXX.

                    CHOLERA INFANTUM.

   Under  this term, it has  become customary with American
 physicians, to treat of every form of bowel complaint  to which
 children are liable beneath a certain period of age, yet, all seem
 disposed to admit, that there is something peculiar or specific in
 the character of the cases thus referred to.   Nay, some of them,
 Professor  Potter,  of  Baltimore, for example, intimate  clearly
 enough their belief, that Cholera Infantum is a distinct malady,
 exclusively confined to  these United States, while they acknow-
 ledge the strong analogy  presented in the similar affections de-
 scribed by Cruveilhier,  Billard and  Copeland, to which  names,
 I will add  those of Underwood and Ayre.
   The history of the disease, usually received, differs little from
 that first given by Dr. Rush, and will be found  to comprise at-
 tacks of cholera,  properly so  called;  of diarrhoea,  both acute
 and chronic;  of dysentery, also in both forms; of atrophia ab-
 lactorum, or  true scrofulous marasmus; of bilious remittents,
 affecting children of tender age;  and of febris infantum remit-
 tens or worm fever.  Nevertheless, I feel  no disposition to re-
 fuse it a separate  consideration in my course,  my  aim  being
 rather practical utility,  than  nicety  of classification;  and in  a
 practical point of view,  so many modifications of treatment  be-
 come necessary, on  account of the peculiarities of the infant
 constitution, that the management of such disorders, as assailing
 young children, will be doubtless better discussed apart and in
 detail.  You will,  therefore, bear in mind, that we are  entering
 upon the consideration  generally, of the bowel complaints of
 children, within the three first years of life; and that by the use
 of the received phrase, I by no means intend the acknowledgment
 of any specific morbid condition.  If any restriction of the name
 be attempted, I would prefer, with Copeland, to regard it as denot-
 ing an affection essentially pyrectic—he calls it Choleric fever__
and partaking of the nature both of diarrhoea and dysentery.
  Its Causes have been duly investigated.   It has been attribut-
      VOL. II.—12 
134                 CHOLERA INFANTUM.

ed—justly, as it appears to me—to the  irritation of dentition,
to the influence of high atmospheric  temperature,  and to the
effect of malaria, or air otherwise vitiated and impure.
  I consider it as capable of arising from either of these causes
alone, though their combined agency is,  of course, much more
efficient in its production.  Hence it is often  met with in un-
healthy situations, liable to malarious diseases, at the commence-
ment of the hot weather of our  American summer, and when
the child is teething.  In our large cities, especially in their nar-
row, ill ventilated  lanes and alleys, it prevails annually,  though
it is'not unknown  even in remote country places.  Cases occa-
sionally, though perhaps rarely, occur in winter; these, we may
ascribe  simply to  dentition; and in situations where it is fa-
miliar, it makes its appearance  early in the summer—even in
April and May—when few, or no other malarious attacks have
yet been noted.
  In our climate, it is met  with between March and October, the
greatest  number  of instances  presenting themselves  in May,
June and July.  It seems also  most  rife in seasons otherwise
unhealthy—as in the spring preceding a yellow fever  endemic
in  the  city,  or the epidemic prevalence of bilious remittents
through the  country.  Dentition predisposes to it so strongly,
that children between eight and fourteen months old at the be-
ginning of summer, rarely escape an attack, of greater or less
violence.  The attempt to  wean a child while teething, and the
substitution  of paps and other kinds  of improper food,  for its
natural and  healthy aliment—breast-milk, often proves fatal, by
exciting a diarrhoea, which soon becomes irritating and pyrectic.
The unwholesome secretion from the breast of a pregnant mother,
called by the nurses, not improperly,  "bad milk," is very apt to
 disturb and  annoy the stomach and  bowels of a teething child.
   These disorders may follow, indeed, the use of any indigesti-
 ble or inappropriate food.  Fruit is  among the most common
 causes of them, a point concerning which, I am obliged to differ
 from Dr. Rush, who expresses his belief, that a moderate use of
 ripe fruit, rather tends to prevent, than to  induce  them.  It
 ought to be  remembered, too, that fruit exposed for sale in the
 markets of large  cities, is  not often  properly ripened.  It is, of
  course, brought from various distances,  and is  usually  plucked 
CHOLERA INFANTUM.
135
 while still somewhat crude and hard, that it may bear transporta-
 tion ; it may hence be said more  correctly, to be  softened by
 pressure,  bruising, or  incipient decay, than to be duly  matured.
 Besides this, I am persuaded that in the stomach of early child-
 hood, there is little power of assimilating vegetable aliment of
 any kind, and that it is probably altogether incapable of the as-
 similation of the acescent vegetables.  Before children have cut
 a sufficient number of teeth, or have properly  learned the use
 of them, they are apt to swallow their food unchewed,  and un-
 mixed with saliva. They ought to be  taught  to  masticate all
 solid articles given to them, and especial precautions should be
 taken, as to those matters which they are fond of,  and if left to
 themselves, will swallow greedily  and in  haste.  I have, with-
 out doubt, seen many instances of cholera infantum, induced by
 the use of ripe fruits,  and  in some of them  in  but moderate
 amount.   Inter multos alios—I recollect a fine  boy, only son of
 a gentleman of this city, who was quite well before  eating a
 part of an orange;  in  less than an hour after, he was seized
 with colic, followed by vomiting and purging, of which he died.
 I have seen  death twice follow  promptly the eating of nuts, by
 children who chewed them imperfectly.
  Exposure to abrupt and improper atmospheric vicissitudes,
 also, and inattention to the requisite changes of clothing, often
 give rise to attacks of this sort; a strong predisposition to which,
 is generated by  uncleanliness, whether of person,  garments, or
 chamber.
  The most fatal modification of cholera infantum, is that which
 supervenes upon a scrofulous diathesis hereditarily derived, and
 hence we  find it specially frequent and mortal in certain families,
 whose hopes are thus  cut  off in the bud, during a long proces-
 sion of years.
  I will attempt a brief detail of the symptoms which present them-
 selves, in the most ordinary class of cases. The attack usually com-
mences with fretfulness and inquietude. The child is more uneasy
at night;  its lips  are hot and its mouth parched; it seems to be in
pain, and when it doses, moans and starts..  Vomiting is frequent-
ly one of the earliest marks of disorder, or the stools are observed
to be watery, passed urgently, rather abundantly  and  unduly
frequent.   They are variously altered in hue, being clay colored, 
136
CHOLERA INFANTUM.
or greenish, or sanguinolent, or mucopurulent, and often very
offensive and acrimonious.
  I have already said that I agree with Copeland, as to the py-
rectic character of this affection.  There is  always some febrile
excitement present, at some period of the twenty-four  hours-
being usually most obvious in  the  evenings.   If dentition is
going on, the child bites his fingers, or  any thing put into his
hands ; his gums are swollen and inflamed ; his head is hot, and
he shrinks from light and  is annoyed by sound;  he grinds his
teeth, both when  asleep and awake.  After a time,  in almost
every variety of case, if not uniformly,  diarrhoea prevails, and
becomes  the  symptom  of paramount importance;  dysenteric
appearances not unfrequently present themselves,  in addition,
the discharges consisting of mucus,  colored  with pus or blood,
and passed with violent straining, fretting  and crying.  The
belly becomes tumid, and pressure  is  complained  of as giving
pain; the tension  is often  elastic and tympanitic.  The  child
lies on his back, with his feet drawn up, tossing his arms and
rolling his head from side to side.  An  annoying cough some-
times supervenes; emaciation progresses  rapidly, with great mus-
cular feebleness; the pulse is frequent, quick and  weak.  The
lips and lining membrane  of the mouth  are  fiery red, polished.
and dry; in protracted cases, ulcers show themselves  upon it,
usually apthous and superficial, but occasionally deep, destruc-
tive and severely painful.   The extreme emaciation  which be-
longs to these  latter  stages, gives to the  countenance a most
ghastly expression, remarkable above all in  scrofulous  subjects,
whose marasmus is owing to innutrition, from the enlargement
and induration of the mesenteric glands, and general failure of
the assimilative functions.   As death approaches, the  little suf-
ferer lies moaning and languid, but still restless;  the eyes are
injected with an inflamed look, though perhaps quite insensible,
flies having been seen to light on the  cornea between the half
open lids, without exciting notice or motion ; there is sometimes
 a muttering delirium, the patient wasting his little strength in
 vain, unquiet struggles, and even biting at its nurse's or its own
 hands.   Livid spots sometimes form on  the surface, and coma
 or convulsions are the immediate precursors of  dissolution.
   The duration of the disease varies much, observing a corres- 
CHOLERA INFANTUM.
137
 pondence with the forms it is wont to assume.   The  modifica-
 tion above described—chronic diarrhoea or marasmus, as it is
 often called, may be protracted for weeks, or even months.  I
 have seen it jmt on the shape of true cholera, in which the irri-
 tability of stomach was the most urgent symptom,  and the little
 patient sunk exhausted by the irrepressible vomitings, and  the
 frequency and quantity  of the serous discharges from the  bow-
 els.   I have known cases of this sort, terminate in twelve and
 twenty-four hours; the alvine discharges consisting of the serous
 or albuminous fluids, so abundantly effused in cholera maligna.
  I do not entertain a doubt, that verminous irritation may  ex-
 cite this state of disease in young children, or  may complicate
 with  it their familiar  symptoms; hence we find  some writers
 enumerating under this head,  all the phenomena  which go to
 show the presence of worms—irregular bowels, capricious  appe-
 tite, foul tongue, foetid breath, convulsions, etc.
  A  hydrocephalic variety is  also recognized by some authors,
 because  of the gastric and intestinal disturbance which arises,
 as a matter of course, in the advanced stages  of this cerebral
 affection—but the diagnosis is easy and obvious.
  The post mortem appearances must differ with  the nature of
 the attack. In  the rapid cases just mentioned, little  change of
 condition is to be observed.   In two  such, I found a very slight
 blush overspreading the external surface of the stomach and in-
 testines ; I could perceive no alteration of the internal or mucous
 coat.   In chronic dysentery, this tissue offers abundant traces of
 inflammation, and is occasionally found ulcerated.  The mesen-
 teric glands are often enlarged and indurated.
  The Treatment of cholera infantum—as you will readily in-
 fer from the history above given—will require to be varied with
 the diversity of forms which it presents,  and  with its different
 modes of access or invasion.  Like the  cholera  of  adults, it
 often arises from some temporary cause, some transient mode of
 irritation.  Improper food may have been  taken, or some excess
 in ordinary diet  committed.   The primae viae will, for the  most
 part, be thoroughly evacuated  by the  early discharges upward
 and downward ; but  if not, a mild emetic of ipecacuanha or a
 moderate dose of castor oil may be given, to obtain  the complete
expulsion of all crude  or  undigested  matters.  After this, we
       12* 
139
CHOLERA INFANTUM.
must resort  to the most soothing  management.  Aromatics and
anodynes  must be  administered  in efficient doses.   The  best
combination  of these is the old  fashioned paregoric elixir—a
very happy union of several useful  ingredients.  Laudanum fo-
mentations should be applied assiduously to the abdomen, and
frictions made with warm  laudanum, to the spine  and limbs.
The stomach is occasionally in so  stormy a state, that nothing
can be swallowed or for a moment  retained, not even the water
for which the little patient  in the  torments of an intolerable
thirst cries urgently.  We must depend here upon the adminis-
tration  of our opiates in enemata.  These  are to be  made of
mucilaginous solutions, containing  a proper proportion  of tinct:
opii; they should be thrown up  gently and carefully, and re-
peated pro re nata.   The warm  bath  should in the meanwhile
be resorted to, and sinapisms applied to the trunk and extremities.
   When the attack arises from the annoyance of dentition chiefly,
there occur, superadded to the ordinary symptoms, or combined
or alternating with them, the effects of undue or morbid determi-
nation  to the brain.  The  child cries much, shuns the light,
appears distressed by noise, starts at sudden sounds, throws its
hands up to its head, which  is hot  and its cheeks flushed, while
the feet are apt to be cold; the gums are swollen and red ; there
is great thirst; the bowels are irregular, being sometimes costive
and at others loose  with griping.  It  is often proper to scarify
the gums, and when this is done, we should pass the instrument
used, down upon the tooth, relieve the tension of the membrane,
 and bleed it freely.   When well  timed, this  little operation will
 often give  much relief; but I cannot recommend it to be per-
 formed promiscuously or indifferently.   I dissent from those who
 regard the cicatrices formed upon  the  healing of these  small
 wounds,  as of similar texture and equally absorbable with the ori-
 ginal textures. On the contrary, I think it proved that an eschar or
 cicatrix is always hard and unyielding;  in parturient women for
 example, we always find cicatrised parts of firmer consistence and
 less easily dilateable than the original  tissue in which they occur.
    Beyond this local aid, we must relieve the organ principally
 assailed,  the brain, by such means of revulsion as are best adapted.
 If the bowels are confined, we must exhibit a purgative.  Castor
 oil answers well in general; some prefer the combination of rhu- 
CHOLERA INFANTUM.
139
barb, with  magnesia or with calomel ;  I  have no objection to
either, though Rush expresses—I know not why—a strong dis-
like to the use of rhubarb  in  any of these cases.  The head
meanwhile must be kept cool by proper refrigerants, and the ex-
tremities well wrapped and warmed, and somewhat irritated by
sinapisms.  If convulsions  threaten or coma supervene,  cold
affusion on the vertex must be had recourse to ;  and, if the pulse
do not forbid, leeches applied behind the ears, to the angle of the
jaw, or upon the temples.
  In that type of cholera  infantum which I have described as
the most common among us, and have  attributed, in  part at
least,  to a malarious origin, the stomach appears to be the prima-
ry seat of the disorder; this soon  extends itself to the rest of
the chylopoietic  viscera, deranging variously the function and
condition of the liver,  and  bringing  on a diarrhoea which ex-
hibits a remarkable proclivity to protract itself into the chronic
form,  or run on into dysentery.
  In the earlier stages  of this  modification, many practitioners
are in the habit of employing  emetics ; and I have seen some
benefit from them, when the tongue is foul and the breath foetid,
with anorexia and  nausea, with or without retching.   I prefer
the ipecacuanha, but even this mild  article, I am unwilling to
repeat frequently.  Of the cathartics so generally employed, the
least irritating should be chosen ; and for this, among other rea-
sons, I select calomel.  The mercurial is especially indicated
when there is torpor or obstruction or engorgement of the liver ;
which may be detected by fullness or intumescence of the organ
perceptible on examination, or shown by clay colored stools.  In
addition to the indispensable remedy just named, we may find
advantage also in the  use of the muriatic acid bath, as a pedilu-
virum for the little patient, whose feet and  legs are to be kept im-
mersed in it for some minutes at a time, at intervals.  Whatever
laxative be exhibited, it should be given in moderate doses, and
at such  periods  of repetition as shall  keep the bowels gently
moved, and regularly, so as to present that alternation of looseness
and costiveness so common and so injurious.
  It is a good custom to add  some alkaline preparation to all our
formulae.  The digestive function is of course greatly impaired
and the  contents of the stomach are apt to undergo a constant 
140
CHOLERA INFANTUM.
fermentation, giving rise  to the presence of an irritating acid.
Alkalies not only correct  chemically this vitiation of the fluids
effused or taken into the stomach, but they exert some peculiar
power beyond this, in tranquillizing and giving tone to that or-
gan.  Where constipation exists, magnesia  may be chosen: if
on the other hand there is diarrhoea, lime water or the carb: sodae
or potassae should be used.
  When we have reason to suspect the presence of worms in
undue number, productive of or increasing the abdominal distur-
bance, we must resort to some anthelmintic remedy.  Of  all the
vermifuges, I regard camphor as most deserving our confidence,
and would propose an aromatic  infusion of it as an eligible basis
for such other medicines as may be indicated.   Even when we
fail to procure the  expulsion  by it of any the troublesome para
sites aimed at,  camphor rarely fails to  sooth those annoyances
which are  imputed to them.  The infusion of spigelia acts in a
similar way, though, I think, with somewhat less certainty, and
if pressed  too far, will impress unpleasantly the nervous system,
occasioning double vision, strabismus, and  even convulsions.
It is,  perhaps, as a mild narcotic, that the spigelia is useful here,
diminishing sensorial and vascular excitement.  Camphor may,
perhaps, exert a like operation, though the question is unsettled
whether it is prominently a stimulant  or sedative.  As an aro-
matic, in diffuse solution, as I  employ it, I  consider  it to  be a
tonic and cordial diaphoretic, pleasantly stimulating the stomach,
and by determining to the surface, restoring the impaired circu-
lation and action of the cutaneous vessels.
   To promote this centrifugal determination, we shall  find the
warm bath an admirable auxiliary.  You will sometimes see
children, placed in  it in a condition of  severe suffering or heavy
languor, revive promptly  and  re-assume an  unexpected degree
of cheerfulness and playfulness.  When the temperature of the
body is  unequal, the head hot, and the extremities cold—when
the abdomen  is tense and intolerant of pressure, the  stomach
uneasy and urged with frequent retching, and  the muscles agi-
tated with cramp  or  spasmodic twitching  or  convulsions, the
bath  should be promptly resorted  to.   When there  is  great
 debility, it may be made  stimulating, by adding salt or mustard,
 cayenne  pepper or ardent spirit.  Warm wine,  suggested by 
CHOLERA INFANTUM.
141
Rush, is too expensive to be among the resources of practice in
this country.  Some children, ill-managed in health, have  so
great a dread of water, that we cannot get them into the  bath
without an unpleasant and perhaps injurious struggle.  In  such
cases, and when any other contingencies offer an objection  to
the immersion of the  patient, we may substitute fomentations
and poultices.—Of all these, heat and moisture combined  form
the common  remedial  principle; and we indulge mothers and
nurses in  the choice of any of them which they may fancy to
be  specially  applicable.   Ordinary bread or meal—aromatic
herbs crushed and stewed, and  flannels wrung out of hot ley,
and hot spirits,  afford sufficient variety.
  I am by no  means in the habit of urging the mercurial treat-
ment in cholera infantum—yet, it is not to be denied, that  in
certain cases, we may derive very great benefit from the cautious
employment of calomel  as  an alterative.  The well-known as-
pect of our low-country children, born in the neighborhood of
swamps and rice-fields—the  sallow visage, with puffed  eye-lid
and cheek, emaciated limbs and tumid belly, will often improve
under this course and no other.   I usually add to the mercurial
a certain  proportion of opium  and ipecacuanha.  A child of
twelve or fifteen months, may take 1-4 or 1-2 grain of the former
with 1 gr. or  2 of Dovers' powder, every third or fourth hour.
This combination determines to the surface, corrects the morbid
secretions of the digestive tube, allays febrile excitement, calms
the intestinal  irritation, disgorges the swollen liver, and subdues
tormina and tenesmus, thus substituting  tranquillity forrest less-
ness, and  inducing quiet and refreshing sleep.   Dr. Miller, of
New-York, in one of the earliest treatises on this disease, urges
a resort to mercurial frictions.  I have no experience with them.
If the stomach will not bear the Dovers' powder, opium must be
given in some other form.   The alkaline diaphoretic mixture
may be alternated with the  mercurial.
  Epispastics are still employed,  by many physicians, among the
means of  revulsion in these cases ; but, for my own part, I  have
great reluctance to inflict a vesicatory upon an  infant, if it can
be avoided.  The delicate skin suffers much, at  this  age,  from
the painful inflammation thus produced, which often becomes 
142
CHOLERA INFANTUM.
diphtheritic, or extends widely, assuming an erysipelatous cha-
racter, and is  exceedingly slow  to  heal, ulcerating  deeply in
patches, or giving rise to  annoying  boils.   Sinapisms or poul-
tices with mustard, will act more promptly, and will effect every
thing that can be desired from revulsives.
  It is almost  unnecessary to direct your attention to the assidu-
ous employment of astringents and  tonics, when  the  diarrhoea
has run into the chronic condition, and is, by its protraction,
wearing out the  strength and constitutional resources of your
little patient.  Of the mere  tonics, Colombo and cinchona have
been generally preferred ;  but it is difficult to administer bitter
medicines to young children.  Some resort to arsenic and iron,
but I must confess, that they have not proved of the advantage
I had hoped  for in  these cases, and I place no confidence in
them.  One of the  metallic  preparations has, however, gained
of late a good  deal of reputation here, whose modus operandi is
not very obvious.   I  allude  to the  nitrate of silver, which is
affirmed by practitioners, of high respectability, to exert a pecu-
liar  and  unequalled influence in controlling the gastric and
intestinal disturbance, restraining the morbid secretions and res-
toring the  functions  of  the affected tissue.  The dose is, of
course, a small one, from  1-12 to 1-6 of a  grain, repeated every
third or fourth hour.   Of astringents, we have  in our hands a
large number  and variety, but they must not be indiscriminately
used.  An almost universal preference  is adjudged to the kino,
both by  the French  and English physicians, who were long
anticipated, however, in this matter by our countrymen. It is,
indeed, an invaluable remedy.  Some would restrict its adapta-
tion within narrow limits, and advise to abstain  from its use
whenever fever  or  intestinal inflammation are  observed to be
present.   This view of its utility, seems to me, to be a mistaken
one.   I would hardly administer it in an  acute  enteritis, or in
the violent invasion of a  bilious  remittent with dysentery ;  but
it seems applicable in  all  protracted  cases occurring in children,
and I have not found it necessary to wait  either for  the subsi-
dence of symptomatic fever, or  the subdual  of inflammatory
irritation, to obtain its good effects.   The best formula for pres-
cribing it, is the familiar one of the cretaceous julap, to which 
CHOLERA INFANTUM.
143
 may be  added, with advantage, a  proper  proportion of opiate,
 either in the old elixir paregoric, or as combined in the Dovers'
 powder.
   Among the domestic astringents  in  good repute with nurses,
 there are some quite serviceable.  An infusion or tincture of the
 rind of the  pomegranate—an infusion of the root of the  dew-
 berry or high blackberry, of galls, and of logwood, are all much
 employed.   Dr. Miller, already quoted as an early authority on
 this subject, extols the  common alum as well-fitted to do good.
 He administered it in doses of 1, 2  or 3 grains, combining with
 it some anodyne, such as Dovers' powder.   The acetate of lead
 is a frequent and favorite prescription with me, apportioning the
 dose carefully to the age of the infant.  I  dissolve it  in  some
 mucilaginous  mixture, to which I  add a  small  amount of the
 acet: morphine or tinct: op: camph.  It  is willingly taken, and
 besides its astringent effect, certainly seems to control the irrita-
 bility of stomach so often present.
   The selection and employment of well-adapted enemata, will
 aid us much in the management of this troublesome disease.
 In the earlier periods of an attack,  if it be  our  object to obtain
 free evacuation of the crude and feculent  contents of the ali-
 mentary tube, and thus to diminish the general morbid excite-
 ment,  we may throw up into the rectum  tepid water alone, or
 containing a little salt or molasses, or olive or castor oil.  After
 this, the mucilaginous solutions will be found serviceable, and
 may be made vehicles for our opiate, or mingled with astrin-
 gents,  either vegetable or mineral, as the solution of acet: plumbi
 or the  infusion of pomegranate rind  or of logwood or  galls.
 These should be  injected cold and in small quantity, and re-
 tained by external pressure.
   Much will depend upon  the general regimen observed.   The
 diet requires especial care.   Such  articles deserve a preference
 generally, as are least liable to undergo acescent changes.  If a
 child has been weaned too early, return it to the  breast of its
 mother, or provide a healthy  and suitable wet-nurse for it.  If it
 has been weaned at the proper age, substitute for its  mother's
 breast  milk, now no longer procurable, diluted  milk from the
cow, tepid, with a little sugar, or some light, farinaceous food.
Thin  corn  or rice gruel,  arrow-root, coonty, boiled biscuit  or 
144
CHOLERA INFANTUM.
bread panada, may  be tried in succession.   Broths suit well
with some children, as chicken, veal  or  mutton broth  or beef
tea.   Others suck  the juicy meats  underdone.   The books
record strange perversions of appetite under these circumstances.
Dr. Rush mentions a child of sixteen months, who recovered on
a diet of rancid English cheese, and Port wine drunk undiluted.
They are often pleased with strong flavors, and become fond of
salt fish and salted meats.   I have seen children in a moribund
state, exhibit this tenacious fondness  for  ham, which they held
in their hands, constantly sucking.
  The clothing should be warm, consisting of flannel or cotton,
according to the season.   When the weather  is damp or chilly,
or changeable, the flannel fold and roller applied about the abdo-
men, will be found useful.   Perfect cleanliness of the person,
the bed and body clothes, and the apartment of the child,  must
be  enjoined. Removal and change of air, must always be re-
garded  as  one of our  most efficient remedies.  It is of impor-
tance, that we should not too long delay  the experiment, and if
well-timed,  we shall find the mere transition from the confined
streets of a city to the open fields, the elevated  ridges of pine
land, or the sea-shore, of itself and at once restorative.
   After all that has been  said, however, it  must be acknow-
ledged, that the  treatment of cholera  infantum,  whether from
anything inherent in the nature of circumstances, or from defect
in our methodus medendi, is far from being as successful as we
would  desire ;  and the bowel  complaints of spring and early
summer, are justly  dreaded by every parent.  It is, therefore,
strongly incumbent upon us, to attend assiduously to  the pro-
phylactic management of young children and infants,  so as, by
our counsel, to  evade or prevent attacks which we find, confes-
sedly, so difficult of cure.
   When  it  is  in the power of the  parents, children born and
resident in  cities, should always spend a part of the year in the
country.  The  results of all observation  go to show, that the
concentration of large masses of human  beings, however advan-
tageous it may be to their progressive intellectual development,
has an inevitable tendency to  occasion  their ultimate physical
 deterioration.  This is, at first, and most strikingly notable, in
 the degenerate vigor and imperfect  growth of their  children; 
CHOLERA INFANTUM.
145
and it is during this early stage of life that disease  assails, and
predispositions are formed, and the constitution takes so often a
morbid bias.
   Yet, it  is not  in every one's  power  to avail himself of the
knowledge of these truths.   The imperious calls  of business
confine men with their families wherever the means of living
are most  attainable; we must, therefore, accommodate our di-
rections to the necessities of the case, and  lessen, by proper
regulations, the force of evils we can hardly hope to shun.
   Children should have free exercise at all times,  and in every
mode suited to  their age and physical  powers.  They should
live as much as possible in the open air;  sun-light is as impor-
tant to animal as to vegetable health.   Their dress should be
attentively accommodated to  atmospheric vicissitudes, guarding
them from cold  and  moisture.    Their sleeping apartments
should be elevated and dry, and cleansed and ventilated per-
fectly and always.  Cleanliness of person and clothing must be
strictly enforced.  The bath should  be used daily—.cold, if it be
well borne and the subject robust, tepid  for infirm and delicate
children.   They  should not  be weaned until dentition is  suffi-
ciently  advanced for  the effectual mastication  of soft  food.
During the process, the gums should be examined from time to
time, and  swelling or inflammation relieved by incisions.   After
weaning,  the diet should be as above  indicated, allowing a lati-
tude proportioned to the appetite and  obvious powers of diges-
tion  in each little subject.   Crude  vegetables should be forbid-
den, and fruit permitted in very small  amount, if at all;— animal
food may form a gradually increasing proportion of the food.
Rush recommends a moderate quantity of salted meat occasion-
ally, and  speaks  in  high terms of  the advantage of offering a
little sound old wine from time to time.  Both these suggestions
are valuable; the latter, however,  in reference to  children of
rather more advanced age than  the  usual  subjects of cholera
infantum.
   These  general rules of regimen  and diet, require  to be at-
tended to with most peculiar care, in  families where there is
reason to  suspect the prevalence of a strumous diathesis.  If the
mother have suffered from any of the forms of open scrofula,:or
being a descendant from a scrofulous stock, has  exhibited the
       tol. n.—13 
146
WORMS.
well known tokens of that vicious constitution, I would unheshV
tingly advise, that the child be taken early from her and put to the
breast of a healthy nurse.  None have ventured to  deny, that
an infant nourished from such a morbid source, is likely, sooner
or later, to  fall  an easy victim to predispositions  thus  engen-
dered or made more intense.
                     CHAPTER XXXI.

                          WORMS.

  As plants  are observed to be preyed on by parasitic plants,
so also all animals are infested by parasitic animals.  The natu-
ral history of these is highly interesting, and constitutes already
an extensive department of knowledge, which is widening every
day.  Some of these dependents belong probably, in an essential
manner, to the  organization to which they are attached, and this
seems  especially true of many classes of animalculae found  in
the normal secretions, as, for  example, the spermatic animalculae
of the various orders, the spermatozoa.   Others seem to connect
themselves closely with, and arise out of diseased secretions and
morbid  conditions  of parts.   Hence,  some pathologists have
been led to attribute  a great number of diseases to the irritation
of particular and  specific varieties  of animalculae ; thus, psora,
dysentery, and  cholera,  have been alleged to originate—and,
indeed,  many  others, as small-pox, cancer,  measles, plague,
syphilis, and hydrophobia.
  How these  creatures  are  generated,  in  the  first instance, is
matter of most obscure speculation.   Many of them,  as the
hydatid, seem incapable of re-production, while others comprise
within their structure an apparatus of organs for the purpose.
It would be an almost  endless task to attempt the mere enu-
meration of these  entozoa, both animalcular and of larger size.
Man has his full share of these troublesome attendants.  There
is no part of the animal body in which such parasites have not 
WORMS.
147
 been found—in the  skin, the cellular tissue, the muscles, the
 eye, the heart, the brain, the liver, the kidney.
   It would be out of place here, to treat of any but those which
 infest the organs of digestion ; and  even among  these, as my
 object is, of course, specially practical, I shall confine myself to
 the discussion of  the presence, effects and  means of expulsion
 and prevention of Intestinal Worms.
   The human intestines are scarcely ever found entirely unte-
 nanted by certain  familiar species of worms, besides being sub-
 ject to the accidental presence of rarer varieties.   Those most
 frequently met with, are the lumbricus, ascaris, and taenia.
   The lumbricus—ascaris  lumbrieoides—round-worm, is  the
 most common of the  human entozoa.  Children may be said to
 be almost  uniformly subject to the  presence of the lumbricus,
 and indeed adults  also.  Their existence in the body does not
 seem productive of any necessary or  definite effect, and is often
 unthought of until after they*nave  been expelled.  From the
 fact, thus alleged,  of their universal domiciliation in the bowels;
 and their occasioning no definite  mischief unless when in extra-
 ordinary number,  or when, from some  incidental  change of
 condition,  the  system is enfeebled  or rendered irritable,  Parr
 was induced to describe them as "forming a part of a healthy
 constitution, and as scarcely injurious but  from accidental  cir-
 cumstances."   Nay,  our own Rush, with  an unaccountable
 perversity, not  only inferred  their harmle^sness, but  even be-
 lieved in their absolute utility, and suggested, that the want of
 them might sometimes occasion disease in children.
   Now, although  it  cannot be  denied, that they have  been
 known to infest the  bowels, for great lengths of time, without
 giving  rise to  any notable  evil,  yet, on the other hand, it is
 perfectly certain, that, whether as cause or effect, their existence
 in any considerable numbers, is  usually coincident with a  de-
 praved state of the general health, and with an infinite  diversity
 of morbid symptoms, to  be hereafter spoken of.  Individuals of
 lymphatic  temperament, such as  inhabit low and damp locali-
 ties, and subsist on  scanty or gross and  indigestible  food, are
 most  obnoxious to them, and the multitudes generated in the
bowels  of such subjects are  prodigious.   In the  examination
of the body of a negro girl, about ten years  old, we  found it 
148
WORMS.
impossible to take hold of any portion of the intestines without
including between the thumb and finger one or more lumbrici.
I have known thirty at one time, and, at another, forty of these
worms, expelled in one evacuation.  In the case of a poor ema-
ciated  and miserable humpback, a black boy of about fourteen
years, I saw a mass which had been discharged in the course of
a single night, amounting, as I was assured, and as seemed pro-
bable from appearances, to not less than one hundred and sixty.
  This worm is, as its name imports, of round, elastic body,
with a smooth, shining surface, of a whitish or yellowish hue,
from five to twelve inches in length, of about the thickness of a
writing quill in the middle, and tapering to the extremities, of
which the anterior is most attenuated, commencing abruptly by
three tubercles which surround  the  mouth.   The  lumbricus
was once supposed to be of the same class with the earth-worm,
which it certainly resembles a good deal; but a minute exami-
nation, shows many essential and*striking points of dissimilarity
both in the external and internal structure.   Thus, for example,
the earth-worm is hermaphrodite; but in the lumbricus, there is
evident distinction of sex.  It usually inhabits  the small intes-
tines, but is  found in all parts  of the abdominal canal, being
known to crawl from the anus, and not unfrequently  coming up
the aesophagus and finding its way with coughing or vomiting,
excited by its tickling motion, through the mouth and nostrils.
  The ascaris vermicularis—ascaris—thread-worm—maw-worm,
inhabits in masses composed of large numbers, the  cavernous
cells of the colon and rectum.  It is round, white, and highly
elastic—filiform in appearance,  from  one-fifth of an inch in
length to  an inch.  The  sexes  are  separate, the males being
smallest.   "The vivacity," says Brera, "with which it skips and
bounds is amazing.  If touched with  the finger, or brought
near the flame of a  candle, it contracts very remarkably.  It is,
perhaps, to this vivacious contractility, that we are  to attribute
those enormous irritations of the intestines, and especially of the
anus,  which torment those infested by them."
   The  trichuris—tricocephalus—tricocephalus  dispar—tailed
thread-worm, is usually enumerated among the intestinal worms.
 It is very rarely met with, and therefore, perhaps, deserves to be
 regarded rather  as a pathological curiosity.  It is an inhabitant 
WORMS.
149
 most commonly of the coecum and colon, seldom seen in the
 small intestines, and  has been found occasionally loose in the
 abdominal  cavity, having perforated the coats of the intestine.
 For about two-thirds of its length, it is of capillary slenderness;
 the remaining portion is thicker, terminating obtusely.
   The taenia or tape-worm is  one of the most annoying and in-
 jurious of all the parasitic entozoa.   It infests a great many ani-
 mals, and is met with, not unfrequently, in man.   Two species,
 which naturalists tell  us belong to different genera, are found in
 the human body, and these are  said to  observe a singular geo-
 graphical or national  distribution.  "The Swiss and Russians,"
 says  Owen, "are troubled  with the bothriocephalus latus; the
 English, Dutch and Germans,  with the taenia  solium; both
 kinds occur, though not simultaneously,  in the same individual,
 in the French."  The former, he says,  may be readily distin-
 guished  from the latter, by the shape of  the segments of which
 it is composed, which are of greater breadth than length, by the
 position  of the genital pores in the middle of one of the flattened
 surfaces, and not as in the taenia solium,  at the margin of each
 segment, and by the head which is  elongated, with two lateral
 longitudinal fossae, instead of the four round oscula, characteristic
 of taenia proper.
  The taenia solium, which is the true tape-worm  that you are
 likely to meet with, consists of flattened, whitish looking pieces
 or segments ; separate joints, once regarded as a special variety,
 the lumbricus  cucurbitenus of Heberden, so called from their
 somewhat resembling gourd seed.   It attains sometimes a great
 length, from ten feet to many yards.  Brera says there is one in
 Padua two hundred and thirty feet  long.  Wilson, in a case re-
 corded in the Philadelphia Journal,  states that three hundred
 feet at least, had been discharged  by the  patient.  The worm is
 usually solitary, but not always, so that the pieces collected may
 belong to or constitute  parts of several individuals.  I saw on
one occasion ten yards brought away from a female patient, eight
of which were connected, the remainder being in small pieces.
 In each piece there is an ovary, containing often  a prodigious
number  of eggs, expelled,  when  mature, through  apertures in
the  margins.  The  animal is a hermaphrodite or androgynous.
It inhabits the upper part of the intestinal canal, and is supposed
       13* 
150
WORMS.
to feed on the chyme and other nutritious juices imperfectly ani-
malized.   The head is usually towards the upper portion of the
tube, and is said to fix  itself in the mucous membrane firmly,
by means of fangs or hooks.   We know it to be very difficult to
dislodge, and unless the head  is brought away, the patient is by
no means freed  from the worm.  It is affirmed  to be in a very
peculiar  degree tenacious of life.  It is asserted that "they have
been known  to live for  hours vigorous and active in boiling veal
broth."  The head, for  which  we should examine  with great
care, is small, nearly hemispherical, broader than long, and trun-
cated  anteriorly;  its four mouths or oscula,  are  situated on the
anterior  surface, and furnished with a double circle of small re-
versed hooks.
   The origin of these parasitic entozoa, is a question of extreme
difficulty and obscurity.  Their production is one of the best ap.
parent examples of spontaneous or equivocal generation.  They
are found in existence no where but in the  situations indicated
 within the bodies of other animals ;  and they all perish in a
brief period  after  their  expulsion or removal.   They all  increase
 by ordinary  propagation, however, and multiply in vast numbers.
 That  there are particular conditions  which  foster their  increase
 is evident.   The  national distribution  of the several varieties of
 tape-worm has been mentioned.  Nothing is better known than
 the greater liability of  children than adults  to the annoyance of
 lumbrici and ascarides.  This liability is most  notable  between
 the time of  weaning and the age of puberty ; perhaps from the
 third to the  eighth year of life.  I have seen but two unweaned
 children much troubled with them ;  each about one year old.
    They are  apter to  prevail  in individuals who  live on a poor
  and innutritious  diet, and whose organs of digestion  are by any
  cause or causes  enfeebled.   Hence,  from transmitted peculiari-
  ties,  there has been supposed to be in some families a hereditary
  verminous  tendency.   It  has even been maintained that they
  cannot  resist or sustain the action of  the perfectly healthy secre-
  tions of the gastric and intestinal  surfaces, endowed as they are
  with powerfully solvent properties; but this notion is untenable,
  as their presence is  consistent  with  the enjoyment of the best
  health, and they are  frequently discovered  accidentally in per-
  sons who have suffered under no mode of disorder. 
WORMS.
161
  The effects of verminous irritation are exceedingly diversified.
It is indeed to be doubted whether  there are any  peculiar or
characteristic phenomena which serve clearly to show the pre-
sence of the most common, the  round worm or lumbricus ;  nor
can we clearly point out any symptoms as being definitely con-
nected, even with their inordinate numbers, in the constant rela-
tion of cause and effect.   "There is  scarcely a disease,"  says
Rush, "or symptom of a disease  belonging to Cullen's class of
Neuroses, which is not produced by worms."  Febrile affections
are often ascribed to this source, and  I have  already treated in
detail, of ordinary worm  fever.  Among  the infinite series of
maladies attributed to lumbrici, I  will merely enumerate epilep-
sy, chorea St. Viti, hydrocephalus, and many varieties of pulmo-
nary and  bronchial disorder, as shown by cough, diarrhoea and
atrophy.   The train of symptoms developed in connection with
the presence of the worms, seems to  be influenced much by the
constitutional predispositions of the subject affected, and they bear
a relation as well to the mobility and sensibility of the patient,
as to the number of worms  present.   During the age at which
children  are most liable, their intestines abound with a tenacious
mucus which offers a convenient nidus to these vermin ; at this
time,  too, they are apt to eat without caution, and immoderately,
of every thing in their reach.
   Among the symptoms alleged to be most commonly produced
by the presence of lumbrici, we  may specify the following as
familiar to parents and nurses, though by no means unequivocal
in their  import,  or decisive as to  the existence of an  exclusive
cause.   The child is languid and fretful;  his appetite is irregu-
lar, often deficient, but sometimes voracious; the abdomen  pain-
ful and  tumid; stools  loose and  offensive, with straining and
griping ; the tongue foul and the  breath foetid ;  there is emacia-
tion and loss  of strength  ; the sleep is uneasy, with moaning,
starting and muscular twitching; the patient grinds his  teeth
and picks his  nose; there is occasionally a teasing, dry cough,
with more or less febrile  excitement at uncertain  periods and
intervals; determination  to  the brain is  a frequent attendant
with  frightful convulsions.   Yet although  the  concurrence of
many or most of these phenomena in any  case, would justify
you in regarding it as verminous, and treating it accordingly, 
152
WORMS*
the expulsion of worms is the only proof of their agency, if
even this be regarded as sufficient; indeed it has seemed to me, in
more than one instance, clear, that although they were brought
away by the evacuants employed, there was no good reason for
ascribing to them the disorder of the patient.
  I shall not go at length into the discussion of the remedies for
lumbrici, the anthelmintics treated of in abundant detail by my
colleague of the chair of materia medica.  Let me remind you, in
passing, however, that  these medicines are too powerful in their
specific influences to be employed promiscuously, or in mere re-
ference to their vermifuge property.   The choice should be care*
fully adapted to the actual pathological condition of the patient.
If the principal irritation affect  the nervous system, you will do
well for the most part to avoid the narcotics, spigelia, melia aze*
darach, etc., and  employ  the cathartics, as calomel, castor oil,
turpentine, etc., which in their  turn, become improper when the
bowels are excited with diarrhoea; and so of  the rest.
  It is a difficult thing, in  many individuals, to prevent their
rapid multiplication and often recurring annoyance.  The free
use of  salt is urged by one, as  prophylactic;  the  occasional ad-
ministration  of wine,  of pungent  articles of food, as cheese,
onions, garlic, and the like, by others of equal authority.  I have
been best satisfied with the exhibition of camphor, in  very dif-
fuse mixture with water,  as in  domestic practice among the
Italians.  A dram of the spts: camphorat: being mixed with f viij
of water, and made in any way agreeable to a child, he  may
be induced to take this quantity during twenty-four hours, for
many days in succession.   Whether it be that the aroma of this
substance is particularly disagreeable to the lumbrici, I will not
pronounce, but 1 have known many of them  come away from
the body during this course, to  the great relief of the patient.
   The thread worm,  ascaris vermicularis, produces either no
annoyance at all,   as is said to  be the fact with regard to the
trichuris, or it gives rise  to more definite symptoms  than the
lumbricoides.   These  are described as follows:  There is great
uneasiness in the rectum,  and an intolerable itching of the anus,
seldom troublesome before the evening, and much aggravated on
going  to bed, with heat in the part, and frequent  tenesmus.
These little creatures  are  found  in  the stools,  entangled in  a 
WORMS.
153
 bloody mucus, and sometimes in the beds  of children,  having
 crawled forth spontaneously.  They are exceedingly difficult to
 get rid of, so that many persons have passed their lives, without
 ceasing to be troubled by them.  They are not absolutely con-
 fined  to the  lower  intestines, but are also met  with in the
 stomach, whence one of their names, maw worm.  They there
 give rise to indigestion, with "an uneasy, faintish feeling at the
 pit of  the stomach;  a capricious or depraved appetite;  pains in
 the abdomen, with itchiness and redness of the nose."
   The best relief seems to be given by  active purgatives and
 aperient enemata.  Of these latter, I have seen the best effects
 follow from the administration of solutions of aloes and of assa-
 foetida; warm milk and oil used in this way, diminish  the  te-
 nesmus ; camphor, turpentine, and the essential oils,  are also of
 benefit.  Brera recommends their mechanical extraction, by  in-
 troducing a bougie or candle into the rectum, smeared, as others
 advise, with mercurial ointment, which, when drawn out, often
 brings away great numbers.  Howship  proposes the occasional
 introduction of the finger for the same purpose.
   These palliatives are much aided by a proper attention to the
 diet and habits of the patient.  The former should be simple;
 all stimulants, both  of food and drink,  being abstained from.
 The bowels should be kept regularly soluble, either by laxatives
 or by occasional enemata, and great cleanliness of the person
 observed.  This injunction should be specially attended to  by
 females, in whom pruritus vulvae may be brought on  by their
 irritation.
   Taenia, or tape worm, deserves at our hands a more particular
 consideration.  It is of the taenia solium that I am about to speak ;
 the lata or bothriocephalus, I have  never seen.   The  influence
 of the presence of this worm, has been  variously  described  by
 many writers, the majority of whom admit,  without  hesitation,
 that it may exist long in the body, without occasioning any dis-
 turbance whatever.   Its proper habitation is the upper and smaller
 intestine, and some suppose that it only becomes annoying when,
by its growth, it has  extended into the larger portion of the tube.
 It surely does happen, as I myself have known, that portions of
the worm, or joints,  have come  away  from individuals, appa-
rently in excellent health.  That it does present itself low down 
154
WORMS,
in the bowels, is strangely proved by a case recorded in the
Med: Chirurg: Journal, in which it is  mentioned  "that the pa-
tient was in the  habit of ridding himself of large fragments of
his tormentor, by introducing a stick into the rectum and twist-
ing it round the worm  till it  broke."  It is still  questioned,
whether there are any  symptoms which distinctly prove the
presence of taenia, previous to the expulsion of one or more seg-
ments of its body.  I think there are none such; yet the con-
currence of  morbid sensations  is  somewhat  peculiar,  and not
likely to occur in any but those  who are suffering from this
parasite.   Louis gives us the results of his  observations of ten
cases, at La Charite.  Among  these were a father and son.  I
have had under  my care, an old gentleman and his great grand
son; from which facts,  may arise suspicion of  predisposition
hereditarily  transmitted.   In almost every case on record, there
seems to  have been  a  voracious,  though  somewhat irregular
appetite.   My patients have, with  scarcely an exception, com-
plained of a dragging sensation, attended  with  cramps, and a
perception of uneasy or convulsive movements in  the bowels.
There is pain in  the  abdomen, which some describe  as colic,
and others speak of as  peculiar and  indescribable.  Some are
teased with diarrhoea,  others  merely with tenesmus.  Some
emaciate, others  do not.   My two first patients presented, in this
respect a  most striking  contrast.   One, a male, was a skeleton,
completely atrophied; the other, a female, was very plump and
in good condition.  Dr. Baillie  recites, as the symptoms most
indicative of the presence of taenia, "a gnawing uneasy feeling
in the region of  the stomach, diminished or removed by eating;
an appetite commonly somewhat voracious, though  occasionally
deficient; frequent nausea, colics and vertigo."  Louis states,
that the functions of the body generally,  were impaired, in all
his cases,  though in very different degrees.
  It is singular to remark, that when joints of the  worm have
begun to come away, this does  not only show itself in the stools,
but pieces are found in the beds of the patients,  and fall from
the anus at  times, while they are walking.
  In the Treatment of taenia, I have no hesitation in adding my
testimony to the abundant records of the preference due to  the
spiritus terebinthinae. I have not failed to bring away more or less 
WORMS.
155
of the worm, in every case in which I have resorted to it freely,
but the doses required may be large.  From one to two drachms
are generally given, at intervals, either alternating with,  or fol-
lowed by proper doses of castor oil.  Fenwick  prescribed two
ounces, to be repeated in two hours, if no effect was produced,
and even a third time,  if required.  Exhibited  in  this way, I
had the satisfaction to see expelled from a female patient, as I
have already mentioned, not less than ten yards  in one day, of
which eight yards  were in connected segments, the rest consist-
ing of loose joints.   This lady remained a long time well; in-
deed, I know not that she was ever  annoyed with tape worm
again, although I failed to  find the  head,  for which, as I told
you, we are enjoined to make diligent search.  There is, perhaps,
some risk, in these large quantities, of producing strangury and
irritation of the bowels.  My patient suffered for  a short time
from the former.  Prof. Elliotson has carried this plan so far, as
to administer two  or three  ounces of turpentine every second
day, for a fortnight, taking care to follow every  such dose with
castor oil, which purging briskly, at last expelled the worms.
   Bremser, one of the best authorities on  this subject, speaks
with highest eulogy of an empyreumatic oil, (Chabert's) made
by mixing empyreumatic oil of hartshorn with oil of turpentine.
Rudolphi and Brera, also recommend it as a most valuable ver-
mifuge.  If given  too largely, it may excite,  however, a severe
and troublesome degree of intestinal and  cystic irritation.
   Louis met with  uniform  success, he tells us, in  the  employ-
ment of a quack remedy, Darbon's potion, a secret  nostrum.   It
seems to have been as  safe as it was powerful.  In one instance,
it was stated to have procured the expulsion of the heads  of
seven worms at one evacuation.  Chomel, Lerminier and Fou-
quier, are said to attest these  facts.   A recent writer suggests,
that this  nostrum  may possibly consist of some preparation of
the root of the pomegranate, a remedy which has long enjoyed
a great reputation  in the treatment of taenia.   A pretty  strong
decoction is made  of the dried bark of the root,  of which an
ounce or two ounces are given every half hour, until there is
nausea, giddiness and pain  in the bowels, which symptoms are
almost always shortly  followed by the  expulsion of the worm. 
156
WORMS.
It seems to act specifically, of which it is regarded as proof, that
a living taenia, plunged into  such a decoction,  writhes, suffers
much, and dies soon.   EUiotson, who thinks highly of the bark
of the pomegranate root, prefers the powder to the decoction.
Some advise it to be followed by a purgative, within a few hours,
and that no food should be taken in the  mean time.
  The male fern, polypodium filix mas,  has also been much ex-
tolled.  This is the basis of the Swiss  remedy, purchased by
the French government, from Madame Nouffer.  While  some
rely confidently on this medicine, others speak of it with con-
tempt.  Cullen regards its good effects as depending entirely on
the drastic cathartics, with which it is combined.  It is of little
consequence to decide this point, but I cannot help thinking the
evidence preponderates in favor of its specific vermifuge power.
Three drachms of the root  reduced  to a fine  powder, form a
dose for an adult, to be taken  in any simple water.  Two hours
afterward, a bolus is to be administered, consisting of calomel
and scammony each grs. xii, gamboge grs. v.   If the purgative
do not operate sufficiently, some neutral  salt must also be taken,
at a proper interval.
  Odier prefers to all other cathartics here, the simple castor oil,
which he used with this view, perseveringly and in large quan-
tities.
  Rosenstein expelled tape-worms, he tells us, by mere purging;
during the operation, causing his patients  to  drink profusely of
cold water, which he supposed rendered it liable to be detruded
by the peristaltic action of the intestines.  The water should be
very cold or even iced.   He urges the  taking of a glass every
four or five minutes until a gallon has been swallowed.
  Some of the  mechanical  remedies are said to have succeeded
well, of which the filings of tin and the cowhage are examples.
Dr. Parr affirms, that  he has witnessed the most happy effects
from the administration of the coarse raspings of a pewter plate.
The amalgam of tin with quicksilver, by whom suggested, or
with what view originally, I know not,  has been highly spoken
of by certain writers, among them the justly celebrated Darwin.
An interesting example of the results  of its incautious employ-
ment, for the expulsion of tape worm, may be found in the Phil. 
HEPATITIS.
157
Journ:, vol: 1st and 2nd.  The patient took of this  amalgam,
not less, it would appear, than twenty ounces, which, failing to
pass off by stool, remained  massed  together  and impacted  in
the intestinal tube during the remainder of his life, occasioning,
as may be supposed, many and severe inconveniences.
                     CHAPTER XXXII.

                         HEPATITIS.

   Of the organs contributory to the function of digestion, the
 liver is the largest.   Indeed, it is the largest of'the human vis-
 cera, its ordinary weight, in a healthy adult, being calculated at
 about three pounds.  It would also seem to be among the most
 important, whether we argue from its size, its almost  invariable
 presence in the different classes of animated beings, or the large
 supply and singular distribution of blood sent to it.
   Of  the immediate agency of the liver, or the particular uses of
 the bile, which it secretes in so large quantity, in the process of di-
 gestion, it may be frankly confessed that we know little or nothing.
 But we  cannot  hesitate to accord to it a principal place,  in a
 pathological point of  view, when we reflect upon the  extent of
 its sympathetic connections with the various parts of the sys-
 tem, and the influence of its diversified morbid conditions, upon
 both the mind and body.   In warm climates, especially, this in-
 fluence is more striking and clearly marked, and  forms one of
 the points to which, in your future practice, your attention must
 be closely and steadily directed.  In miasmatic regions of coun-
 try, indeed, you will scarcely meet with an  instance of disorder,
 either  of the circulatory or digestive functions,  in which the
liver is not primarily or secondarily affected, in a  greater or less
degree.  Numerous exemplifications of this fact,  have crossed
us at every step of our progress, as in bilious fevers, dyspepsia,
dysentery, etc.
  Many pathologists have attempted to account for this peculiar
       vol.  ii.—14 
158                     HEPATITIS.

liablity of the liver to derangement in hot climates, but in plau-
sibility and apparent soundness,  their speculations are all ex-
celled by those of a writer, whom I have had lately occasion to
quote more than once :  I allude to James Johnson, and his trea-
tise on the Influence  of Tropical Climates, a book which has
received just commendation from the highest professional names
of the age.
  This author has  advanced the opinion, and maintained it with
no little ingenuity and force of argument,  that  there exists be-
tween the skin and the liver, a direct and  close sympathy, ren-
dering them liable  to be equally, regularly, and similarly influ-
enced by particular agents, acting upon either.  Thus, from this
connection or consentaneous action of the extreme  branches of
the vena  portarum, and the extreme cutaneous vessels, it fol-
lows that the biliary secretion and  the perspiration will be ob
structed or increased, by the synchronous  effect upon them, of
any agent applied to either.  Heat, therefore, which invariably
stimulates the exhalents of the surface, and vastly increases the
quantity of perspirable matter  thrown off, necessarily urges the
liver also, to proportionally increased  secretion of bile.  But it
is well known and acknowledged,  that if any organ be stimu-
lated to inordinate action, it  either falls  into occasional torpor
and exhaustion, or if this inordinate action be kept up, for any
length of time, by the incessant application of unusual stimu-
lus, serious injury, and even  structural alteration will be the
consequence.  And this doctrine of cutaneo-hepatic sympathy,
 (for the proofs of which, I refer you to the work itself,) will be
found, he argues,  to account for, and explain all the various de-
 rangements and disorders of the liver, so commonly met  with
 in warm climates.
   Whatever  form  of hepatic  disease may  be generated by ex-
 treme heat, as above specified, it will be  apt to give rise to, or
 run into an inflammatory condition of the liver, and the inflam-
 mation may  be either of the acute or chronic character.
   The distinction between  these two species  of hepatitis, you
 will observe, does not simply refer to the time occupied in their
 course, or the rapidity of their progress, but is generally under-
 stood to imply a difference in kind, as well as in degree. Thus
  many  believe acute  hepatitis  to consist  in  an  inflammatory 
ACUTE HEPATITIS.
159
 state of the membranous  envelope of the organ ;  and chronic,
 in inflammation of its parenchyma.  Others  attribute the acute
 species to an inflammatory condition of the ramifications of the
 hepatic artery, and the chronic, to a like state of the vena portae.
   To decide  these disputed points, is, I confess, altogether be-
 yond my power; yet, I am disposed to think there is  some rea-
 son for the first of these distinctions.  The pain in acute hepati-
 tis is often extremely severe, and much unlike the deep seated
 aching connected with  inflammation of parenchymatous struc-
 tures generally.  Yet, neither can I  doubt  that they, at. times,
 run into and produce each other; the  acute leaving often be-
 hind it the  chronic inflammation ; and  the chronic, needing,  in
 many instances, only the  application of some exciting cause to
 become acute also.   Here it is evident, that  both the intestinal
 structure and the external surface or membranous coat, must  be
 affected at the same time.   "When in disease of the liver," says
 Baillie, "inflammation is confined to the membrane of the liver,
 it is not frequently extended over the whole of it, but more com-
 monly takes place in that portion of it which covers the anterior
 or convex part.  I have also seen  inflammation or its effects, on
 that side of the liver which is in contact with the stomach  and
 the duodenum.  When the membrane is inflamed, the substance
 is sometimes inflamed which lies immediately under it."

   Acute Hepatitis commences with rigors, and an accelerated
 hard, jerking pulse; there is a pungent pain  in the  right side,
 which is felt under the margin of the ribs, shooting to the back
 and to the top of the shoulder.  The pain is permanent, usually
 without sickness at the stomach, but occasionally, if extremely
 severe, attended with nausea.   The tongue is whitish and furred,
 and the skin hot and dry,  and there is much thirst; the  bowels
 are irregular, but for the most part, costive.   The respiration is
 hurried and uneasy, and a deep inspiration increases the pain in
 the side.  Cough comes on, short and dry, some hours after the
 access of the disease.
   It is not always easy to distinguish an attack of hepatitis from
pleurisy.  We have a case related with great  candor by Cleg-
horn, which he imagined to be pleurisy; the patient died on the
twelfth day, and on examination there was found a large abscess 
160
ACUTE HEPATITIS.
in his liver, his lungs and pleura being quite sound.  The diagnos-
tics, however, are nof usually so difficult.  We have in hepatitis,
the pain at the top of the right shoulder, a symptom difficult to
explain or account for.  Much insisted on by writers generally
in hot  climates, its frequency and importance are both denied by
Mcintosh, Andral and Stokes.   I have always  met with it.
There  is at first, no cough, which  comes on in pleurisy  simul-
taneously with the pain and fever.  The patient  complains of
pain lower down in his side, placing his hand, when desired to
point out the seat of his sufferings, upon the cartilages of the
false ribs, and when the hand is pressed pretty firmly inwards
and upwards under  the ribs, he shrinks and starts back.  Ex-
ploration of the thorax and abdomen, carefully made, will obvi-
ate any farther liability to mistake.  If  the lungs be  unaffected
with inflammation, resonance or percussion will be unimpaired,
and the respiratory murmur will  be distinguished.  Allowance
must be made, however, for some projection  upward, of an in-
flamed and swollen  liver,  which  will  encroach  somewhat, on
the usual limits of the thoracic cavity,  by pressing up the dia-
phragm.
   Heat, though as you have heard, the principal  predisposing
cause  of acute hepatitis, and capable in itself of generating it,
as it would appear, is not yet the only source of the disease.  It
is liable to be brought on  by the  application of other agents or
excitants;  among them,  the chief may be  considered  alterna-
tions of temperature.   "Cold," says Dr. Mosely, "is the cause of
almost all the diseases in hot climates, to which climate  alone is
necessary."  The application  of even a slight degree  of cold,
is affirmed by Johnson, to be pregnant  with  danger,  in  the de-
bilitated state of the extreme vessels of the skin and liver, con-
sequent upon the continuance of heat for some time.  "For not
only is the animal  heat too rapidly abstracted, but  both  these
 sets of vessels are instantly struck torpid ; the biliary secretion
 and perspiration are  both arrested; the passage of the  blood
 through the liver is obstructed, and  congestion  and inflamma-
 tion are the results."  Any excess, either in eating or drinking,
 indulgence of any of the passions, exposure to rain or moisture,
 night dews,  etc., have all been known to bring on attacks of this
 form  of disease. 
ACUTE HEPATITIS.
161
   Acute hepatitis may terminate in various ways ;  either pros-
 trating the patient like other inflammatory diseases and running
 at once to a fatal issue; or giving  rise to  a chronic affection of
 the organ; or ending  under favorable  circumstances of habit
 and  constitution, and skilful, energetic treatment, in resolution
 more or less  complete.  It occasionally produces suppuration,
 when one or more large abscesses will be found in the organ. The
 secretion of pus in the liver is known by chills and rigors taking
 place, a sense of weight and heaviness in that part of  the abdo-
 men.  Sweats about the face  with  increased frequency of pulse
 are also enumerated by Pemberton  among the tokens of the oc-
 currence  of suppuration.  This is  always an alarming circum-
 stance,  though  not  necessarily  fatal.   Annesly, in  the  East
 Indies, has met  with several examples of cicatrization of the
 liver, after "cured  hepatic abscess."  One such  case occured in
 the Meath hospital, in a soldier formerly serving in Hindostan.
 The cicatrix, described by Stokes, consisted of a depression, with
 puckering of the hepatic tissue and deposition of cartilaginous
 structure.  If adhesions have preceded the suppuration, the pus
 may  point outwardly, and the abscess  open on the side, in which
 case the  patient  may ultimately recover.   Adhesions have con-
 nected the diaphragm  with  the upper surface of the liver, and
 the lungs with the diaphragm ; and ulceration taking place, the
 matter has found  its way into the lungs, and  been spit and
 coughed up  in  large quantities.  By  similar adhesions  it has
 made a passage  into the stomach  or intestines, and been dis-
 charged by vomiting and purging.
   Pemberton  mentions his having seen a large abscess in the
 liver, capable of containing, at least,  two quarts, which by a
 very  gentle pressure, could be  made  to ooze through the dia-
 phragm by innumerable small orifices, into the  lungs which
 were  adherent.   In the matter  of  the abscess,  he informs us,
 were  great numbers of hydatids, from the size of a pin's head to
 inches and a  half diameter.   Hydatids, by the  way, are found
 in the liver, as frequently perhaps,  as  in any other  part of the
human body.  It would form an interesting, but difficult specu-
 lation, to endeavor to account for  their production, taking for
granted the generally received opinion, that they are actually
animated creatures.   They are of very different  sizes, and ac-
      14* 
162
ACUTE HEPATITIS.
cording to Baillie, sometimes enclose each other in a series, like
pill-boxes.  You will find a  case related by Thomas, in which
sixteen pints  of water were  drawn off from a tumor in the re-
gion of the liver, probably a very large hydatid.
  The Treatment of acute hepatitis, requires nothing peculiar in
principle, but must be directed  by the rules below given for our
government,  in all active inflammations of  internal organs. Our
most important remedy is, in the first place, venaesection, and
this must be carried to the  fullest extent compatible with the
strength of our patient.   Bleed until you have relieved the pain,
or brought down the force and frequency of the pulse ;  and if
the circulation appears excited again in an hour or longer period,
bleed again to the same result,  and repeat the operation as often
as the same  circumstances  may demand it.   Local abstraction
of blood by  leeches and cups, is here of great importance, and
should without delay be had  recourse  to.  Active purging, is
our next reliance.  Calomel, so much recommended by some, does
not seem to me  adapted to the case.   I  prefer, infinitely, the
neutral  salts, which  tend much more clearly to  the rapid dimi-
nution of the  inflammatory excitement.  I may observe here,
and would wish  your particular attention  to the  remark, that in
the inflammation of parenchymatous structures  and of the mu-
cous  membranes, mercury is unrivalled in  its beneficial influ-
ence ; while upon inflammation of the serous membranes as of the
peritoneum,  pleura, (dura mater) etc., it has comparatively little
remedial effect, unless when the  affection is of  a chronic form.
 In the case under consideration, your  safer dependence will be
 upon  the free administration of the neutral salts, as sal: epsom,
 combining perhaps some antimonial, which will slightly nauseate
 and determine to the skin ; or an active  cathartic, as the com-
 pound powder of jalap and sulph:  potass:  may be prescribed
 with similar addition. Local blood letting  may be still employed
 from time to time ; cups or leeches being applied and re-applied
 followed by  assiduous fomentations until the vascular excitement,
 local  and general, has  been sufficiently reduced, when  a large
 blister should be put on  the part in pain, which may either be
 kept running or renewed as often  as necessary.   These impres-
 sive measures being entered on with sufficient promptness,  and
 carried into energetic  execution, the  disease will rarely fail to 
ACUTE HEPATITIS.
163
yield at once.   Indeed I have never seen a fatal case of the kind.
When the nature of the attack has been mistaken or imperfectly
understood, the patient not seen until the morbid action was too
well established to be subdued, or the case improperly managed,
we must expect it to issue in one of the unfavorable terminations
formerly enumerated,  the rapid prostration and exhaustion of the
patient, the  supervention  of the suppurative  process, or the es-
tablishment of  inflammatory  action  of an obstinate low and
chronic form.
   If suppuration has  distinctly come on with  great reduction of
the pulse and general prostration, the patient's strength  must be
supported by a  nourishing diet and  tonics, of which the bark
will be preferable, if it be  retained on the stomach.  If not, any
of the bitters may be  substituted.   The bowels must, however,
still be kept in a soluble condition.   If any tumor should appear
upon the side about or under the ribs, it should be  opened, and a
free vent given to the matter, which being thus evacuated exter-
nally, and  the patient properly supported, offers us hope of his
restoration to a certain degree  of health.   Graves  has proposed,
ingeniously enough, to invite the matter contained in a hepatic
abscess to  the surface, by the  following operation.—Having as-
certained the condition of the liver  by careful examination, he
lays open, by a free incision over the tumor, the various tissues
that form the abdominal parietes down to the peritoneum, pre-
venting the union of the incised parts.  The pressure being thus
removed, the pus within projects the walls of  the abscess at the
uncovered  spot,  and  escapes readily through  a puncture made
there.   An  incidental, but important advantage, is supposed to
be gained here, by the  occurrence of adhesive inflammation,
which unites the external  investing membrane of the liver to the
opposite surface of the peritoneum,  thus preventing the admis-
sion of the matter into the abdominal cavity when the abscess is
opened.  An attempt is  recorded,  to substitute caustic for the
knife, in a case  of this sort.  It was a failure ;  the pus getting
into  the abdomen, brought on peritoneal inflammation, of which
the patient  died.  It has  been observed,  that abscesses in the
liver sooner heal, when opened, than similar affections in other
parts  of the body.  I should,  however, very much  doubt the
possibility of a complete  recovery of the powers  of digestion 
164
CHRONIC HEPATITIS.
after so extensive a lesion of the structure of an organ, the  due
performance of whose unknown, yet  certainly important func-
tions, seems to be absolutely necessary, not only to the ordinary
process of foecification, but to the assimilation of our food,  the
proper elaboration of the sanguineous fluid, and the due  nutri-
tion of the various parts of the body.

  Chronic Hepatitis—as being of much more  frequent oc-
currence in our climate, than the acute species, claims from you
a particular attention.  Indeed, it is scarcely possible, that any
of the numerous agents which, especially in hot climates, affect
the liver, should not produce, in  a greater or less degree, the
sort of morbid  condition  intended to be described  under  the
above title.  For, whether torpor or exhaustion, or  venous con-
gestion,  or  arterial  or  secretory obstruction,  be the  primary
consequence of the application of  the various causes of hepatic
disease formerly noticed, inflammation, in some shape, must be
the almost necessary result of the irritation  thus produced.
  Chronic hepatitis is, for the most part, developed slowly, and
the symptoms which denote  its  presence, are at first  obscure.
There is a sense of weight and fulness, with a dull pain in  the
right side, yet so slight, that no notice would be taken of them,
if enquiry were not  made.  On pressing with the fingers  up-
wards and inwards, the  patient will usually shrink, and the edge
of the liver will  be felt thicker  and heavier than natural.   In
instituting this examination, we direct  the  patient, to  make  a
strong inspiration, so as to force it  down as far as possible by
depressing the diaphragm. "When the liver becomes enlarged,"
says Bell, "its hard margin comes down, so as to be felt through
the abdominal parietes under the ribs.  This enlargement of the
liver, and consequent descent of its margin, is to be felt more
easily by grasping the  integuments of  the  belly, as if  you ex-
pected  to  lift up the acute edge of  the liver, than by  pressing
with  the point of the finger.   By this means, we shall be sensi-
ble of the elasticity  and softness  below the  liver,  and of the
resistance and firmness  of its margin.  The physician, however,
should not forget," he goes on to observe, "that the  depression of
the diaphragm, and  the consequent  protrusion of the  liver by
disease in the thorax, may give the feeling of enlargement and 
CHRONIC HEPATITIS.
165
 hardening in that organ."  There is generally pain and  uneasi-
 ness, too, at the top of the right shoulder.  I have seen cases of
 hepatitis marked with sufficient distinctness, in which the pain
 was in the left side and  the  top of the left shoulder.   In these,
 the left lobe of the liver was probably the seat of disease.  "The
 left great division of the liver," says the writer just now quoted,
 "is,  perhaps, as  often diseased  and enlarged  as  the right, in
 which case, it is more difficult to ascertain it by examination."
 The appetite and strength are diminished—the spirits are dejec-
 ted ;  there is emaciation more or less perceptible.   The tongue
 is usually whitish; there is some thirst;  the sleep is harrassed
 and disturbed with disagreeable  dreams.  The bowels are irre-
 gular, sometimes rather  costive, but most frequently  loose with
 ill-conditioned passages,  showing a deficiency or vitiation of the
 bile; and this state of the  intestines has obtained the  specific
 appellation of hepatic diarrhoea.  It is, indeed, of no little im-
 portance, to observe the qualities of the alvine  evacuations, and
 to note the various changes in the appearances of the bile mixed
 with them.   These  appearances are exceedingly  diversified,
 from a thick molasses or tar-like color and consistence, to yellow,
 bright and healthy bile, the discharge of which is, perhaps, the
 most favorable token of the restoration of healthy, hepatic ac-
 tion.   A scalding sensation in the bowels and at the anus, marks
 generally the  evacuation of bile  highly vitiated.   The pulse is
 quickened, and somewhat tense and corded, though  contracted
 and  small.  There  is a sallowness of the countenance, a  yel-
 lowish tinge of the adnata of the eye, and the face seems some-
 what tumid.  There is a febrile exacerbation every evening, and
 an increase of a dry, tickling  cough,  which usually attends.
 The patient lies  most comfortably upon the side  affected.   In
 the progress of the case, the feet and ankles are swollen, and the
 strength  of the patient  is more  and more rapidly sunk by the
 continuance  or  increase of a chronic  looseness  or  diarrhoea.
 Those err who anticipate jaundice as among the ordinary results
of hepatic  inflammation, whether acute or chronic.   It is more
apt, indeed, to follow a duodenitis, than a hepatitis, for  a very
obvious  reason.   The  former has much the  most direct ten-
dency to induce swelling and  closure of the duct, and  thus
prevent the passage or elimination of the secreted bile. 
166
CHRONIC HEPATITIS.
  Among the variety of causes enumerated by authors as pro-
ducing the disease, are excess in the pleasures of the table, and
in the use of alcoholic liquors, and in the indulgence of the
various passions; exposures to atmospheric vicissitudes ; mois-
ture in its several modes of application; fatigue, etc.  It has
been affirmed to have followed  as the consequence of obstinate
quartans, having been affected in lieu of the spleen, the usual
seat of internal congestion and  inflammation from  this  class of
agencies.   I have seen it  developed  in three  young females,
without the application of  any evident  or  prominent  exciting
cause; a strong predisposition to hepatic  disease was however in
one of them hereditarily derived.
  Chronic hepatitis is  more likely to run into suppuration than
acute, as affecting already the internal structure of the liver.  I
have  myself seen, in a long standing case, the  whole viscus
converted into an immense  abscess, a seeming  bag containing
pus, the sides of which were diminished, by absorption, to the
thickness  of half an inch.   These abscesses may point or break
outwardly, as above mentioned, or find a vent through the lungs
or through the stomach or intestines.  I have more than  once,
however,  seen the patient sink  and die  from the  irritation and
hectic state connected with  this morbid condition of  the  liver,
without the abscess bursting.   This slow form of inflammation
terminates, too, in schirrous induration of the liver, in which
state the patient drags out a miserable existence, tormented by
all the harrassing symptoms of dyspepsia, with  the most intole-
rable  depression of  spirits,  sleepless nights or  horrid  dreams,
and gradual wasting and decay.  These  are among the ordinary
consequences of intemperance.
  Prognosis.  In the first instance hepatitis, whether acute  or
chronic, does  not necessarily imply anything beyond a marked
disorder of the functions performed by the vessels of the  liver.
This  however  will, in a longer or shorter time, according to the
violence of the attack, or the intensity of the  causes producing
it, run into  a  morbid  derangement of the very structure of the
organ, a case  evidently differing from  the  first very  widely in
both  danger and obstinacy.  We  can, in general, without very
great difficulty, restore to the liver its proper tone, and bring it
back  to a  correct state of action, provided  the  disorder with 
CHRONIC HEPATITIS-.                167
which it is affected is simply functional; and  this is done  by
taking away the causes which induced the morbid excitement,
and applying the remedial means spoken  of.   But I  fear that
the regeneration of healthy structure, after it has become altered,
is altogether  beyond a reasonable hope.  We  may, by prudent
management, check and restrain its farther progress, and enable
our patient to lead  a life, perhaps, of comparative comfort, but
no more.
   It may be set down, then, as a  rule generally correct, but
admitting of exceptions, that in proportion to  the duration of
the complaint, will be the danger of an unfortunate termination,
and the difficulty of treatment.   Allowance must here be made,
as has been remarked, for the intensity of the causes.  Habitual
and excessive intemperance affects the liver almost irrecovera-
bly, and that, too, in very short spaces of time, in certain  in-
stances.
   The  Treatment of chronic hepatitis, differs  as much  from
that of the  acute species, as in the  probable  primary  seat of
morbid action.   The lancet may be used with  advantage, if the
patient be young and robust,  and the pain in the side considera-
ble ; and  moderate  venaesection  may be repeated pretty fre-
quently in these cases.  But, in  the employment of this remedy,
be careful to observe whether the detraction of blood does not
rather sink the powers of  the patient, than make an impression
on the disease.  If the former effect is disproportionably great,
you will afterwards abstain  from further depletion in this way.
Topical blood-letting, by cups  and  leeches, will then be  your
best substitute, and  indeed  can scarcely ever be omitted with
justice to your patient.
   Mercury holds the very first rank in the farther treatment of
chronic hepatitis ; it should be introduced into the system slowly,
and its influence upon  the  secretory vessels, as exhibited by a
slight  soreness of the mouth and gentle  ptyalism, kept up for
some  length of  time.  In the  meanwhile, however, it will be
necessary to have the bowels regularly and freely open, and to
promote a due determination  to the surface. For these purposes
I am accustomed to prescribe calomel in small  doses, in  combi-
nation with pulv: antimon: adding jalap or pulv: rhoei in suffi-
cient quantity to affect the bowels moderately.  This plan will 
168                 CHRONIC HEPATITIS.
however, require to be persevered in, as no immediate beneficial
results are to be expected from it.  "The mouth," says Pember-
ton,  "should be kept in this state of gentle  salivation, till all
symptoms of the  disease disappear;  and the practitioner  must,
therefore, modify  the quantities of mercury to be used, by the
effect produced."   Next, in efficacy, to mercury, we rank the
mineral acids,  which may often, indeed,  be successfully em-
ployed  as  substitutes for mercury,  when  any circumstance
contra-indicates its  use.  After a great  deal of discussion upon
the subject, it seems now  to be agreed on, that the nitro-muria-
tic acid, formed by mixing equal parts of nitrous and  muriatic
acids,  deserves a preference.   I  have, however,  been much
pleased with the use of the nitric alone; the muriatic unmixed,
is said  to be  less applicable.  The nitro-muriatic acid may be
administered, internally, in the dose of from 3 to 10 drops, three
or four times a day, in  any pleasant vehicle—some mucilagi-
nous syrup is generally employed.   The nitric may be given in
the same manner.   Care should be taken, in  prescribing these
strong acids, to preserve the teeth from injury or corrosion; the
patient  should, therefore, be  advised  to wash  the  mouth com-
pletely after each  dose, or, as some recommend, to  suck up the
fluid through a cane or glass tube, or  pour  it  down the throat
from the spout of  a proper vessel, introduced far into the mouth;
nor is the external application of the acids  wanting in power or
effect.   The facts tending to the proof of their efficacy, when
used in this way, are nnmerous and strong, and are triumphant-
ly recorded  by Dr. J. Johnson, as confirming his theory of the
close and direct sympathy  between the skin and the liver.
   The feet and the legs of the  patient are to be  immersed in
the warm nitro-muriatic acid bath, from twenty minutes to half
an hour, just before going to bed, every night or every second
night.   It  is said to cause a prickling sensation,  and a warm
perspirable state of the feet and legs of the patient.   The effects
attributed to the use of the acid, either internally or as a bath, are
said much to resemble those of mercury, in exciting the secretions
and the excretions.   It induces  very  considerable  perspiration,
and sometimes augments  very suddenly and remarkably, the
secretion and flow of bile,  and occasions, in some persons, faint-
ness and an increased  flow of the  saliva.  Internally, I have 
CHRONIC HEPATITIS.
169
 often prescribed the acid, and with much satisfaction.  Taraxa-
 cum, the tomato,  and various compounds  of aloes, scammony,
 colo'cynth, and other drastics, have  been urged  upon us, and
 highly eulogized as substitutes for mercury.  I am not willing
 absolutely to deny them any efficacy, but whatever benefit may be
 occasionally derived from their use, it is not such, by any means,
 as to enable us to dispense  with  our most invaluable alterative.
 Iodine, in several forms of preparation, has  been recently em-
 ployed in the treatment of obstinate chronic hepatic affections.
 I cannot speak very confidently of its effects when uncombined,
 yet  I think I  have derived advantage from it  in very minute
 doses, as in the diffuse solution of Lugol, one grain to 2 pounds
 of water, persevered in for a considerable period of time.  As
 similarly diffused  in  many mineral  waters, the White Sulphur
 Springs of Virginia, for  example, it  has gained, and justly, I
 think, a  high reputation.  I am disposed, too,  to place  much
 reliance upon  the exhibition of the  deutiodide of mercury and
 potassium in these tediously protracted cases, and am now much
 in the habit of resorting to  it, after the  preliminary measures
 necessary for subduing general and local excitement  have been
 duly carried into effect.
  While  pursuing the means  above  detailed, we should  not
 neglect the topical remedies applicable  to  the case.   If there is
 much pain,  we may, in  addition to the moderate venaesection
 directed above, or when  this  mode of general depletion is inad-
 missible, detract blood locally, from time  to time, by leeches or
 cups applied to the side—after which, a large blister  should be
 put on, and a succession  of them made use of, in preference  to
 keeping open  the vesicated surface by other  stimulating dres-
 sings. Flannel should be worn  next the skin, for the purpose
 of promoting  free perspiration, restoring, in  some measure, the
 regular balance of excitement, and preventing the evil influence
 of atmospherical  vicissitudes, which are among the agents most
 prejudicial to  the sufferer in chronic hepatitis, and which must,
 therefore, be carefully avoided  by every means  in  our power.
 Exercise in the open air, will form an essential part of the regi-
 men  to be observed when the weather is warm, equable and
favorable, and the  patient's strength and circumstances  as  to
      VOL II.—15 
170
CHRONIC HEPATITIS.
pain, etc. will admit of it; when  otherwise, you will find  the
swing an excellent substitute.
  Rigid temperance must be strictly enforced.   The food must
be of the plainest kind, and prepared  in  the least stimulating
manner.   Rice, with boiled  meats, as  poultry, mutton, etc. will
constitute the utmost limit of indulgence in the pleasures of the
table.  No distilled  or  fermented drinks are to be allowed;
water, however insipid and disgusting  it may seem to a palate
and stomach long accustomed to the  factitious excitement of
wines and ardent spirits, must constitute the  chief beverage.
The moderate use of tea and coffee is all else that  can be per-
mitted.
  Chronic hepatitis becomes connected with, and  indeed  gives
rise to dyspepsia and other modes of morbid action of the diges-
tive organs.  In such  cases, a resort  to  some  mineral  spring
will be of much service.  The  gently purgative waters are to
be preferred—indeed,  continued mild  purging, of itself, seems
often adequate to the removal of the lighter forms of the disease
now under discussion.
  I have mentioned the singularly deep depression of spirits so
invariably the result of an improper and  diseased  performance
of the hepatic function.   This, too, is best relieved by the so-
ciety, amusements and bustle of a fashionable watering place;
and some have even doubted whether  these are not quite suffi-
cient to account for the  recoveries which occur at such resorts,
without the supposition of any curative property inherent in the
fountains themselves.   Be this as it  may, a residence at such
places, is among  our  most successful remedies  in the  case
before us.                      ?
   In obstinate  chronic hepatitis, however, we should not fail to
recommend, if within the reach of our patient's  means, a  sea-
voyage and change of climate.  These are not only useful, by
their own remedial influence, but  they seem often  to be neces-
sary, in order to renew the  susceptibility  of the system to the
effect of our medicines.   You will readily infer, from what has
been said, that some attention must be paid to the kind of
change which we advise; thus, we should not send a  patient
from a warm climate to a cold one in  winter, where  he will be 
ICTERUS.
171
sure to sink under the chilling effect of such a sudden decrease
of temperature, or will be rendered liable to an attack of acute
supervening upon his chronic state of inflammation of the liver.
Nor, on the other hand, would you permit him  to venture into
a more southern region during the heats of summer or autumn,
<here to encounter, in increased intensity, the same causes which
had previously exerted, on his hepatic system, so injurious an
influence.  By a careful consideration of the circumstances, you
will be enabled so to direct his course, as often to effect a won-
derful improvement in his health.  But you are not to inculcate
in him the expectation, that a removal or voyage will obviate
the necessity of observing the plan of treatment above detailed.
  In conclusion, I cannot fail to impress  upon you, the  impor-
tance of the prophylactic or preventive  mode  of conduct, so
strongly indicated in  a climate like ours—warm, relaxing and
miasmatic.  Temperance not only as regards the grosser indul-
gences of eating and drinking, but  as implying the avoidance of
excess  in the  gratification  of all our appetites and passions,
should be strongly enforced  upon the community, for the care
of whose health you  will  be  responsible, not only by  your
precept, but by your example.  So  shall you  escape many, or
most of the evils "that  flesh is heir to,"—so shall  the days of
your early manhood be like  the morning sunshine,  bright and
unclouded—and so  shall you descend  into the  evening of life,
after a long  course  of usefulness and enjoyment, tranquil and
honored.
                   CHAPTER XXXIII.

                    ICTERUS--JAUNDICE.

  Our present subject affords us a very striking instance of the
conventional application of a nosological term without definite
significance.   In  using the word Jaundice, physicians  seem to
mean nothing  but an allusion to an unnatural color of the skin, 
172
ICTERUS.
which,  in  a vague way, and, doubtless, originally  from mere
analogy of hue, they refer to a suffusion of the integument with
bile.  This  again, they connect  reasonably enough, but inde-
terminately, with some unknown condition of hepatic disorder,
expressed by the phrases obstruction, engorgement, torpor, etc.
  It is  assumed, that, on the one hand,  the secretion of bile
being suspended, it remains mingled with the other component
parts of the blood, which its non-separation occasions to acquire
a yellow or  brownish tinge, noticeable on  all  the surfaces and
tissues; and, on  the  other, that  having been elaborated by the
hepatic  vessels, its  excretion is impeded or prevented—it is re-
absorbed to be mixed again, mechanically,  as a  foreign ingredi-
ent with the circulating fluid, which being  itself thus discolored,
dyes the whole body  more or less.
  The sallow hue, universally regarded as characteristic of this
disease, is indeed the  only constant symptom of jaundice. Co-
incident with it, for the most part, we have anorexia or impaired
appetite, loss of muscular  strength, diminution of all the ener-
gies of the  system, physical  and mental,  dejection of spirits,
constipation, and absence  of the natural brown tint of the  alvine
discharges.   The tongue  is usually coated with yellow mucous
saburra, and a bitter taste is perceived in the mouth; there may
be nausea and occasional vomiting, especially in the mornings.
In some instances, a  fulness, weight, or pain, is felt in the right
hypochondrium ; the lower extremities become aedematous, and
anasarca or ascites gradually supervenes.
  Less  frequently, the patient is attacked, in addition to these
symptoms, or perhaps first in the train, with violent pain  at the
epigastrium or in the right side—dyspnoea—retching and vomi-
ting—great  anxiety—extreme oppression, with a sense of  swell-
ing, and, indeed, actual  intumescence of the  abdomen,  which
quickly becomes intolerant of the lightest pressure.   The bowels
are  acted on slowly and with difficulty,  and stools, when pro-
cured, are clay-colored or quite pale—perhaps, on careful exami-
nation,  we may find small concretions—"biliary calculi" voided
with them.
  I have said, that  the  discoloration  of the skin  is the only
constant token of the icteric state.  The skin, and the adnata of
the eye, are of a deep orange yellow ; the  urine is high colored, 
ICTERUS.
173
 giving a yellow tinge to paper  or white cloth dipped in it;  the
 perspiration sometimes discolors the linen.  "Milk  alone," says
 Heberden,  "of all  the secretions, is not  thus changed in jaun-
 dice."   Marsh, however, tells us of a case, in which "the breasts
 were full of a yellow fluid  possessing the  properties of bile ;"
 and Eberle says, that he tasted  bitter milk from the breast of a
 jaundiced patient.
   Poets and philosophers have, in all ages, made frequent allu-
 sion to the fact, that the jaundiced eye sees all objects clouded
 with its own sickly hue, from the peculiar suffusion of  its
 humors.  It has never happened to me, to meet with an instance
 in which this affection of vision was alleged to occur, although
 I  have  not failed to  enquire concerning it of  all the subjects of
 the disease  under my care.  Mcintosh, however, asserts that  he
 has "known  several individuals who saw every  object disco-
 lored,"  and speaks of one in whom  this was  "the  first circum-
 stance that excited attention."   Good affirms, that the phenome-
 non actually took place in  his own person.  Be this as it may, I
 am, with Gregory, disposed to doubt the often repeated state-
 ment, that the solids also,' as well as the fluids, are universally
 stained—at any rate, I have not met with any example of it.
   The  discoloration of jaundice is  spoken of  habitually as yel-
 low, and such it is, indeed, in an infinite majority of  the cases.
 But in  times long past, icterus  was divided  into species, in re-
 ference to the variety of discoloration  presented, whether, of the
 bile discharged, the mucous  secretions, or the general surface.
 Thus three forms of jaundice, can  be recognized—the yellow,
 the green and the  black ;  and these distinctions are  not left to
 rest upon tradition  merely, or ancient authority.  Baillie recog-
 nizes and describes the two first.  Good retains the division and
 acquiesces  in its correctness  and propriety,   Marcard of Han-
 over, regards the distinctions  thus  offered as  truly specific and
 characteristic; not  dependent on intensity alone, as has been
 imagined.
   In the month of August, 1825,  I chanced  to  meet with a
 strongly marked  example  of  icterus viridis, in a negro patient,
who was attacked while apparently convalescing, though slowly,
from small pox.  Of course no change in the hue of the skin
 was here perceptible, but the  conjunctiva  was strikingly green 
174
ICTERUS.
with a slight tinge of yellow ; the tongue and the mucous lining
membrane of the mouth were greenish,  and the saliva and bron-
chial mucus which she coughed, hawked, and spit up were per-
fectly green—deeply grass-green.  Her  alvine evacuations were
also of a deep dark green.
  That there is, as has been contended, something peculiar and
specific in these cases, is rendered probable by the fact that icte-
rus viridis almost always ends fatally, while the prognosis  in the
ordinary form, known as yellow jaundice, is very generally favo-
rable, making due allowance for the causes which brought it on,
and the constitution of the subject affected.  Baillie saw but
two recoveries  from icterus viridis; Good and others represent
it as almost uniformly fatal.  It seems disposed, in a majority,
to protract itself indefinitely, proving slow and chronic, and en-
during for years perhaps.   My patient died  in about a month
from the  commencement of the attack, worn out with atrophy
and miserably emaciated.
   Jaundice has been divided by some  authors, under the heads
of idiopathic and symptomatic ; but the distinction is hypothe-
tical, and besides, is not capable of being observed with definite
clearness.   So  many causes indeed, have been assigned for the
phenomena which are brought  together under the general term
icterus, that it will not be found easy to connect or classify them,
I shall endeavor to enumerate the most prominent, constant and
 familiar of such as  are fairly made  out, and then go on to offer
 as satisfactory  a rationale of their influences as I am able ; notic-
 ing afterwards in a brief way, the conjectural sources to which
 pathologists have attributed the attacks that arise from contin-
 gencies not obvious.
   In  following out the  attempt  above alluded to,  and laying
 down the distinction of jaundice into primary and  secondary,
 it will, I think, be very difficult to establish  the  existence of an
 idiopathic, primary, or as  it  has been called simply, "hepatic"
 jaundice.   It will be seen on  an examination  of its numerous
  alleged causes, that few, or more probably none of them, can be
  proved to possess any direct influence,  or to exert any direct im-
  pression upon the liver; which indeed  they all seem  to affect
  and act upon  sympathetically, and by previous disturbance of
  the sensorial system, the cutaneous functions, or the  gastroente-
  ric mu sous memt rane. 
ICTERUS.
175
  1.  Every obstetrician and nurse is familiar of course with the
"yellow gum" or jaundice of the new-born infant.   This is attri*
buted,  with much  plausibility, to the greater promptness with
which  the  absorbents commence the exercise of their  offices
than the emulgent vessels begin  theirs ; or  the bowels take on
their peristaltic  movement  to discharge their contents.  Some
ascribe it to the mechanical obstruction of thick mucus impacted
in the duodenum at the mouth of the ductus communis choledo-
chus, preventing the passage  of  bile into the intestine.  It is an
affection attended  with no serious consequences,  and for the
most part, easily removed.  A single mild cathartic puts an end
to it at once, or it subsides of  its own accord within a few days.
   Similar to this probably, both in nature and cause, is the attack
which we  sometimes meet with in an adult, betrayed by no
sign but a  transitory sallowness of visage; the  health of the
individual being so little deranged that but for the remarks of his
friends, or the information caught from his mirror, he would not
know that any thing was wrong with him.
   2. Jaundice—as  the consequence  of mental emotion—is not
at all uncommon.   Fear has been often known to produce it sud-
denly ; the sallow complexion is almost as certain and well known
an effect of long-continued care and anxiety, as the haggard
expression of the  countenance ;  but grief seems of all the pas-
sions, most  adapted to occasion  it.   In  such cases as  these, pa-
thologists have supposed the  direct impressions made upon the
brain, to be  promptly though sympathetically communicated to
the liver, whose functions become  soon  deranged and icterus
thus results.  The whole  train  of evils may perhaps be  more
rationally ascribed to an intermediate disturbance of the stomach}
the shock to the digestive apparatus so readily diffused by means
of the  ganglionic  nervous system to all the abdominal  viscera,
whenever the mind suffers in any manner.
   It is doubtful whether we should properly arrange here, the
attacks alleged to  follow  protracted and  vehement mental ap-
plication.  I am disposed to question whether study alone,  how-
ever intense and long-continued, can exercise directly or in any
other mode than its widely  influential effect in depressing the
physical tone of the general  system, a morbid impression  upon
the hepatic  function.  The great magician of modern  times, Sir 
176
ICTERUS.
Walter Scott, has been referred to as an instance of the produc-
tion of spasm of the hepatic ducts and consequent icterus by
mere "mental application"—hard labor of thought and pen ;  but,
besides his habits, those of his age and circle, of free living, he
had been, when assailed, struggling long with the anxious cares
that pressed upon him, in his  efforts at once to  prop up a failing
copartnership, and to gratify his violent ambition of becoming
a large landholder,
  3. Icterus is the concomitant or sequela of several other mala-
dies.   It connects itself, indeed,  with a very large proportion of
the autumnal diseases of hot climates;  a  tawny  darkening of
the complexion being a symptom, not  only of  the yellow fever
of tropical regions, but of  the  ordinary remittents and inter-
mittents;  its ratio to  the whole  number of  subjects of such
fevers, varying from one  year to another,  in dependence upon
contingencies not understood.  In my own case, a transient, but
oppressive attack of jaundice followed a few hours intense  sea-
sickness,  occasioned by a rough  sea, in crossing the British chan-
nel, from Dover to Calais.   I have seen the same thing, also,
happen to others.   We now and then  meet with it during  con-
valescence from our common cholera,  especially in summer and
autumn.
   4. Nothing is more generally acquiesced  in, than the belief
that the malaria of miasmatic districts, acting  readily upon the
skin and liver, is exceedingly apt to produce icterus; but it has not
been so distinctly noted as it deserves to be, that  as I remarked
above, the malaria of certain years is distinguished by some un-
defined modification,  which  very strikingly increases  this  ten-
dency.  Cleghorn, in his "Observations upon the  Diseases of
Minorca," mentions as "a common distemper  in July  and  Au-
gust, of the year 1746, a  slight jaundice without a fever, which
soon yielded to purgatives and saponaceous medicines." A similar
prevalence of jaundice was observed in this city, in the autumnal
and winter months, of 1824. During that season we had  been
visited with bilious and yellow fevers, and convalescents  from
both these, were almost universally affected with jaundice, as
the cold weather set in.  Nor were they the exclusive  subjects
of such attacks; for  many  were  similarly assailed, who  had
 previously enjoyed good  health throughout the year.   The cases 
ICTERUS.
177
 were usually mild  and manageable,  but their  great number
 seemed to me unaccountable, except  by reference to such a con-
 stitution of our atmosphere,  as  Sydenham would have called
 "epidemic."
    5. In many individuals, examined after death,  the  gall blad-
 der is found occupied by concretions of various form, size, and
 chemical  composition.  It happens  that  such concretions are
 occasionally voided in icteric stools.  This may take place with-
 out inconvenience or suffering, and the excretion of such bodies
 may seem of no consequence whatever; but in general, about,
 or a little before the time of the passage of a gall stone, the sub-
 ject of such  accident, labors under certain definite symptoms, of
 which, jaundice belongs to the  usual train.  The  inference is
 easy, and not illogical.  We suppose, that in cases of this  sort,
 the following history is applicable.  A  gall stone or biliary cal-
 culus, however unfelt or inert it  may be in the gall bladder, if
 by any agency it is thence expelled and forced to travel onward
 through the  duct, towards the  duodenum, finds more  or less
 difficulty in its progress ;  its size or form, often angular, prevents
 its easy transmission; its presence at every step of its passage,
 gives more or less pain and irritation, obstructing, meanwhile, the
 regular and  necessary flow of bile through its usual channel,
 into the primae vias.   Hence we  have discoloration of the  sur-
 face, from its absorption into, and diffusion throughout the mass
 of blood, and hence the other symptoms, whatever they may be,
 which result from default of mixture  of bile with the other con-
 tents of the alimentary tube, and those  which flow by radiation
 or sympathetic  communication  from the  irritative excitement
 mechanically created by the position of the calculus.
   6. It sometimes happens that all these symptoms show  them-
 selves concurrently, in a given case, without  our being able to
 detect, on the most careful and unremitting  inspection, any bili-
 ary concretions in the alvine  discharges.   Yet we have  every
 proof of obstruction to the passage  of bile—of its resorption
 and diffusion, pain in the very region affected by pain when a
 gall stone is passing, and all the sympathetic irritation aroused by
 its progress through the ducts.  Here we cannot but infer  the
closure of the duct, but the  question  arises, as to  the  mode of 
178
ICTERUS.
occlusion.  From the suddenness with which the attack comes
on, from the equal suddenness of the relief obtained sometimes,
and from the nature of the remedies most generally successful,
a topic which we shall discuss  in its proper place, it is  inferred
that the duct may be, and is affected with spasm.  Such, indeed,
seems to be very probably  the fact, in certain instances.  But I
am disposed to agree with those who regard such attacks as not
unfrequently inflammatory in their nature, and refer their origin
to an obscure duodenitis, which has given  rise to a continuous
inflammation, extending into the ductus communis choledochus,
and perhaps the smaller branches of the same  excreting canal;
the thickened condition and irritable state of whose internal
membrane, may well account for all the phenomena.  Nay,  it
does  not seem to me unreasonable  to believe, that inflammation
of the mucous tissue of the duodenum alone, would, by its swell-
ing and pressure upon the orifice of the  duct,  produce all the
results in question.
   7.  Finally, I must not  omit to allude to that form of icterus,
occasioned, as writers allege, by the presence  of abdominal tu-
mors within  the abdomen—enlargement and schirrhus  of the
pancreas, etc., lying in  contact with,  and forcing  together the
sides of the  hepatic  and common  ducts.   This  condition of
things, I have not been so unfortunate as to encounter.
   After the above enumeration of the various contingencies with
 which icterus is associated, or upon which it is dependent, no
comment is necessary to impress you with the obscurity of the
 subject, or with the extent of our  ignorance, as to the true pa-
 thology of the disease.  In this discussion,  indeed, are involved
 some of the  most difficult  topics of physiological inquiry.  The
 nature  and uses of the bile; the consequences of its non-secre-
 tion, of its superabundance, of its non-elimination ; the modes in
 which  it may be vitiated;  the possibility of the retention of its
 constituent elements in the blood, and the consequences of such
 retention; the probability  of their  chemical union in the mass of
 circulating fluid and the formation  of bile in the blood by the ac-
 tion of chemical affinity; the possibility of its being taken up by the
 absorbents within the substance of the liver, immediately on its
 secretion there, its passage through the ducts of that organ being 
ICTERUS.
179
in any mode obstructed; its absorption from the gall bladder—
all these demand investigation and elucidation, before we can
fully comprehend the nature and pathology of jaundice.
  The symptoms of icterus  present  themselves under circum-
stances apparently contrasted; thus, whether the secretion of bile
be deficient in quantity, defective by imperfect elaboration, or
obstructed in its passage to the intestines, we shall observe sal-
lowness of the visage, a gamboge tinge on the  conjunctiva, and
an impairment of the digestive  function.  Though the bowels
are usually costive, they are sometimes  irritated with diarrhoea,
the stools being  generally of a light  or  whity-brown color, the
spirits are deeply depressed,  the physical powers diminished, the
pulse slow.   Cullen refuses to admit (§  1818,) that these symp-
toms are in any case, the  result of non-secretion; but it  cannot
be denied that they occasionally present themselves unattended
with any uneasiness whatever,  in the region of  the liver, any
feeling of fullness or weight, and  go off as gradually as  they
have been developed; and it must not, without proof, be assumed
that the defect of separation of the coloring matter and the other
constituents of bile may not, as well as  their resorption and the
defect of their mixture with the chyme of the digestive tube,
give rise to all the consequences detailed as portions of the icteric
state.
   That icterus is often a  simple derangement of function ap-
pears from the fact, that post mortem examinations so frequently
betray no lesion whatever; and indeed, some of its forms super-
vene and subside too readily, and with too much  seeming spon-
taneity, to allow of any structural changes being connected with
them.   It is a chronic  disease,  and  generally  unattended  with
fever.   The discoloration  of  the skin, is not usually  associated
with any irritation, but some patients complain of itching, espe-
cially at night.
   The consequences of jaundice, are more apt  to  be serious and
troublesome than we are led to apprehend, from the want of vio-
lence in its course; or rather, it  is,  not unfrequently,  as  I am
disposed to believe, one merely in a  train of evils resulting from
some obscure defect or impairment of constitution of the patient.
Thus, we see it followed by  dropsy, by chronic diarrhoea, by a
species of atrophy, and as some writers say, by  cerebral affec- 
180
ICTERUS.
tions, among which, apoplexy is enumerated.  I cannot con-
sider these as properly the sequelae  of jaundice, but rather as
the coincident or successive effects of some common cause which
has produced them all.   The  modifications of icterus,  most of
all to be dreaded are, that which is connected with  the passage
of gall stone,, and that which is attended by the same symptoms,
though  without our being able to find any secretion, and usu-
ally spoken of as spasm of the duct.   In  both these, I have been
much struck with the liability of the patient  to inflammation of
the intestines, as cause, perhaps, in the latter, of all his suffer-
ings—in the former, as  the consequence of the presence and
passage of the calculus.  In either case, it is  well to be aware of
the risk.  Some of these attacks exhibit all the tokens of a gastro-
duodenitis of great severity and obstinacy, combined  with the
other elements of distress and injury.  A more diffused enteritis
sometimes supervenes, extending to the colon and rectum.  The
most extensive mortification  of the  intestine that I have ever
seen was of this nature, more than two feet of the mucous coat
of the lower bowel having become gangrenous.
  The Treatment of icterus must obviously  depend very much
upon the contingencies with which  it is  associated; the appa-
rent or probable cause, the state of constitution, and other cir-
cumstances of the patient.  Referring to the  divisions  formerly
instituted, I shall treat of these varieties separately.
  1. Infantile jaundice  is, as  I  have said,  attributable to the
non-elimination of bile in the  new  born child, and its conse-
quent diffusion over  the body, by admixture with the circulating
fluids.   Some suppose a mechanical  obstruction  to exist in the
fullness of the duodenum, which they imagine to contain a suffi-
cient quantity of thick mucus,  to press upon  and close  the  ob-
lique orifice of the ductus communis.  Others take for granted,
a want of propulsive energy in the canal  itself.   Others again,
assume, in these cases, and in certain similar  attacks suffered by
adults, that the bile is in some manner imperfectly  elaborated,
and undergoes obstruction in the ducts, by an undue "viscidity,"
(Mcintosh and Gregory ;)  a sort of  insipissated condition, if I
comprehend the language  of the books, "its own viscosity,"
(Good.)  We have on record, instances of immense accumula-
tion of this thick concentrated bile in the gall bladder, when the 
ICTERUS.
181
 liver has gone on secreting and pouring it  into this receptacle.
 Good tells us of its having amounted, in one  instance, to eight
 pounds.  It is even said to have given rise  to fulness and en-
 gorgement of the organ itself, producing  an obscure  and dull
 variety of hepatitis.
   The practice here is usually very simple, and readily success
 ful.  It is rarely necessary to do any thing beyond the exhibi-
 tion of a cathartic.  For the infant, a dose of castor oil is to be
 chosen ; the adult will require an active purgative, such as calo-
 mel, with  rhubarb or jalap.  If this fail,  an emetic should be
 administered;  and the antimonial is to be selected, unless there
 be present  some  contra-indication to its  use.  It deserves this
 preference, because of the more active succussion which it gives
 to the whole of the abdominal viscera,  and the greater excite-
 ment which it  communicates, through the  stomach, to all the
 chylopoietic organs.
   In obstinate cases, we must examine if there be any fulness of
 the right  side, or pain aroused by pressure there.   Leeching or
 cupping may be required, but for the most part, there is  evidence
 of torpor, rather than of irritation or inflammation.   We should
 then direct frictions over the  whole region  of the liver and the
 abdomen generally, with  the hand, flannel, the  flesh-brush, or
 the hair glove.   Fomentations should also  be assiduously  ap-
 plied.   Shocks  of electricity across  that part of the  trunk,  are
 advised by Darwin, who ascribes to this  agent a  remarkably
 beneficial influence, in a case of supposed paralysis or torpidity
 of the bile ducts.  Perhaps a gentle current of the galvanic fluid,
 kept passing for some time through the  inactive viscus, would
 prove an  efficacious excitant.   Rough and harsh exercise,  such
 as riding long distances on a hard trotting horse, has been found
 useful.  Care must be taken, meanwhile,  to keep  the bowels
 regularly soluble by aloetics and mercurials, in moderate doses,
 and at proper intervals.   Saponaceous formulae have  been  long
 in vogue here, with some  obscure chemical purpose;  and the
 common "turpentine soap" is affirmed to possess a specific ener-
 gy and adaptation.
   2. Jaundice from mental emotion, requires very similar treat-
 ment to that detailed above.  "Time,  the  great  consoler" is
indeed,  the best remedy here.   Its gentle influence may be aided
       VOL.  II.—16 
182
ICTERUS.
by the prudent use of the saponaceous and aloetic laxatives, com-
bining with them small and distant doses of opium, or some one
of the salts of morphine, and above all,  by advising a removal
from every object likely to awaken painful associations.  In this
especially, but indeed in all the forms of jaundice, a visit to some
pleasant and gay watering place, is apt to be very notably bene-
ficial.   The  gently purgative springs are, perhaps, to be pre-
ferred ; those which, as at Ballston and Saratoga,  contain a large
and exhilirating proportion of carbonic acid gas,  are most use-
ful.  The natural  hot baths, too, do  excellent service, by the
centrifugal determination  which they  excite and keep up, thus
relieving internal congestion and visceral engorgement.
  3. Icterus, as a sequela  from whatever mode of previous dis-
ease, is very likely to subside,  when convalescence  has been
perfectly established; yet this may be a very  slow process, and
may demand to be aided by some of the  measures above  indi-
cated.   Horseback riding, if the  patient is able to  bear it, is-
among the best of these.   Frictions upon the  side, and the em-
ployment of galvanism or electricity, may be recommended.
  4.  Spontaneous  icterus—the  jaundice  of  hot climates and
malarious districts—endemic and epidemic jaundice,  as  it has
been styled, is not  usually of serious character,  or difficult of
cure.   It disappears in many, with change of residence to  a bet-
ter air, or the return of cold weather, and is often dispersed by
active exercise. If it protract  itself, an  emetic  should be ex-
hibited, or an efficient mercurial cathartic.   Persevering efforts
have been and continue to be made, to discover some medicine
or combination of medicines, capable of acting on  the liver as
mercury is supposed to do—stimulating this gland to more abun-
dant secretion, while it removes at the same time  all obstruc-
tions,  and enables it to disgorge the bile freely through its natu-
ral outlets.   The  ill consequences so often following the injudi-
cious, mechanical and extravagant administration of mercurials,
have given great  interest to  this search  after substitutes, and
several have been proposed,  drawn chiefly, though  not exclu-
sively, from the vegetable kingdom.  Cook recommends to our
 special confidence, a combination of aloes and rhubarb.   Pem-
 berton presses the claims of the taraxacum or dandelion, with
 little foundation, I fear, having often tried it altogether in vain; 
ICTERUS.
1S3
 and of late, one of our western brethren, Dr. Bennett, of Chagrin,
 Ohio, maintains that the tomato, so much employed  upon our
 tables as an acid sauce, possesses similar efficacy with calomel,
 being entirely free, at the same time, from any  evil tendencies.
 An extract has been prepared, which is said to embody and con-
 centrate its peculiar properties; but I have been unable  to pro-
 cure any definite results from its use.
   As mineral substitutes, the muriates of gold and  of barytes
 have been brought forward, but are not received with any confi-
 dence.   I mention with far  more  approval, the nitro-muriatic
 acid, so highly eulogized by Dr. Scott,  who introduced it into
 practice in  the East, as applicable to all the forms of hepatic dis-
 ease, whether engorgement, torpor, obstruction, etc., provided no
 token of active inflammation be present.  The  internal  admin-
 istration of this formula, is not very much dwelt on by its advo-
 cates ;  but  its application as  a partial bath, to the extremities, is
 alleged to have exerted,  in  numerous instances, a prompt and
 energetic influence upon the liver,  exciting without  delay, the
 desired hepatic action, and procuring at once a free discharge of
 bile through the pruper emunctories.  Wallace  proposes, as de-
 cidedly preferable to this nitro-muriatic pediluvium, the immer-
 sion of the whole body in the chlorine vapor or gas.  Fumiga-
 tion thus made, he assures us, renews and augments the hepatic
 secretion, and relieves the oppressed organ with more  certainty and
 readiness, than can be obtained from any other  remedy.  A pecu-
 liar cutaneous eruption, known as the "chlorine rash," is produced
 by the action of this stimulating gas on the surface, which is con-
 sidered as beneficially revulsive, and  its appearance  regarded)
 therefore, as a highly favorable symptom.
   It is in this form of jaundice that the  tonics, especially the
 vegetable bitters, have done most service.   I prefer to unite them
 with some mild laxative, as the bowels are so generally slow and
 torpid.   The combination of Colombo with rhubarb and  an aro-
 matic, is a convenient formula.
   5.  Icterus, from obstruction associated with, or occasioned
by the presence of biliary concretions—gall stones, next demands
our notice.  These bodies are of very different constitution and
appearance.  They are mostly of a dark brown color, often yel-
lowish grey, greenish, etc.  I have seen them  of an intense jet 
184
ICTERUS.
black,  beautifully polished and  lustrous.   They are  of every
shape and sometimes attain a great, size.   Heberden tells  us that
a calculus weighing two drams, was found in the gall bladder
of Lord Bute.   Baillie mentions one as large as "a pullet's egg."
Small  ones in great number, are collected in some patients.  The
author last named, says that he saw more than a thousand taken
out of one body.   Some  of them  are  intensely bitter, others
quite tasteless.   They are soluble in boiling alcohol,  in  heated
oil of  turpentine, in aether, and in nitric acid.  They  are gene-
rally inflammable; but Baillie describes a species of very dark
hue, "which did not melt or blaze, but burnt  like a cinder."
They  often consist, externally, of concentric  lamellae,  being in-
ternally radiated or partly crystallized.
   Writers distinguish these calculi into three varieties—1.  The
cholesterine,  of whitish  or grey color, or brownish, crystallized,
shining, lamellated.  Cholesterine is a peculiar animal  principle,
erroneously supposed by Fourcroy, to be identical  with adipo-
cire.   It is partly soluble in boiling acohol; melts in  a high
heat, and sublimes in a vacuum.  2. Mellitic calculus, the most
common  species  of gall  stone;  of a brownish color ;  always
exists  in numbers,  and of course, takes  an  irregular  polygonal
shape.  The outer crust is composed  of concentric  layers of
cholesterine,  crystallized in small rays inclining to the  centre.
The nucleus consists of inspissated bile, picromel,  and other
animal matters.  3. Concretions of inspissated  bile;  these are
not common, but their existence is undenied.
   How these concretions originate, or by what vitiated  state of
the hepatic secretion they are generated, is not  known.   They
are formed, at least in the vast majority of instances, in the gall
bladder, where their presence seems to give no  uneasiness.  In
the case of Lord Bute, above alluded to, the  monstrous calculus
there  mentioned, had produced neither jaundice nor  any other
derangement of health.   I have myself, often found  such con-
cretions in subjects presenting no additional appearance of dis-
ease of the liver or its appendages.  To this rule of their entire
 inertness within the gall bladder, there  are,  however, some ex-
ceptions on record.  Soemmering states that he has seen several
 instances in  which their presence had brought on  ulceration  of
 the inner surface.   Baillie tells us he had met with but  a single 
ICTERUS.
185
 example of this kind.  Generally speaking, it is only when one
 or more of them has entered the cystic duct, and is  passing on-
 wards to the duodenum,  that the patient becomes affected with
 any definite symptoms.  Yet this  membranous canal is so dis-
 tensible and yields so readily, that it is not rare, on  examining
 the alvine discharges,  to find in them calculi of notable size,
 which have made  their way without  difficulty or  annoyance.
 Baillie tells us, too, that he has seen the duct  dilated to nearly
 an inch in  the transverse diameter.
    The presence of gall stone, which from its  size or  shape is
 hindered in its passage, is inferred from the sudden  occurrence
 of great and very acute pain at the  epigastrium, soon extending
 itself into the right hypochondriac  region ; it is complained of
 as intolerably severe and depressing, and is attended  with dysp-
 noea and orthopnoea; the patient cannot sit erect, but chooses a bent
 posture, leaning forwards.   There is sometimes pain at the top
 of the right shoulder,  as  in hepatitis.   Nausea  comes on, with
 great languor, frequent retching  and vomiting.  The abdomen
 feels full and oppressed, and all the clothing about the person is
 eagerly loosed; and this sensation is soon  followed by actual disten.
 tion, a tympanitic resonance and elasticity being perceived on ex-
 amination.  At this stage, the pulse is little if at all affected;  it is not
 until some hours have elapsed that it becomes tense and  corded.
   The effects of this mechanical irritation and obstruction are three-
 fold : first, we have the liver engorged, and  its acini and  smaller
 tubuli filled  with its secreted fluid ; the whole organ thus suffers,
 and must either be relieved by  the resorption of bile into the
 system and  its diffusion through the circulating mass, or hepa-
 titis must ensue, of more or less acute character, according to
 circumstances.  In either case, we have icterus produced—sim-
 ple or complicated.  Next, we have the digestive function im-
 paired for want of the due admixture of bile, which, whatever
 may be  the  nature of  its agency in the affair, cannot  be dis-
pensed with.   Without it, we know that fecification is, to say
 the least, incomplete ; the contents of the primae viae are unna-
 tural, and give rise to  irregular  and irritative movements, and
assimilation ultimately ceases.  Thirdly, a very important train
of  consequences  may set  in, not sufficiently dwelt on in your
books, perhaps, not clearly pointed out hitherto by any patholo- 
186
ICTERUS.
gist.  The mechanical irritation of the duct, gives rise in certain
instances, to a degree of inflammation, which, either by continu-
ity of structure  or from  functional sympathy, is readily carried
out along the intestines.  Hence  we have a duodenitis, some-
times obscure, it  is true, but occasionally well marked and vio-
lent.  Nay, I have  seen from this source, inflammation super-
vene of the stomach and bowels, gradually running on in two
cases to a fatal issue ; in one with very extensive mortification.
Bla»den relates  a  case,  in which inflammation  of the duct
caused an abscess which pointed outwardly, discharging a cal-
culus of an oblong shape, of nearly  an ounce and a fourth  in
weight.   Thomas and others give us similar histories.
   We cannot in practice distinguish from the cases thus described
as depending upon the actual presence of biliary calculi, such
attacks as have been attributed to mere spasm and inflammation
of the ducts themselves.   Indeed, the only diagnosis possible be-
tween them would be the discovery of these  concretions in the
stools.   Some have doubted the occurrence of a spasmodic clo-
sure of the duct in any instance, preferring to ascribe the ob-
struction to the inflammatory fullness  and thickening of its tis-
sues ; but the suddenness with which  the attacks come on, and
the abruptness with which they subside and terminate, point out,
 I think, a condition different from the  more permanent changes
thus  indicated; and where  we cannot,  with  every proper atten-
 tion, detect the existence of a calculus, we may not unreasona-
 bly infer that there is spasm of the duct.   Perhaps it would
 even be  proper to  say that in so dilatable a membranous tube,
 the supposition of  a spasmodic constriction is absolutely neces-
 sary to  account for the  detention of a concretion  of moderate
 size, and all the consequences following thereupon.   And if the
 irritation of a gall stone may produce such spasm, such constric-
 tion, why not the  passage of morbid, vitiated, acrimonious bile!
 The occurrence of these attacks is  almost entirely confined to
 persons who have lived in malaria  districts, have been affected
 with miasmatic diseases or liver  complaints, and have suffered
  from alvine discharges of a highly acrid, nay almost corrosive
  and burning acrimony.  I  saw in many paroxysms of this sort,
  assailing suddenly and—until the last  fatal attack—subsiding as
  promptly, a medical friend whose constitution had been broken 
ICTERUS.
1S7
 up by practice in our low  country.  Examination  of his stools
 made for several months failed to detect a single gall stone;  nor
 did we find one on post mortem inspection.
   The symptoms of this  class of cases  are precisely similar to
 those recorded under  the  last head; pain at the pit of the sto-
 mach ; sometimes  also in  the right hypochondrium and at the
 top of the right shoulder  ; nausea and vomiting;  flatulent dis-
 tention ;  tenderness on pressure over the belly;  meteorism ; ob-
 stinate costiveness  or teasing diarrhoea  with unnatural stools,
 acrid  and inflaming the  parts about the arms; great  mental
 anxiety;  the  pulse  not affected for some hours, but afterward
 excited, frequent and  tense ;  the  eyes and whole surface assu-
 ming a deep yellow or orange hue.
   The predisposition to this form of icterus consists, doubtless,
 in some obscure hepatic derangement which the minutest  ex-
 amination after  death has failed to point out.  The exciting
 causes are generally such as disturb the digestive function; a meal
 of improper  food, or the undue use of acids ; violent agitation
 from any passion, more especially grief and  anxiety ; exposure
 to cold, moisture and sudden changes.
   The Treatment applicable to the two last classes of cases is pre-
 cisely the same. If the patient be of ordinary strength and
 vigor  of  constitution, venaesection must precede every other re-
 medy, and requires to be carried out with a boldness and free-
 dom proportioned to the  urgency of the symptoms.  The pa-
 tient should he kept in the erect posture, or near  it, in order that
 a  more prompt  and complete  relaxation of the whole system
 may be effected.  The warm bath will aid very  much in bring-
 ing on this condition.  Opiates must be freely administered and
 repeated until the intensity of pain is subdued.  If  the stomach
 will bear  it, the tincture of opium should be preferred; solu-
 tions of the salts of morphine are less offensive, but sometimes
 the pill only will be retained.  Full doses are required ; I pre-
 scribe from two  to four grains of the drug or their equivalent re-
 peating every hour  pro re  nata.  It is well to combine with it
calomel also  in  efficient  amount.  Opiate enemata should also
be exhibited  without delay, and fomentations or  warm mustard
poultices applied over the whole abdomen, but especially to the
pit of the stomach. 
188
ICTERUS.
  When we have thus obtained some respite, an active cathartic
must be  given.  If the patient can retain  castor  oil, it is to be
preferred ; if not, the neutral  salts may be substituted, and the
use of these in proper doses and at requisite  intervals should be
continued for a considerable period, in combination with some of
the resinous  purgatives—aloes  or rhubarb.   Mercurials  do
not seem  to me to be  of the  special necessity or advantage so
often contended for,  until the case  has been protracted into  its
chronic condition, and the sufferings of the patient, whether from
mechanical  or specific irritation, have, at least in great measure,
subsided.  They are now of great utility ;  small  doses of them
may be persevered with until the production of a light ptyalism,
the disappearance  of the sallowness of skin and eyes, and the
return  of appetite and alvine regularity mark  an established
convalescence.  In this stage we may also make trial  of the
nitro-muriatic bath,  whose inventor, Dr. Scott, affirms that he
has "often known  it when used in the midst of a severe parox-
ysm of spasm in  the bile ducts, operate  like a charm, giving
almost immediate relief."
   Some practitioners are in the habit of prescribing emetics in
these attacks, with the hope of promoting the  more rapid ad-
vance of the calculi  through  the  duct into  the  duodenum.
They select,  for this  purpose, the mildest  and most  relaxing
articles, such  as oil or ipecac:, and administer them in such
doses as to give rise to prolonged nausea and full, free vomiting.
But the cases  that I  have met with, have all been attended with
retching and vomiting, frequent and abundant enough to render
any farther efforts in that way unnecessary, if not injurious and
improper.   Nor do I place any confidence  in the exhibition of
the proposed solvents of biliary calculi—turpentine, aether, nitric
acid,  etc., though  recommended by Durande and others.  I do
not understand how their agency can be applied,  and, except
aether, they are all irritating and unsuited.
   It  is  highly desirable to prevent the recurrence of these pa-
roxysms, as they are attended not only with unspeakable suffer-
ing  to the patient,  but with urgent risk of enteritis, and must,
by repetition, break  down and destroy the firmest constitution.
I know no means which promise more benefit than those already
advised, as tending  to promote, hasten, and render permanent, 
SPLENITIS.
1S9
the lingering, irregular and uncertain convalescence from  chro-
nic hepatitis—a change of climate, carefully avoiding the  sum-
mer  and autumn of hot  malaria  districts; annually  repeated
visits to the established watering places, purgative and diuretic
springs, such as  Ballston, Saratoga, the White Sulphur, etc.;
great prudence in abstaining from all excesses, mental and phy-
sical ; the observance of nice temperance in the pleasures of the
table and the use of vinous and  alcoholic drinks; the  wary
adaptation of the  clothing to  alternations of atmospheric tem-
perature and condition; the abandonment  of all sedentary and
indolent indulgences ;  and the establishment of resolute habits
of energetic occupation and systematic exercise.
  7.  It  only remains  to  speak of that form of icterus which
occurs, as authors tell us, from local pressure in cases of  phys-
conia, where visceral  enlargement or schirrous induration occa-
sions an impediment to the passage of the bile along its proper
ducts.   It is obvious that this may happen, though  it  is rarely
met  with ; it is  equally clear, that our  treatment, under such
circumstances, must be directed  to the  relief of the deranged
organ, and that  the sympathetic jaundice  which depends upon
the cause assigned,  admits of no  cure, or even palliation, from
any other measures than  those which tend to restore the health
and diminish the  enlargement of the affected viscus.   It would,
of course, be out  of place to enter here into any consideration
of this subject, which divides  itself under various heads, to be
discussed in proper  order and succession.
                   CHAPTER XXXIV.

                         SPLENITIS.

  In all warm climates, subject to the  influence of malaria, en-
largement and induration of the  Spleen are familiar phenomena.
As  the consequence  of intermittent  fever, it  is, indeed,  well
known, wherever that disease prevails, whether in Lincolnshire, 
190
SPLENITIS.
Walcheren, or South-Carolina.  The nature of this enlargement
is not well understood.  The organ is of the  erectile structure,
and is liable to  sudden intumescence, as has been  repeatedly
observed during the chills of a tertian.  Andral noticed remark-
able changes of bulk in the spleen  of  a  dog, during a painful
experiment  upon the animal.  Ague-cake is supposed, by some
writers, to be a  mere passive congestion or hypertrophy, and
sometimes attains, from the repeated concussions of  ague, an
immense size.  Lieutaud mentions a woman who had  for  sev-
enteen years a spleen  that  weighed  thirty-two pounds.  Sau-
sages speaks of a schirrous spleen weighing thirty-three pounds.
The largest that  I have ever seen,  weighed but  ten  pounds;
some of the most enormous  in bulk do not prove, by any means,
proportionally heavy.
  I am satisfied, that this ordinary condition of mere hypertro-
phy degenerates  not unfrequently into  a chronic inflammation.
It may—though this must be very rare indeed—it may give rise
to acute splenitis.  Yet, I am unwilling to allow even  this, un-
less some incidental contingency be  added, some influential and
energetic cause  of novel  character brought into play.   Among
all the numerous cases of enlarged spleen that I have had occa-
sion  to see, but a single one has  terminated in this way. A
little girl  set: five years, who had suffered much from fever in our
low country, and had labored under  a chronic  inflammation of
the spleen with great enlargement, giving rise to much suffering
and extreme inconvenience, was seized, while on a visit here in
May, 1838, with scarlatina.   She  passed through  the disease,
which  treated her  severely  enough, but when  convalescent,
complained anew and loudly of her,side, which was very much
distended and painful when  pressed  upon.   After some weeks'
illness, she  died vomiting pus in  large quantities  and of very
offensive odor.  I was not permitted to examine the body, but
was fully satisfied that the matter flowed from a splenic abscess,
 which, by adhesion, had  connected  itself with the stomach, and
burst into  its cavity.   In  a very  large  majority of cases, the
 swollen and indurated viscus remains little changed throughout
 life,  giving annoyance by  its weight  and  bulk, and inducing
anasarcous swellings of the lower extremities, and perhaps even
ascites, by its mechanical pressure  upon the abdominal vessels. 
SPLENITIS.
19>1
"There is a prevailing notion among the  French pathologists,"
says Marshall Hall, "that the source  of intermittents is in the
spleen."  He refers to Louis,  Cruvelhier, Piorry, and  Andral,
the first  of whom, he quotes,  as affirming  that "this organ is
affected in  the commancement of such fevers," and the last, as
putting the question, "whether the change in  the spleen is the
cause or effect of intermittents."   I have  seen many instances
in which an intermittent of short duration or few repetitions^
was not attended by any apparent affection of the spleen.  The
coincidence is by no means uniform, except in protracted attacks.
  I have had under  my care two well-marked instances of
chronic splenitis, neither  of which had any  connection  with
previous  fever.   Their cause was obscure ;  in one the termina-
tion  was fatal—the other, after suffering many months, has
perfectly recovered her health.
  The symptoms are not likely, I think, to be in  any degree
equivocal.  The  locality of pain complained  of—the  bulk of
the tumefied viscus, and  the absence of the specific tokens of
disorder of other organs, leave little or no room for error ; and
these remarks apply  as  well  to the  acute  as to  the  chronic
variety of splenitis.
  The changes which the spleen  undergoes from the action of
disease are various; suppuration, hemorrhage, tuberculation, hy-
pertrophy, with induration, on the  one hand, and softening, on
the other, and a peculiar alteration or dissolution of its substance.
This latter is described by Heberden and Abercrombie, and is
affirmed to have been the usual consequence of fatal attacks of
the celebrated Walcheren  fever.  The  term schirrous  is  often
employed in speaking of indurated spleen, but  Baillie denies its
propriety.
  It is not well understood, why  this organ  should suffer so
much in  fever.   Andral has suggested, that  in malarious cases
it is owing to changes wrought in the blood itself by the mias-
matic poison.  But it occurs in  typhoid  cases also, in forty-six
dissections of which  by  Louis, the spleen  was found  natural
only in four.  Rush, and some  other physiologists, have ima-
gined  the function or use of this organ to be, to  serve as a
diverticulum in  fevers universally, and the  idea  is  at  least
plausible.  The  distensibility  of its vessels  is remarkable, and 
192
SPLENITIS.
 it is  peculiarly liable to passive  congestion.  Its tissue seems
 deficient, too, both in elasticity and in tenacity.  It is subject to
 rupture of vessels from many causes, and to laceration of its
 substance,  an  accident  that  frequently occurs  from  external
 violence.
   The Treatment of splenitis is  unsettled, and by  no means
 successful.   In acute cases, depletion by the lancet, cups, leeches
 and saline purgatives,  is  indicated, and  must be carried into
 effect  promptly, and with as much energy  as circumstances
 demand  and  admit of.   If it  assume the chronic form, our task
 is a very difficult one.   The mercurial treatment, formerly so
 much relied  on, has of  late fallen into comparative disuse.  A
 majority of modern  physicians prefer to depend upon the  con-
 tinued exhibition of drastic cathartics,  as  the combinations  of
 aloes  with  rhubarb, colocynth, etc.   Some, borrowing from the
 practice of the Hindoos, who give vinegar and steel while they
 purge the patient actively, have added tonics to their purgatives,
 and prescribe  both  iron and bark  alternately with their ca-
 thartics.
   For my own part, I cannot recommend any  particular formula
 with great  confidence, in this obstinate malady.  I think I have
 found most benefit from the use of iodine  combined with mer-
 cury,  as in  the dentiodide of mercury and potassium, while the
 patient's  bowels were kept soluble  by the employment of blue
 pill with rhubarb in  such doses as were requisite, never pressing
 this matter very far. Cups  or  leeches over  the tumor relieve
 pain.   Fomentations applied to the side are also useful.
   The diet of the patient should be  light and nutritious.  To-
nics may be occasionally required,  in  which contingency 1 have
been  disposed to prefer  iron, especially in  the new preparation
known as  the tinct: aeth: acet: ferri.   If  the  pain be constant
and annoying, I do not hesitate to resort to anodynes and seda-
tives ; many  have recommended conium and hyosciamus, but
the preparations  of  opium and the  salts of morphine are the
only articles of this  class that deserve the least reliance. 
PAR0TI1IS.
193
                    CHAPTER XXXV.

                    PAROTITIS--MUMPS.

   Among the affections of the collatitious viscera, we must not
omit to notice this familiar form of disease, which derives some
importance, indeed, from the very fact of its frequent occurrence.
It is, as its name imports, an inflammation of one of the salivary
glands—the parotid; arranged in Cullen's nosology as a species
of Cynanche C. Parotidoea, and entitled by Parr, Angina  Paro-
tidoea.  From the difficulty of opening the mouth to speak, and
the sullen expression of countenance  produced by this enforced
silence and the attendant swelling, it has received  the English
appellation of Mumps, by which it is universally recognized.
   It consists  in a painful swelling of the parotid, which renders
all motion  of the  lower jaw difficult and  uneasy ;  there are oc-
casional paroxysms of severe  suffering, intense aching, in which
the ear  of  the swollen side is apt to partake;  deglutition is very
inconvenient.  Both  glands  may be  affected,  but  it is often
confined to a single one; in the former  case, the tumefaction
occasionally becomes enormous, extending over the neck beneath
the chin,  down upon  the breast, impeding respiration more  or
less, and up along the cheeks  and eye-lids and  forehead, so  as
very much to disfigure the countenance.   It is attended  mean-
while by  symptomatic  fever, with the usual phenomena—hot,
dry skin,  hard, frequent pulse, thirst,  furred tongue,  gastric
uneasiness, sometimes  running on  to retching and  vomiting,
general distress, restlessness and dejection of spirits.  It is spe-
cifically contagious, and attacks but once.
   A singular  and interesting point in its history, is the remarka-
ble disposition which it exhibits to metastasis—translation of the
morbid affection from one gland to another, from the part origi-
nally  assailed to other and remote organs.   In males  the testis,
and in  females the mamma, are liable to this secondary inflam-
mation, which occurs only at or after the age of puberty.   A
similar  metastasis, or transfer  of morbid action, or obscure sym-
pathetic extension  of  inflammatory  excitement, is  sometimes
       VOL. n.—17 
194
PAROTITIS.
determined to the brain, producing phrenitis.  Of this, which is
denied by some writers, I have myself known  three very seri-
ous and perfectly well-marked instances.
  The duration of parotitis, when it runs its ordinary course in
a single gland, and subsides without metastasis,  is not generally
more than four days, and the patient, especially if a child, may
complain very little, except when eating or after talking freely.
If it extend  to both  sides successively, a  day or two will  be
added  to  the indisposition.  If a metastasis occur, as  I have
said is very apt to take place in the adult, the protraction of the
case is irregular and indefinite,  depending somewhat upon  the
constitution of the patient, and not a little upon the energy and
propriety of the remedial management pursued.   Suppuration
of any of the glands thus inflamed, whether the mamma, testis,
or parotid, is  a rare termination.  A perfect resolution sooner or
later ensues, whether spontaneously, or as the effect of judicious
treatment.
  I  have met with a few instances of a lingering tumefaction,
or, as some have styled  it, an  induration of the parotid, which
continues enlarged, hardened, and somewhat painful on hand-
ling ; but even this is not permanent.  I have, however, known
this affection  of the gland twice terminate in suppuration, after
lasting several weeks, in  children three and four years old.
  The breast and testicle sometimes fall into a contrasted condi-
tion, when the first stages of inflammatory excitement pass off,
the injured gland wasting away, softening and remaining smaller
than its fellow, with a morbid degree of sensibility to  external
impressions, such as cold, pressure, or slight blows.
  The  general Prognosis in  mumps is of course favorable,
although, as above stated, the metastatic attacks may be produc-
tive  of some  risk.   This is particularly  true  of the  cerebral
affection, which occasionally seems to occupy this relation to
the original inflammation of the parotid.
  Treatment.  Under all the  ordinary contingencies  of  this
familiar disease, very little medical interference  is  required.  It
is precisely to such cases as  these—transient, destitute of ma-
lignancy, and  self-limiting  in  the  true sense—maladies which
run  a definite course, and  then spontaneously subsiding, pass
entirely away,—it is precisely to such cases, that  the medicine 
PAROTITIS.
195
expectante, and its  German  modification in homoiopathy, are
adapted.  It is from such as  these, that it was  at  first derived,
and spread, by timid and  illogical inference,  over  the whole
field of rational therapeutics.   Yet, even here, although in gene-
ral it is as well to advise merely rest, seclusion  and  abstinence,
you will  not do wisely to  neglect your patient.  The  local
symptoms  may assume an inordinate  intensity—the constitu-
tional  irritation may run unduly high, and  your patient  may
derive  from  your prudent and judicious interposition, a very
notable and grateful palliation of his sufferings.  The adminis-
tration of a gentle  cathartic—the application  of  a few leeches
upon the tensest point of the  swelling at first, and afterwards of
tepid fomentation, will give some relief.  If the glandular en-
largement  persist more than two or three days, the skin over
the tumor may be irritated  moderately with  the lin: volatile, or
some other mildly stimulating embrocation ; a strip of flannel
being worn around the neck and jaws.
   When the  patient on the  third or fourth day complains of a
feeling of uneasiness, weight, or tenderness, in the  mamma or
testis,  matters have assumed an entirely different  aspect; the
secondary  affection  has nothing of the self-limiting character
which belonged to its original, and  a vigorous interference on
the part of the medical  attendant becomes  necessary to avert
impending evil.   The diseased action  thus  transferred or ex-
tended, must be subdued promptly, or a foundation may be  laid
in these structures newly disordered, for troublesome and lasting
mischief.   Venaesection,  if it can be borne, is at  once to be
resorted to, and carried  to  as free an extent as  circumstances
permit.  Topical depletion is  not less important, and leeches
should be applied, in large numbers, to the painful parts.  Warm
irritants are advised  to be applied upon the parotids, to invite the
malady back to its primary seat.  There is no objection  to  this
measure but its absolute futility; the speculation  upon which  it
is based, is not more groundless than the practice is  unavailing.
The period of parotid affection having past away, returns no
more.
   Purgatives are  useful here  both as  depletory and revulsive,
and the neutral salts deserve  an unqualified preference.  Indeed,
the anti-phlogistic regimen, in  its full  extent,  must be carried 
196
PAROTITIS.
into  strict  execution.  Some  physicians  lay great stress upon
the efficacy of emetics frequently repeated.   The course appears
to me unnecessarily harsh, but I  place not a little confidence in
the sedative  influence of antimonials, in  doses which nauseate
slightly or  not  at all.  The solution of  tart: antimon:  or  the
pulv: antimon: with nitrate potass: may be employed in quanti-
ties sufficient to reduce the force of the circulation and keep up
a free diaphoresis.  I  do  not hesitate to relieve pain and subdue
restlessness by the use of anodynes.   The pulv: doveri, or solu-
tions of the salts  of morphine, may be given pro re nata.
   As local applications,  1 prefer,  at  first, warm  and relaxing
fomentations; they promote  the  flow of  blood  from the leech
bites, and diminish the tension and pain complained of.  After a
while they become irksome, and  should  be abandoned, substi-
tuting for them, not abruptly, but after a short interval, sedative
and  astringent lotions of acet: plumbi, etc., alum-curd, etc.  The
recumbent  posture should be long and steadily persisted in,  and
the male convalescent, when he rises  from bed,  directed to keep
his testicle suspended properly and carefully.  Females must be
warned to avoid all  undue pressure from  stays, corsets,  and
other articles of  dress, which will  give rise  to prolonged or
repeated inflammation of the  gland, and  may even produce
schirrus and its results.
   These swellings may  become  indurated and  indolent by  pro-
traction. Epispastics should be laid upon them from time to time,
or iodine lotions  and  ointments, while the solution of iodine is
administered internally and with  perseverance, occasionally in-
terposing frictions with  mercurial ointment externally, and the
internal administration of a few grains  of calomel  or of  blue
pill.
   When the brain becomes the seat of consecutive or metastatic
inflammation from parotitis, the system of unshrinking depletion
must be carried out promptly and decidedly.  Here we have at
once developed a wild delirium or furious mania, with  turgid
visage,  blood-shot eye, a full, hard, bounding pulse, and every
token of high febrile excitement.
   The  lancet holds the  first  place among our  remedial means.
The patient should be placed in a sitting posture with his head
erect, and  bled freely, from a large orifice, until  syncope  or 
SORE THROAT.
197
yielding of the strength warns us to stop.   The hair should be
cut close or shaved, and cold affusion made repeatedly upon the
scalp ;  purgatives, the saline especially, freely given; and sinap-
isms, and afterwards vesicatories laid to the extremities.
  But the minute detail of the treatment demanded by this class
of cases, will be more appropriately offered under  the head of
phrenitis, which is hereafter to receive a due share of our atten-
tion.
                    CHAPTER  XXXVI.

                        SORE THROAT.

   Sore Throat.   I employ here in preference, the  phrase by
 which, in common conversation, we denote every variety of in-
 flammation in the throat, whether with or  without abscess or
 ulceration, because it is  sufficiently significant  and expressive,
 and better adapted in a general way, than any term in the tech-
 nical nomenclature  of the  books.  "Cynanche," a word which
 Cullen has brought into use, and under which he has included
 a large number of diseases,  "agreeing," as Parr  has  it,  "in no
 one principle but affection of the parts connected with the neck,"
 is like "Angina," derived from, and indicative of a single symp-
 tom only, and one that  is often wanting in this class of mala-
 dies, viz: a difficulty of breathing,  suffocation,  or strangling.
 "Paristhmia," by which Hippocrates denotes a "throat affection,"
 in  a very literal way, and "Paristhmitis," a coinage of Good, to
 express the same meaning, or rather to convey,  while he  pre-
 serves a uniformity of terminations,  the  idea  of "inflammatory
 affection" of the throat,  are  unobjectionable nosologically speak-
 ing, and may perhaps come  into general  usage.
   Sore  throat  then—paristhmitis—may be divided first into
 common and malignant.  The former, in its several varieties is
one of our most familiar diseases, and is designated variously to
point out its exact  location, as  well as  the different modes in
       17* 
198
sore throat.
which the part is affected.  Thus we have simple superficial in-
flammation—inflammation with the formation of plastic lymph
or false membrane, diphtheritis—inflammation with ulcer—and
phlegmonous inflammation or abscess.
   Malignant sore throat may be  either diphtheritic or ulcerous,
yet it is important to be aware, that whatever may be  the incon-
venience and annoyance of the  membranous depositions, or the
destructiveness  of the ulceration  present, the  local  disorder is
comparatively  of little consequence,  whether  we look on it as
primary and essential, or merely as a symptom.  It is accompa-
nied by fever of the lowest grade and  most adynamic form, and
a grave and prompt prostration  of all the vital powers is among
its most characteristic conditions.  The local affection, however,
is of peculiar  nature  and  appearance,  and shall be carefully
described.
   1. Simple superficial  sore throat, is occasioned by any, or all
the causes that give rise to catarrhal  fever, with which, indeed,
it is very often connected.   Exposure of the neck or head to a
current of  cool or damp air, damp clothing, wet feet,  sudden
ehanges of temperature, bring  it on,  and repetition  gives a re-
 markable susceptibility to  it in certain delicate subjects, so that
 the very  slightest  difference in their dress, or  alteration in any
of their habits, as in being out under the open sky at an unac-
 customed hour in the evening, will be followed almost inevitably
 by  an attack.
   The patient first perceives a slight sensation of dryness in  the
 throat, and a pricking or  uneasiness in swallowing, and an irri-
 tating frequency of the desire  to swallow his saliva.  This un-
 easiness soon amounts to pretty constant and severe pain, which
 gradually extends  itself, and very often, indeed, reaches into the
 ear of one or both sides—perhaps from continuous inflammation
 of  the eustachian tubes.  Fever comes on early with or without
  a chill, the pulse  being full, quick and hard, and the skin hot
  and dry  : the headache is usually great, with some  gastric  dis-
  comfort  and much thirst.   On looking into the throat, which is
  best  done by placing the  patient opposite a  strong light, and
  pressing down the back of the tongue firmly with  a spatula or
  the handle of a spoon, we distinguish the deepened redness of
  the mucous surface and the engorgement  of  its vessels, the in- 
SORE throat.
199
tensity of the hue corresponding  generally with  the pain com-
plained of; it is greater on one side than the other, and at parti-
cular points; the uvula is deep red and swollen. The dysphagia
is occasionally extreme, the saliva flowing  largely and giving
out an offensive odor, and fluids attempted to be swallowed, re-
turning with a gush through the nostrils.  There is not often
any notable impediment to respiration.  After three or four days
of  this suffering,  the febrile symptoms subside, the dysphagia
grows less and less, and  an entire resolution of the inflamma-
tion ensues.   In  very severe cases, however, the  restoration is
not thus complete ;  the uvula is sometimes left relaxed, elonga-
ted and oedematous; sometimes the mucous surface, especially
of the pharynx, appears roughened or as if papulous with slight
pointed eminences  scattered over it;  or the vessels remain—as
after  some opthalmias—permanently  enlarged,  giving a feeling
of lasting irritation and annoyance.
  2. In certain constitutions, such as we term plethoric perhaps,
and under some undefined contingencies, the inflamed surface
becomes covered  with a coating of plastic  lymph.  This false
membrane which is often  mistaken by careless observers for an
ulcer, should always be distinguished.  I  will not say that it
always portends evil, for I have occasionally met with it in cases
not otherwise remarkable, and which recovered quickly and per-
fectly ; but I would always regard its  presence as  suspicious.  It
is precisely identical with the  so-much  dreaded  membrane of
croup, and in  children there is great reason to fear that the ten-
dency to deposit it will spread from the pharynx or fauces into
the larynx—a combination of maladies full of menace and very
often  promptly fatal.  It  is apt to be attended with great local
inflammation, and much constitutional disturbance.  By its pre-
sence it mechanically increases the difficulty of swallowing, and
may even somewhat impede respiration by the loosening of tena-
cious shreds which fall over and irritate the glottis. The vessels
of the surface beneath it sometimes effuse blood, which discolors
it, and the flakes thrown off thus infiltrated, being of very offen-
sive  odor,  have  been frequently  mistaken for  sloughs,  to the
great  alarm of the inattentive and inexperienced.
  I have met with cases in which, this tendency to the deposi-
tion of adherent lymph assumed a sort of chronic  character.  In 
200
SORE THROAT.
one of these, a lady—the disease lasted a year ; during the whole
of which time she was annoyed by the mechanical irritation arising
from the flakes or shreds  of fibrinous membrane scattered over
the back and upper  part of the pharynx  behind the uvula, the
surface beneath continuing red  and roughened.   I suppose it to
be owing to the same tendency in less  degree, that we must as-
cribe the  formation of a thick,  condensed and highly offensive
concretion, gathered in the foveas or crypts which  indent the sur-
face of the  swollen  tonsil.  These  small  hard lumps whose
whitish or yellow surfaces are seen through a thick mucus, are
easily  mistaken for  ulcers.  I  sometimes press them out with a
probe,  to the great relief of the patient.  If they remain in the
cavities in which they are  found, they occasion swelling with
much  pain, and perhaps are loosened by suppuration and hawked
out.
  2. Paristhmitis ulcerosa.   Ulcers occurring upon this mucous
surface present  a very great diversity of appearance, which to
describe in  minute  detail, would occupy much time, without
leading us, so far as I am aware, to distinctions of specific cha-
racter,  or affording us inferences  of  any very definite practical
utility.  Indeed the supervention of ulcer upon inflammation of
the lining membrane of the throat, does not seem to modify in a
material degree, the treatment necessary to be pursued, unless in
cases of chronic obstinacy, or  such  as  are connected with some
peculiar morbid constitutional  condition, such  as the syphilitic
strumous etc., of which I do not propose to speak at present.
  This modification of sore throat, is often from the first very
sharply painful.  The surface of the ulcer is gray or  whitish, in-
terspersed with red points; the edges being swollen it seems
excavated ; it is disposed to extend itself in all directions with a
rapidity proportioned to the intensity of the inflammation con-
nected with  it.  After a time, if the ulcers do not heal, they be-
come  indolent, stationary,  chronic ;  while  the sympathetic con-
stitutional irritation subsides slowly or in part.   They occasion-
ally extend  slowly down the esophagus, healing at some points
and spreading at others, with irregular cicatrization, which con-
tracts the tube and renders deglutition exceedingly difficult and
painful.
  3. Phlegmonous Sore Throat—Cynanche tonsillaris—Quinsy. 
SORE THROAT.
201
 On looking into the fauces, if we find one or both of the tonsils
 projecting forward,  with a fiery and  glossy  surface, exhibiting
 great fullness of the vessels and much distention, we have rea-
 son to fear the formation of abscess.   Their enlargement becomes
 in some instances enormous, touching and pressing against each
 other, so as to close  up the passage,  rendering deglutition im-
 possible, and impeding very seriously  the respiration of the
 patient.  Collections of highly offensive and foetid pus, find their
 way out or escape by artificial opening,  and the sides  collapse
 and heal.  The repetition  of these  attacks, even when  we suc-
 ceed in procuring  resolution, gives rise to enlargement  and per-
 manent  induration of the tonsils,  which impair both the hearing
 and the  intonation of the voice.  This condition mechanically
 predisposes too, I think, to all the forms of throat inflammation,
 and adds to their risks and inconveniences.   Abscess, now and
 then, though  perhaps rarely, forms at the back of the pharynx ;
 I have seen it occupy that situation ;  and we have on  record a
 few terrible instances of abscess in  the esophagus,  an  affection
 full of suffering and danger, and  very little within the  reach of
 the resources  of our art.
   The Prognosis  in the ordinary inflammations of the throat,
 which I have been describing,  is generally favorable.  The de-
 gree of risk  bears a certain relation to the particular  form  or
 locality,  and to the  age and  circumstances of the individual.
 Simple superficial sore throat is scarcely ever fatal; ulceration of
 the surface does not  add very greatly  to the chances of serious
 injury, except in young children,  who seem less sensible to the
 pain than adults, and who  frequently do not complain  or  give
 us  any notice  of the state of the  fauces,  until  the  fetor of the
 breath, or the  dysphagia or the regurgitation of fluids  through
 the nose, in swallowing, compel us to  make an  examination.
  Diphtherite, I have said, is never to be lightly regarded. This,
 also, is far more menacing to the  child than the adult; both the
 ulcerous  and membranous  inflammations show,  in  the young
 subject,  much disposition  to  extend themselves through the
glottis into the larynx, producing a combination  of  diseases
almost inevitably mortal.   I have spoken of the ill effects likely
to follow the inflammation  of  the tonsils; these also, are more 
202
SORE THROAT.
frequent in  the  younger subjects;  but I have  never met with
quinsy below the third year.
  The Treatment of inflammation of the throat is plainly marked
out, and is usually efficient and successful.   We resort at once,
as in all the other phlegmasia!,  to  the antiphlogistic  regimen.
In the simple forms, nothing more will be  required than a pur-
gative followed by some diaphoretic, while we confine the  pa-
tient to  a warm chamber and absolute diet, for a day or  two.  In
the severer attacks, occurring in young and robust subjects,  the
lancet may be called for, but I rarely find  it indicated.  Some
scarify the inflamed surface, making incisions with a lancet across
the engorged vessels; Crampton, of Dublin, passes a  leech di-
rectly into the  fauces—doubtless  an  efficient  mode of topical
depletion, but one which my patients have refused to submit to.
If there be any considerable swelling externally, it will be well
to apply them in proper numbers, to the  angle of the jaw.   It
is my custom to prescribe,  as in catarrhal fever, a full  anodyne
at night, with pediluvium,  and a warm mustard poultice round
the neck.
  Gargles are, in domestic  practice, remedies, almost of course;
but in the early  stages of all  these  throat affections, I strongly
disapprove of their use.  While the surface  is thus newly in-
flamed and painfully irritable, they can do  nothing but harm.
Their employment requires the fauces  to be thrown  into vehe-
ment action, by which the local excitement is notably augmented.
A vastly preferable substitute is  the inhalation  of warm vapor,
which relaxes the swelling and tension  of the parts,  and pro-
motes a free flow of saliva  and the other mucous secretions, to
the great relief of the engorged  vessels.  The simple  steam of
water, not too much heated, answers every purpose, but is often
medicated by adding vinegar or camphor, or infusing  aromatic
herbs.  This inhalation has also the advantage of acting very
often as a most effectual general relaxant and sudorific.
  It is,  I think,  to Velpeau that  we are indebted for the practice
of applying powdered alum directly to the inflamed part. This is
often very useful, nay, it sometimes arrests abruptly  the  inflam-
matory processes, probably by its strong  constringent  action on
the vessels. 
SORE THROAT.
203
  In quinsy, the tonsils  should be deeply  incised—at first, to
bleed freely from the affected part,  which is our best  means of
procuring resolution, and putting an  end to the disease; and
afterwards, to give vent  to the pus deposited within the sub-
stance of these bodies.   It was formerly, and I fear, with some
practitioners continues to be the practice, to resort  here  to the
forcible action of emetics "to rupture the abscess."   If this class
of remedies can  be beneficial under any circumstances, it must
only be by their sedative and  sudorific effects.  The  vehement
muscular efforts in vomiting, cannot fail to give great and unne-
cessary distress to the patient.
  Cases occasionally occur, as we are told, for I have never been
so unfortunate as to see  any thing of the  kind,  in which the
swelling of the tonsils and parts adjacent, has been so enormous
as entirely to occlude the passage of air into the  glottis.   Here
it becomes necessary to  give relief, and save  the  subject from
impending suffocation by the operation of tracheotomy.
  It often happens that  an indolent enlargement  of the  tonsils
remains as a permanent result of the attack—productive of con-
siderable annoyance, and affecting  unpleasantly the speech, hear-
ing and deglutition.  This is an obstinate  condition  of  things.
The cure  may be attempted by means of stimulant and  astrin-
gent gargles, deep and frequently repeated scarifications,  pencil-
ling the indurated tonsils  with strong solutions of iodine,  or
sulph: cupri, or mere: corros: sub: or nitrat: argenti—and if these
fail, by their extirpation  with  the  scalpel,  or scissors, or Tie-
man's ingenious instrument. The operation, as far as I am aware,
is attended with no risk, and very little pain, comparatively, and
is not followed by any evil consequences.
   The chronic diphtherite,  of which I spoke above, is also an
obstinate ailment.   I have found it best relieved by the use of a
gargle composed of a small portion  of mere: corros: sub: dissolved
in lime water—the yellow wash, as it is called in some of the books.
   The chronic protraction, even of the simplest and most super-
ficial sore throat, is sometimes so tenacious  and  indomitable, as
to wear out our perseverance and exhaust our resources.   Under
these circumstances, gargles,  which I have objected to  in the
first instance, become  indispensable.  The milder astringents
and sedatives may be first tried, the sulph: zinci, the acet: plumbi, 
204
SORE THROAT.
alum, infusion of cinchona or of the red oak bark; mixtures con-
taining camphor, the tinct: kino, catechu, myrrh.   The sulphate
of copper is much used, and when the case has lasted long, the
infusion of cayenne.
  It is perhaps among the worst consequences of this variety of
paristhmitis, that the uvula becomes edematous, relaxed, elonga-
ted, reaching down upon the back of the tongue, and by irrita-
ting the epiglottis giving rise to a frequent and troublesome cough.
Hence follows, as has been believed, a sympathetic or secondary
irritation and inflammation of the respiratory organs, running
on into actual phthisis.   To prevent these evils, it is proper to
remove the pendulous portion of the uvula  by excision.  We
owe this suggestion to Dr. Physick, though the honor has been
unjustly claimed by the French, for a M. Cuynat.
  I have already alluded to the chronic tenacity of ulcerous sore
throat:   It becomes occasionally, a merely local affection, and
in this state, may endure for months, and even years, harrassing
the patient beyond measure, and embarrassing, and indeed, foil-
ing the  most sagacious practitioner.  In  some  examples,  the
ulcer  remains stationary and indolent,  unaffected  either by our
remedies or any other contingencies.   In some again, it assumes
from time to time a healing aspect, and when we  are flattering
ourselves with sanguine  hopes of a speedy and complete cure,
suddenly begins to spread anew,  and in  a few hours attains its
former extent, or attacks a fresh portion of the surface.  It takes
its course, sometimes, down over the back  of the  pharynx and
along the esophagus, destroying the capacity of the parts for their
natural actions, or perhaps rendering  deglutition mechanically
impossible, by the contraction attendant  upon the cicatrization
of the lining membrane of the tube.  In these unhappy cases,
with few exceptions, the patient sinks  ultimately,  exhausted by
the long continuance of the irritation he endures,  or worn out
by the annoyance inflicted in the attempt to aid him—the pain-
ful application of caustics, or  the forcible  introduction of dila-
tors ;  or worse  still,  as  it would seem, from actual inanition
and thirst, after  being tantalized by our  vain efforts to sustain
him by thin fluids conveyed  through tubes, and by nutritive
enemata.
   Chronic ulcer of the  throat is best treated, I think, by a slow 
MALIGNANT SORE THROAT.
205
 and gentle mercurial course, carried to the extent of incipient
 ptyalism, and persevered in for some time, while we administer
 cinchona, and give farther tone to the  system by a change of air.
 Among the local applications recommended, are the pyroligneous
 acid, kreosote, the  mineral acids  generally, but especially the
 nitric and nitro-muriatic.  When  the  discharges  are offensive,
 I employ the chlorates of lime and soda.   Revulsion should be
 instituted, meanwhile, in the most efficient modes.  The  throat
 and upper part of the chest should be vesicated again and again;
 and a seton or issue inserted in the back of the neck or  in the
 arm. The diet should be ordinarily, rather nourishing and gen-
 erous;  the clothing warm  and well adapted to the weather; the
 apartment in which the sick man resides, must be kept neat and
 well ventilated;  and if his  strength  will suffice, exercise not
 only permitted but enjoined.
   An entire  change of climate should  be  advised in the last re-
 sort, and the warm and equable  atmosphere of the  islands in
 high latitudes preferred.  There is, besides, some favorable influ-
 ence produced by the diet  of inter-tropical regions, consisting so
 largely as it  does, of fruits and fresh vegetables, throughout the
 prolonged summer of their sunny year.

   Malignant  Sore Throat—Cynanche  Maligna.  To
 the history of this  terrible and destructive form  of disease, as
 given by Cullen, succeeding writers have added but little.  Con-
 cerning its specific nature and its  origin, there has been con-
 siderable dispute.   Although a sporadic  or solitary  case may
 occasionally  be met with, yet it almost  always occurs in masses,
 and  is therefore regarded as epidemic, and  its characteristic pe-
 culiarities ascribed to some diffused or atmospheric  influence.
 Its contagiousness,  too, is  maintained  by a very large majority
 of those who have described it; although, as usual, the doctrine
 is warmly debated and strenuously denied by others.  The evi-
 dence adduced on the affirmative  side of the question, seems to
 me entirely satisfactory;  and I never fail  to  adopt all prudent
measures of precaution,  to prevent the  spreading of a malady so
grave and unmanageable.
  Persons of all ages are liable to be  seized by it, but it affects
principally young children,  and among them its proportional
      VOL. II.—18 
206
MALIGNANT SORE THROAT.
mortality is very great.   Weak and infirm people, in every pe-
riod of life, are subject to its attack.   The fever, which consti-
tutes an essential part of its description, is of the lowest grade
of typhus.   Its  access is usually ushered  in by  chilliness or
slight shivering ; the patient complains of great anxiety, uneasi-
ness and dejection ; is languid and feeble.   The stomach is op-
pressed, and disturbed  sometimes with nausea  and vomiting.
The voice  is observed  to have  undergone a change, being in
some, unnaturally shrill  and sharp, in others, hoarse and husky.
There may or may- not be present  soreness  or pain in the
throat, nor is there apt to be any serious complaint  of difficulty
in swallowing;  but on examining the  fauces, we shall  find at
first, a dusky redness overspreading the tonsils, uvula, pharynx.
etc.; one or more ash-colored ulcers soon appear, spreading with
considerable rapidity, but in general, with  no very  severe pain
or local suffering, and usually throwing off successive  sloughs,
thus becoming deeper and deeper.
   The surface  of the body is of very irregular temperature; the
skin dry and harsh; the  tongue, at first foully and thickly furred,
becomes red, smooth and apththous; the thirst is unquenchable;
the pulse is frequent, small, and easily  compressed.  There is
great and rapidly  increasing prostration of muscular strength,
with obvious tokens of sensorial disorder;  the hands and knees
tremble; the eyes glitter with an uncertain expression, and a
vague, wandering gaze; the visage is pale,  and a slight  inco-
herence of thought and  language displays  itself early,  and  re-
mains throughout.
   In a very notable proportion of instances, there, occurs in the
course of the attack, an efflorescence upon the cutaneous surface,
in patches of a dull red  color.   This is looked  upon by many
pathologists, as a symptom  uniformly  attendant and character-
istic, and hence they have drawn the  inference  of an  essential
connection, or  to  speak more clearly,  an absolute relation of
identity, between  scarlatina maligna and cynanche maligna.  I
cannot coincide in this  view of the  matter.   I have met with
repeated examples of the pestilence under  discussion, in which
the eruptive affection was wanting altogether; and this in severe
as well as  in the less violent cases.  Besides  this, it is, in my
experience, very rare, to find the sore throat of scarlatina consist 
                  MALIGNANT SORE THROAT.              207

  in a malignant or  putrid ulceration.  It may be  so, doubtless,
  but is much more frequently  diphtheritic,  and very often  con-
  sists merely of an  intense superficial inflammation,  without any
  breach of the surface.  The  pulse sinks more and more;  is
  irregular, rapid, intermittent;  a low muttering delirium  super-
  venes, or a sort of  affected liveliness and playfulness, forming a
  striking contrast to the haggard hippocratic countenance  of the
  patient.   I  have seen a child sitting  up  in her cradle,  in the
  very last moments of waning life, without pulse,  and almost
  without voice or breath, busily and cheerfully engaged in play,
 as she imagined, with her usual train  of little associates.
   The ulcers in the throat, which we  described above, put on
 as the disease progresses, a marked gangrenous tendency.  They
 assume a livid or even  black  hue; give  out a fetid and oppres-
 sive odor, sometimes producing nausea and syncope in the at-
 tendants, and discharge an abundant thin  ichorous fluid,  which
 inflames and excoriates the nostrils and lips, and seems to excite  in
 children,  who can scarcely help swallowing it, (for even an adult
 voids it with  difficulty,  disgust  and  fatigue,) a diarrhoea, with
 sharp griping and much gastric and intestinal irritation.
   It may happen, that the inflammation  and ulceration extend
 themselves from the pharynx into  the larynx, especially  if the
 weather be cold and damp.   This combination proves almost
 irretrievably fatal—exhibiting itself in  the stridulous hoarseness,
 ringing cough and hurried panting of croup,  the patient  dying
 quickly suffocated.
   Instead of ulceration of the throat, and indeed, sometimes com-
 bined with it, we may have diphtherite—the deposite of fibrinous
 layers  upon  the mucous surface.  Nay, this condition seems par-
 ticularly ready to connect itself with the  low  form  of inflamma-
 tion and general typhoid state, of which we are speaking.  This
 is a most gloomy and appalling modification of disease, perhaps
 not necessarily hopeless, but admitting, very seldom, of recovery.
   It is in  these typhoid  diphtherites that  we most  frequently
 meet with the irregular efflorescence, so much dwelt  on by wri-
 ters ; and these constitute the intermediate cases—a sort of con-
necting link, as it were, between  scarlatina and  cynanche ma-
ligna,  that have given rise to the error,  above alluded to, in con-
founding them. 
209              MALIGNANT SORE THROAT.
  The general Prognosis in malignant sore throat, I need hardly
announce to you, is unfavorable.  The proportion of mortality
is very great, and  especially when  its epidemic  influences  are
strongly pronounced.  The hope of recovery is somewhat bet-
ter, in cases occurring sporadically.   We distinguish the milder
attacks by the less degree of physical prostration  and sensorial
disturbance, and by the higher apparent powers of resistance in
the constitution. The patient is more sensible to the pain and in-
convenience of the ulcer, which is of a more florid hue, throw-
ing off its livid or ash-colored surface ; the breath is less foetid;
the stomach and bowels less disturbed; the skin softer and more
diffusedly of pleasant  temperature; the countenance more ex-
pressive and mind less wandering, while the pulse improves in
force and volume.
  In the Treatment  of malignant sore throat, we  are to direct
our special attention to the  condition of the general system,  re-
garding the local affection which  has given name and character
to the disease, as in  truth one  only of its specific  symptoms.
Essentially pyrectic, it belongs  to the worst grade of typhus,
which it resembles in all its dreaded peculiarities—its contagious
property,  and its epidemic tendencies.
  The indications presented, and the  means of fulfilling them,
are  also very much the same as were formerly detailed, in speak-
ing of typhus o-ravior.  To restore and  keep up  the subdued
energies of the sensorial and vascular organs ;  to relieve oppressed
viscera by proper derivation to secretory surfaces, especially  by
determination to the  skin ; to regulate the intestinal discharges,
partly upon this principle of revulsion, and partly to get rid of
foul and irritating excretions,—these are the objects whose attain-
ment we are  to aim at most assiduously.  To accomplish  these
purposes,  it will, in a large proportion of  cases, be  well  to em-
ploy at the commencement, an emetic—one of the  few points of
practice here, on which physicians seem generally to have agreed.
Various  formulae  have  their advocates.  The combination of
ipecac with an antimonial, is proposed, as at once mild and effi-
cient, cleansing the stomach and bowels effectually,  and deter-
mining forcibly to the surface.
  The sulphates of zinc and copper are well adapted, when the
strength is so much  enfeebled  as to make us afraid of the ef- 
MALIGNANT SORE THROAT.
209
 fects of depletion or evacuation.   They nauseate little, acting
 promptly, and occasioning no depression or prostration.  The
 latter seems to exert, besides, some usefully specific influences
 upon the ulcerative  inflammation.   If the bowels are not spon-
 taneously moved, a cathartic will  be indispensably  necessary.
 Calomel deserves our preference here; its alterative effect is bene-
 ficial as far as it goes, and as a purgative  it is most gentle, most
 easily regulated, and least likely to  induce exhaustion or increase
 debility.   The dose should be small, and repeated at proper in-
 tervals.   Ptyalism is unnecessary, and should be avoided.
   Early recourse should  be had to diaphoretics, of which those
 articles possessing also some stimulating qualities should be se-
 lected ; and deserve to be considered indeed, perhaps, as our chief
 remedies.   Ammonia—both the carbonate  and acetate, may be
 added with benefit to  the infusion of serpentaria or of seneka ;
 or camphor exhibited in the same combination.  The compound
 infusion of cinchona and serpentaria is also highly useful. Aci-
 dulated slightly with the vitriolic elixir, it is pleasantly aromat-
 ic, and corrects the fetor issuing from the fauces and mouth.
   When the tokens  of typhoid prostration increase in force and
 intensity, we must not hesitate to  administer  the diffusible sti-
 muli in such quantities as circumstances may demand.  Wine-
 whey, wine undiluted  or made more cordial with spices, brandy
 and aether, may be mingled in such preparations as are most con-
 venient, and given largely and freely to excite the flagging circu-
 lation.  We shall have need of all our ingenuity and persever-
 ance to  induce a proportion of our patients  to swallow a suffi-
 cient quantity of these prescriptions to exert any efficiency in
 sustaining them. * The  best  tempered and most  manageable
 children sometimes  become sullen  and indocile  under the dis-
 comfort and dejection of this disease, and refuse doggedly what-
 ever is offered them.   Among  the  several modes of obviating
 the difficulties presented here, we must not omit the employment
of the same or similar articles  as enemata, in triple or quadruple
 amount.   We may also use baths, medicated and made stimula-
ting with  salt, mustard or ardent spirits.  Frictions must be re-
sorted to, over the whole trunk, while we irritate the extremities
with  sinapisms extensively and frequently applied.  The em-
ployment  of vesicatories  under the  present contingencies, is a
      IS* 
210
MALIGNANT SORE THROAT.
point much  disputed.  While some practitioners recommend
them highly as well  adapted to  prove beneficial both by their
excitant and revulsive action, others advise a careful abstinence
from them on account of the tendency to gangrene and slough-
ing which they allege to be frequently observed in the blistered
surfaces.  I prefer the sinapism, as equally  efficient and freer
from inconvenience ;  yet I have not met with the evils thus as-
cribed to the epispastis.  If applied in the earlier stages of the
case__where only they are called for—and before the cutaneous
circulation has sunk too far—there seems but little risk of spha-
celation.  I make little use of them, as I have already said, ex-
cept where  stridulous  hoarseness and  a ringing cough menace
the  supervention  of  croup; an  evil to be  prevented by every
possible means.   I have observed that a blister applied to the
throat where there is diptherite,  is apt to  heal very slowly, its
surface being covered with a soft spungy albuminous or fibrinous
exudation, and irritable and sore.
   Local applications to the ulcerous fauces,  though by no means
our  most  important remedies, as some have regarded them, are
yet of much utility and must not be neglected.   The infusions
of cinchona and of red oak bark are made vehicles for the acids,
especially the nitric and muriatic—these  correct the fetor of the
surface and its discharges.   So do the chlorates even more per-
fectly.  Kreosote is thought specifically remedial.  The  nitrate
of silver—the deuto-chloride of mercury—the sulphate of copper,
enjoy a similar reputation.
   Adults sometimes cannot, and children often will not  gargle,
We wash the affected parts thoroughly and frequently with the
preparations just  mentioned, by passing  down to  them a bit of
lint  well fastened on  the end of a probe,  and previously  soaked
in the solution preferred.  It may be proper to resort occasion-
ally to a still more effective mode of cleansing the throat, when
the  foul  mucous secretions are abundant and thick, and  the
sloughs tenacious.  Some  mild  liquid, as tepid water, alone or
mixed  with milk, or acidulated slightly with  vinegar, may be
thrown in by a syringe, exerting a moderate degree of force in
the  injection.
   I  have not yet  mentioned a remedy which is held very gene-
rally in great esteem both in the professional  and domestic man- 
                 MALIGNANT SORE THROAT,             211

 agement of malignant sore throat.   I allude to the capsicum or
 cayenne pepper.  The infusion is employed, and is administered
 internally, as well as used as a gargle.   I  cannot but regard it
 as one of our best stimulants; though I have often seen it become
 worse than inefficient by the violent resistance made to its admin-
 istration on the part of the patient, who complained of its severe
 pungency.   Yet in the cases  in which it is best adapted, we a/e
 not likely to find the sensibility, either local or general, such as
 to interfere with its use, and  you will do well to make trial of it.
    During  the treatment of malignant sore throat, it will be re-
 quisite to  enforce the strictest attention to cleanliness  in the
 chamber and about the person and bed  of the patient.   Every
 thing discharged should be  immediately removed, and the ves-
 sels which receive his offensive saliva or into which the gargles
 and washes are emptied very frequently changed ; and the most
 complete ventilation  established, which  the temperature of the
 season will permit with safety and without actual discomfort.
   Whatever may be our habits of thinking on the hotly-disputed
 doctrines of contagion,  and  in whatever light we may be dis-
 posed to view the disease under discussion, in reference to its
 supposed endowment or non-endowment with this dreaded  pro-
 perty, it is our unequivocal duty  ever to lean to the side  of
 ultimate and general safety in the regulations which we establish
 for the  management of the  sick.   The abandonment  of the
 plague-struck and suffering which  in days past—we hope for-
 ever—resulted  from the prevalent and  unmanly dread of the
 contagious influence of many maladies, cannot be  too severely
 denounced as the height of cowardice, inhumanity and impiety.
 But a certain degree of caution is surely  reasonable and neces-
 sary in cases like the present, allowed by the most sceptical to
 be at  least suspicious.   We should, therefore, enjoin  that none
 but the requisite  attendants  be admitted to the bed-side of the
 patient, and if a child, his little companions must, for a time, be
 totally separated from him; a measure which, indeed, can' be
 considered  in no point of view objectionable.
  Convalescence from this cruel  malady is slow, irregular, and
apt, for a long time, to be imperfect.  It requires to be aided by
a judicious  management of  the regimen and habits.  The cloth-
ing should  be warm, the diet nourishing and generous. Tonics 
212
MALIGNANT SORE THROAT.
of which  cinchona and wine  and iron are  the  best, may be
prescribed pro re nata ;  and if diarrhoea—as is not unfrequent—
supervene, astringents advised, the tincture of kino  being the
best.   Exercise  must be  taken when the weather will admit,
and, if possible,  a pleasant voyage or journey resorted to for
change of air.

  I am unwilling to conclude without offering you one or two
remarks upon the prophylactic management of such subjects as
show a special  liability to attacks of sore  throat.  Great pains
are usually taken to guard these persons  against  the  exposures
to which, as exciting or occasional causes,  we ascribe the inva-
sion of the disease, and they are enveloped with peculiar care in
additional garments, or imprisoned within doors when the sky
is inclement or threatening.  Experience has fully proved  the
fallaciousness  and inefficiency of this course,  which indeed can
never be carried into operation without  interfering with all the
duties of active  life, and  seclusion from all  ordinary pursuits
and amusements.  It creates, too, a peculiar and morbid suscep-
tibility which will not fail to be affected by any interruption of
the customary protection, and  some such must, from time to
time, happen both from accident and necessity. Habitual familiari-
ty, on the other  hand, with all  the common atmospheric vicis-
situdes of cold, heat, dampness, etc., tends much to diminish the
sensibility to  the impressions which they make upon the body.
It is  found, that we may thus anneal the constitution so as to
enable it  to bear with  impunity all exposures within a certain
range of reasonable prudence.   Among these means of harden-
ing, as the phrase is, the safest, and one of the most efficient, is
the transient  application  of cold, frequently made  by the ablu-
tion of parts occasionally  and irregularly exposed.  I have suc-
ceeded in banishing sore throat from families in which it was an
almost constant  guest, by thus  enjoining a daily and liberal use
of cold water  as a bath  to the head, arms, neck, breast, and
lower extremities.
  "Your face does not suffer from the cold wind or rain," said a
naked savage, "and I am all face." From  this, we may learn a
lesson  of much  utility, with regard to the physical education of
children.   As far as is  consistent  with the established habits of 
EXPLORATION OF THE THORAX.
213
civilized society, and with the  increased mobility and delicacy
of constitution  necessarily produced by these habits, let us en-
deavor to make thern, as nearly as possible, "all face," and thus
render the entire surface  as little susceptible of abrupt and seri-
ous impressions from familiar and unavoidable exposures.
                   CHAPTER XXXVII.

 DISEASES  OF THE RESPIRATORY SYSTEM.--EXPLORATION OF
                        THE THORAX.

   Next in  order, we  proceed to treat of the diseases of the
 organs of Respiration, under which head we include the larynx,
 trachea, bronchi, and lungs.   Here we shall meet with many of
 the most destructive, and some of the most rapidly fatal mala-
 dies to which the human constitution  is liable.  The necessity
 of an  adequate  supply  of atmospheric  air, and of its easy and
 unimpeded access to the cells constructed to receive it, is urgent
 and absolute.  Any affection of the pipe or tube through which
 it passes to  the lung, must therefore be distressing and danger-
 ous, in exact proportion to the degree of impediment presented
 to its entrance and escape, thus  presenting an obvious mechani-
 cal risk in  addition to the general irritation, and other ill-conse-
 quences, which  may arise from the nature and ultimate effects
 of such disorder.
   The functions of this set of organs are complicated as well as
 delicate, in a  peculiar degree.  Some chemical changes evidently
 occur from the admission of air, and  its contact with the blood
 diffused over the pulmonary tissue ; these are cognizable to the
 senses, both as regards the blood and  the air.   But these consti-
 tute only  a  portion of  the results ; certain  other changes of a
 vital and undefined character, are inferred with little less clear-
 ness, although they cannot be made  the subject of experiment
and calculation.   I allude to the  animalization—the assimila-
tion of the chyle, which is now conceived to  be in great mea- 
214            EXPLORATION OF THE THORAX.

sure effected, during the passage of the blood with which it has
just  been mingled, from the right to the left ventricle.  This
blood is found to be not only redder from its loss of carbon  and
union with oxygen, but more highly  vitalized  and better fitted
in every way for the support and nutrition of every part of the
organism.  Diseases of the respiratory organs may then become
fatal in three modes, of which we shall meet with examples—
1. By their general influence upon the  constitution, depending
upon their nature  and the  sympathies  which they excite,  and
analogous to the  effects of similar derangements located else-
where.  2. By impeding or impairing the assimilation of chyle,
and  thus depriving the blood of a due supply of its nutritive
and  stimulating materials,  whence emaciation, exhaustion,  and
fatal debility.  3.  By impediments offered to the passage of air
in the air-tubes, producing mechanical suffocation.
  It is but of late years that  the Exploration of the thorax  and
abdomen has claimed the special attention of the practitioner,  and
has been made the source of important  and  definite inferences
concerning  the actual state of the  organs contained in these
cavities.   We find it always easy to go back beyond  any alleged
discoverer, and to prove that the  first idea did not originate with
him, but that he was  anticipated by somebody else who lived
and  speculated in earlier ages.   Thus, Harvey is  accused of
having taken the doctrine of the circulation of the blood from a
cotemporary, Warner, whom the injustice of that  and succeed-
ing times has permitted to sink into obscurity, or more indirectly
from certain ancient philosophers and modern anatomists; thus,
Newton is affirmed to have borrowed, without acknowledgment,
from Flamstead, and  others, those speculations that make his
name a household word—and our own Fulton is shown to have
been preceded in his application of the illimitable power of
steam to navigation, by half  a dozen unheard of adventurers of
all nations on the globe.  As it is undoubtedly true, that "brave
men lived before  Agamemnon," so it is very possible, that the
chest was explored before the time of Laennec ;  yet nothing is
more certain, than that we  owe  to this illustrious  Frenchman
all  our  present satisfactory knowledge on this  subject.   In a
thorough history of this matter,  we should be  obliged to begin
in the early ages.   We must refer to the Father of Medicine as 
EXPLORATION OF THE THORAX.
215
  the author of the succussion which bears his name to this day,
  and which was intended  to detect the  presence of fluid in the
  chest by its agitation.  We should then come down  to  Aven-
  brugger, in  1761, for the  suggestion of percussion, which  he
  boasted of as "novum  inventum," but which attracted little
  attention until extolled  by Corvisart in 1808.  The distention
  of one side of the thorax in hydro-pleura,  obvious to the  eye,  is
  mentioned by early writers, and dwelt on  by Cullen especially.
  The "crackling of the lung," the mucous rale of catarrhal fever,
  has been heard, felt, and often  commented on;  and the wheez-
  ings and sibilations of asthma  and croup are familiar, and have
  always been to every professional ear.  But these  observations
  formed "a rude and undigested mass," until Laennec was led to
 arrange and classify them—to investigate the sources of all these
 phenomena, and ascertain the inferences  proper  to  be drawn
 from each.  It  will  not  be pretended that he committed no
 errors,  or allowed no  deficiencies.   Nothing  is at  once perfect;
 but he  has opened a mine of clear  and undisputed  truth, from
 which  succeeding laborers have^ continued to extract  the most
 valuable matter.   The  fall of an  apple was  a simple and com-
 mon event, but  it led, in  the mind of "a patient  thinker," to
 new and important deductions.  Listening to  the thoracic noises,
 immediate auscultation, had been a common thing doubtless
 with physicians—nay, Laennec himself had been accustomed to
 resort to it for  information, with  Bayle; but it was not  until
 1816, when he was obliged to  find a substitute for the  close
 application of the ear, that he was led to ponder on the variety
 of sounds discovered, their  definiteness, the  mechanical condi-
 tions to which they were to be  attributed, and the causes which
 produced these mechanical changes or structural alterations.
  There are still a few practitioners who speak lightly and  affect
 to think slightingly of mere physical methods of enquiry and
 diagnosis, but I trust none of you will be induced to follow their
 example.   Truth—the only  thing valuable or worthy, is to be
 sought  in  every  possible mode; and  we should  feel deeply
 grateful to all who exhibit to us any additional modes of putting
 nature to the question, and rendering our knowledge less vague
 and more positive.  After every effort in our power, made with
conscientious deliberation, zeal and perseverance, there are many 
216
EXPLORATION OF THE THORAX.
things which will still  remain  indeterminate  and  doubtful;
and we shall often be obliged to proceed to act upon conjectural
and uncertain premises, in the endeavor to save life and to relieve
suffering.   Our  only solace  under the mortification of failure
then is, that we have omitted  no means of examination, and
neglected no inlet of knowledge.
  I shall not detain you with any farther preliminary remarks,
but proceed to a brief history of the physical  exploration of the
thorax.  1.  When there is nothing to prohibit the exposure of
the upper part of the body, the patient  should be stripped and
carefully examined with the  eye and hand.   Any want of sym-
metry of form;  any inequality of, or difference  between the
two sides of  the chest, must be carefully noted.   Observe if the
whole structure is heaved and elevated regularly, by  the mo-
tions  of respiration; making  the subject  respire slowly, and
deeply, and rapidly.  Note the relative position of the  sternum
and the arch of the cartilages,  and examine  the spine.   There
are many deformities which  are consistent with  the  enjoyment
of health,  such  as the one  sided projections of the cartilages
and  sternum, denoted by the phrases "cuirass," and  "pigeon-
breast," and  so on.   All  these, however,  as implying, of neces-
sity, a flattening of some part of the ribs,  on one side or the
other, interfere more or less,  with the prospect of recovery from
pulmonary diseases.
   2.  It is next proper to inquire into the capacity of the thorax.
Unless in extreme cases, it is perhaps right  to acknowledge, that
no great stress is to be laid on this method, considered absolute-
ly ; but in a comparative point of view, it is  of great value.  If
the capacity of the  lungs to admit  air diminish sensibly from
time to time, it is evident that the situation of the patient must
be o-etting worse ; on the contrary, we draw  the most favorable
inference from the fact, that  his inspirations are becoming fuller
and deeper.   It should  be  farther admitted, that none of our
methods of examining into  this  question of thoracic capacity,
are very definite.  There are three modes  proposed.  The first
is a  careful measurement externally.  This being  done accu-
rately at proper intervals, we shall know  if the flattening of the
chest on either side increases or diminishes.  The second is, I
think, more  to  be relied on.   It consists  in breathing  into a 
               EXPLORATION OF THE THORAX.           217

gasholder or bell-glass or common  large bottle filled with water
and  inverted over a trough or basin.  It is easy to mark how
much water is thus displaced, and  to compare  this quantity at
different periods in the progress of a chronic  case.  The third
is often intuitively resorted to by patients for their own informa-
tion.   A subject whose lungs are capable of containing a large
amount of  atmospheric air, may retain his breath  a  greater
length of time  than  one who labors under any disease which
renders the lung  contracted in  its  capacity.   The latter  must
breathe  oftener to supply the  demand  for the depuration  of
venous blood sent into the pulmonary vessels.  There is scarcely
anything which annoys a patient more than the quick panting
to which he finds himself a prey ;  it distracts and fatigues him.
The extent of capacity differs  in different individuals—some
divers  remain under  water a full minute  or even  more—but to
retain the breath or inspire slowly from thirty to fifty seconds, is
good proof, I would  say, of average capacity.  Of course,  we
are better satisfied with comparative than with absolute  infer-
ences, yet the comparison must  be  fairly made.  We must al-
low for the  contingencies of  accelerated circulation from  fever
or muscular action, which hurry the breathing greatly ; and for
the diminished cavity  of the thorax after a full meal.
  3. Of the Hippocratic succussion, I shall say little.  It is not
in every case of thoracic effusion, that this sort of agitation will
detect  the anticipated  sounds.   No result will  follow the most
abrupt movement or  arrest of motion of the trunk in the manner
proposed, unless where both an aerial fluid and a liquid are con-
tained  together in the sac of the pleura, as in pneumo-thorax, or
in a large abscess or  tuberculous cavity in  the  lung.   Here we
have a noise similar  to, and produced in  the  same manner  as
the gurgling of water in a half-filled bottle.  It is not heard  in
simple empyema  nor in hydro-thorax, as many thoughtless ex-
perimenters seem  to expect. Although, as I have said, it may occur
in a large pulmonary cavity, yet this so  rarely happens, that it is
now assumed as a  positive  diagnosis of pneumo-thorax.   To
hear this sound, you shake the  patient  by his  shoulders to and
fro while sitting before you, and then stopping the motion sud-
denly, listen for the fluctuation described.
  4.  We come now  to  Percussion—Avenbrugger's valuable
       VOL  II.—19 
218            EXPLORATION OF THE THORAX.

suggestion.   It is easy to point out to any one acquainted with
the most elementary principles of acoustics, the rationale of all
the inferences drawn from the reverberation of the  chest when
struck upon at different points.  Suppose the thorax of a healthy
subject dried with  all its contained  air, it would return, upon
being beaten like a drum, a hollow sound similar  to what we
hear from that instrument.   The yielding  nature of the soft
intercostal tissues in  the living state, will obviously give less
resonance than the rib when struck, and hence, Dr. Todd, of
Connecticut, a sagacious disciple of Avenbrugger and Corvisart,
was accustomed to examine exclusively, by tapping each rib
separately, and all  round, from the sternum to  the spine, with
the end of a single finger.  It is clear, still farther, as the sound
depends upon the air within the chest immediately beneath the
part struck upon, there will be less resonance just over the heart
than on either side of it; and as a  drum is muffled by being
overlaid with any soft or comparatively inelastic material, so the
thoracic resonance is impaired by solid  deposit externally, as in
corpulence,  and by  effused  fluid, as in  anasarca,  and is less
distinct under the scapulae than elsewhere.  When you have
learned the kind and degree of resonance to be expected at the
various points  of  a healthy thorax, you will  be  prepared to
detect the presence of disease  by the modifications and impair-
 ment and want of resonance.   These are occasioned by all the
 causes that affect the access and amount  and movement of air
 within the pulmonary structures.  Fluid  contained in the pleu-
 ral sac, will of course make the sound beneath  it dull.   Solidi-
 fication of the tissue, from whatever change of condition, has
 the same effect in proportional degree—whether it be constituted
 by hemorrhagic or inflammatory congestion or hepatization, or
 tuberculous deposition, or any form of infiltration.
   It is important to be  aware, that  the resonance may be too
 great as well as defective in intensity.   This augmentation may
 be combined with fluctuation in pneumo-thorax—may exist in
 asthma, and in perforating ulcer of the  lung.  You will thus
 perceive, that the inferences from percussion require  to  be cor-
 rected and rendered definite by collation with the  other modes
 of examination—a remark which, indeed, applies  with equal
 truth to all  or nearly all.   Scarcely one of them is so obviously 
               EXPLORATION OF THE THORAX.           219

diagnostic, that we may venture to rely on it  independently of
concurrent observations made in different modes.   Percussion
is applied mediately and immediately, and Piorry, who is justly
celebrated  for his  experience  and his sagacity, preferring  the
former, has laid much stress upon the use of the pleximeter, as he
entitles a plate of ivory upon which he directs the percussion to
be made.  Leather and caoutchouc have been also employed.
With Piorry, I generally depend upon mediate percussion, but I
use no other pleximeter than the fingers of my left hand, pres-
sing them closely on the  surface and striking upon them with
the ends of those of  my right.   Some have talked a good deal
of "the  tactual sensations" communicated to the tips of  the
striking fingers, and  therefore object  to mediate percussion or
the interposition of any pleximeter.  I am not able, I confess,
to appreciate these sensations, and therefore am obliged  to  de-
pend exclusively upon the sounds elicited.
   5. Manual  examination of the thorax and its movements, and
the vibrations which these  produce, is  always of some impor-
tance, and  should be  made  available, unless  some prohibition
present itself.   It is most useful in the cases of children, in its
reference to affections of the respiratory organs.  In all, it gives
very definite  information of cardiac disease.  We thus discover
the enlargement or violent  and irregular action of this viscus,
and detect its  displacement by pulmonary derangement or tho-
racic effusion.  This mode of exploration, however, it should be
observed, rather exhibits to  us  the locality and degree of  disor-
der, than its nature.
   6. Auscultation.  This is divided, like  percussion, into me-
diate and immediate, and is defined "the listening to, or perceiv-
ing the various sounds produced  in the  chest  during the per-
formance of  the  functions of the viscera contained therein,
whether  in a healthy  or  diseased condition."   Direct ausculta-
tion is effected by laying the ear flat upon the chest at the point
to be examined.  This is always desirable  to be  done, when it
is within our option;  but it. will be at once obvious to you, that
there  are  very numerous cases, of  every day occurrence,  in
which this is totally forbidden—and  it was in an example  of
this sort, that  the ingenuity  of Laennec suggested  to him  a
resource in the  employment of a medium for the conveyance of 
220
EXPLORATION OF THE THORAX.
sounds.  Recollecting the  facility  with which a  solid body
communicates an impression made upon one end throughout its
whole length, and  a tube transmits the vibrations  of air that
produce sound along its canal, he "rolled a quire of  paper" thus
"into a kind of cylinder, and applied one extremity of it to his
patient's chest and  the  other  to  his ear, and was  not  a  little
surprised and pleased, to find that he could thereby perceive the
sounds within the chest more distinctly than by the ear."
  Thus was  constructed  the  first  Stethoscope, an instrument
which, since that time,  has undergone many  changes of sub-
stance and of form.  They have been made of various woods—
of ivory, bone, horn, paper, and caoutchouc—with and without
a central bore—of one, two  and three pieces.   I prefer a stethos-
cope made of a single piece of light but not too porous wood-
cedar and apple are generally chosen—with  a pretty large cen-
tral  bore.  A solid cylinder is said  to be  better  adapted for
examination into  the cardiac sounds ; the  one  I show you, is
made  for  listening to the vocal and respiratory noises, but here
is a  plug  fitted  to a concavity in  one  end, which  converts it.
partly into the solid cylinder for  exploring  the movements of
the heart.
  It is necessary that I should offer you a brief description of the
natural sounds heard within the healthy thorax, and in contrast
with these, such as are produced by disease of the several organs:
and first,
  Of Respiratory auscultation.  The normal sounds elicited in
the acts of breathing, differ  somewhat in the various regions in
which we  hear them ;  the general sound is known as the "respi-
ratory murmur."  This  you must  ascertain for yourselves, and
become experimentally familiar with ; as a just appreciation of
it can only be acquired by personal  attention.   This murmur is
naturally louder in children than in adults—whence the phrase
"puerile respiration ;" it is perceptibly louder in inspiration than
in expiration.  There is a notable difference, which however is
not  easily  conveyed to you  by description, between this respira-
tory murmur, as it is  heard in the pulmonary air  cells, in the
bronchi, and in the trachea.  Vesicular or cellular respiration is
properly a mere murmur; tracheal respiration gives you the im-
pression rather of a rushing—slight, but similar to that made 
EXPLORATION OF THE THORAX.
221
 by the passage of air through the nostrils or a bellows nozzle ;
 and  bronchial respiration  partakes  of both :  in health it is dis-
 tinguishable only over the largest bronchi.  In an entirely natu-
 ral state of things, the respiratory murmur is heard most plainly
 at those points which are most loudly resonant upon percussion,
 as upon the anterior chest, above the clavicle, and in  the axilla.
 These sounds are liable to simple  increase  and diminution of
 intensity.  A mere  increase  of the respiratory murmur  in an
 adult, known as  "puerile  respiration," belongs to a stage of dis-
 ease.  The highest intensity of tracheal or bronchial respiration,
 is heard in a  broken-winded horse, or a roarer, as the jockeys call
 him :  it is a species of defect proving, generally, a diseased state
 of the organs, but, as we learn from high authority, both on the
 bench and in the saddle, sometimes consistent with "soundness''
 in the technical sense at least.  Puerile  respiration in any part
 of the lung, gives the inference that the remainder or some con-
 siderable portion of  it is occluded or impeded, and performs its
 office  imperfectly.   It occurs in all  diseases which  impair the
 functions therefore of the lung, as pneumonia, hydrothorax, etc.
 Wherever it  is  very extensive, without  obvious cause, we may
 suspect  an obscure  or  insiduous  tubercular deposition to have
 been commenced.
  The respiratory murmur is  defective, wherever the cells and
 tubes refuse to admit air, as in pneumonia, congestion, hepatiza-
 tion,  infiltration ; and wherever  any effusion is interposed be-
 tween the parietes of the  thorax and the lung, as in empyema
 hydro-pleura,  pneumo-thorax.   Always compare the  results of
 percussion with auscultation to prevent mistakes.
  Of new or adventitious sounds produced by a morbid state of
 the respiratory organs, we have a considerable number noted and
 described by authors. I shall  speak of those among them which
 are most  frequently  met with, which I myself have heard, and
 can recognize when  I hear, and  from which I am prepared to
draw specific and definite inferences.
  1. The mucous rale or  rhonqus you are all familiar with ; it
is heard in common colds, catarrhal fever and humoral asthma;
it is  loudest just when  a patient  is  about to  cough and expec-
torate.
  2.  The crepitous rale is heard in the early stages of pulmonary
       19* 
222
EXPLORATION OF THE THORAX.
inflammation, either  acute  or chronic.  It resembles the sound
made by the healthy lung when pressed in the hand.   This is
variously compared; by Dr.  Williams, to the rustling of a lock
of hair rubbed between the finger  and thumb ;  by Laennec, to
the crepitation of salt on a hot iron ; by Andral, to the crackling
of a piece of parchment.   I  infer it to be owing to  a slight im-
pairment of the  polish or smoothness  of opposed membranous
surfaces, and  perhaps some  diminution of their  pliability and
extensibility.
   3.  The gurgling or bubbling sound is owing, as Forbes says,
to the presence of a very great  quantity of mucus ; or, as I am
disposed to believe, to the undue tenacity or  viscidity  of the
fluid present, as where mucopurulent  matter is effused and ex-
pectorated.
   4.  A cooing or purring noise is in some patients very distinct;
it depends, I  would suggest, upon partial occlusion  of certain
portions—rather extensive than abruptly defined—of the bron-
chi, the air cells or vesicles  beneath them being permeable.  I
have met with it constant for months in two young subjects of
bronchitis; it is loudest during  a  febrile exacerbation,  when
Active exercise is taken, and  just before a fit of coughing.
   5. The sibilant,  hissing or whistling sound.  This I attribute
 to an occlusion—less extensive than the former, but more abrupt5
 and  making a small aperture in the tube through which the
 air forces its way.   It is less uniform or constant than the above.
   6.  The metallic  tinkling—"tintement metallique" of Laennec,
 is said to resemble the sound emitted by a cup of metal or glass
 when gently struck  by a pin, or  when a grain of sand or a mi-
 nute pebble is thrown into  it.  He ascribes it  to the fall of a
 drop of some fluid from the top to the bottom of a  large cavity,
 where it strikes on the surface of  a similar fluid, and causes the
 sides of the  cavity to resound.  You will not often hear it. I
 do not  think the rationale just given at  all clear or satisfactory,
 and if  I may venture to differ from  such authorities as Laennec
 and Forbes, would attribute it to the same cause which produces
 the tick or clicking sometimes heard; the resistance, namely, to
 the passage  of air made by some very viscid secretion, which
 suddenly yields and gives way.
    Of Vocal sounds.  On laying the ear to  the chest of a healthy 
EXPLORATION OF THE THORAX.
223
 person speaking—or applying the stethoscope—we perceive the
 same thrilling sensation that is felt by the hand; if it be sound,
 it may be described as a diffuse vibratory murmur.  If we place
 the concave end of the instrument on the trachea, we shall hear,
 though  with some indistinctness, the articulated  words he is
 uttering.   Over the largest  bronchi we may still perceive arti-
 culation, though with still more indistinctness and somewhat
 confused with bronchial respiration; the vocal resonance lessen-
 ing as we proceed along the tubes,  until it disappears.   As pue-
 rile and bronchial respiration are the first effects of impairment
 of  the function of the lungs, so we shall find bronchophony to
 extend itself in the earlier stages of pulmonary inflammation.
 When this has been some time protracted,  it is converted into
 what Laennec has chosen to call "aegophony," as resembling the
 bleating  of a goat.   He explains it thus.   "I consider aegophony
 to be owing to the natural  resonance  of the voice in the bron-
 chial tubes, rendered more  distinct by the compression of the
 pulmonary texture, and modified by its transmission through a
 thin layer of fluid, in a state of vibration."   This fluid must of
 course be in small quantity; if the amount is much increased,
 the sound is lost.  He affirms, that he observed it in  almost
 every case of pleurisy under his care.  Forbes says it is most
 noticeable  " in a zone from the lower angle of the scapula follow-
 ing the lines of the ribs round to the nipple."  I have seldom
 met with it.
  7. Pectoriloquy means, as the phrase imports, articulation  or
 speaking within  the thorax—breast-speaking, as  it  might be
 translated.   It is one of the earliest and most  striking discove-
 ries of Laennec, and its explanation is obvious.  It occurs only
 when there is a large cavity filled with air,  into which opens
 freely  a  large air-tube.  The articulatory  vibrations are con-
 tinued downwards, from the larynx into this cavity, and there
 renewed or repeated, so as  to give rise to the phenomenon.
 Whenever  it exists, we are made aware of disorganization some-
 what extensive; the softening and evacuation of a tubercle, the
emptying of an abscess.  It is usually attended with loud reso-
nance on percussion.
  Of the sounds  perceived  in the  examination of the Heart, I
shall say little, because of  my want  of opportunities for making 
224
EXPLORATION OF THE THORAX.
any extensive investigation of the subject; the  few occasions
that have presented themselves, of verifying (by autopsy,) such
observations as I have made;  and lastly, my failure to perceive
clearly and distinguish accurately, the peculiar noises or modi-
fications of sound described by authors, and to comprehend defi-
nitely their relations with the  several conditions to which  they
are ascribed.
   On listening carefully  to the  movements  of  the heart,  Dr.
Hope tells us, we shall first become sensible of the ventricular
systole, coincident or nearly so with the auricular diastole; these
movements give the first sound, the impulse of the apex against
the ribs, and the pulse. The second sound attends the ventricular
diastole; then follows an interval of repose. Laennec gives us a
different rationale.   The first  sound, he  affirms,  is caused by
the contraction of the ventricles ; the second sound, by the con-
traction of the auricles.   The  weight of evidence and authority
would seem,  at present, to be with Dr. Hope.
   The  natural or normal  sounds of the heart, may be irregu-
lar in rhythm, in extent, and in relation to the impulse: in
rhythm, from any cause which disturbs the heart's action, as the
passions or mental emotions, or unequal hypertrophy.  This lat-
ter cause will  also  give  undue extent  to the cardiac  sounds.
The relation to the impulse is clear; if the parietes of the organ
be thickened, there is more impulse and less sound, and vice
versa.
   The morbid or adventitious sounds of the  heart,  are  named
by Laennec "bruit de souffiet"—sound of a bellows; "bruit de
scie"—sound of a saw; and "bruit  de rape"—sound of a rasp.
It is generally agreed, that the phrases thus chosen, are  happily
and  correctly significant,  and that the  first  sound resembles
strongly, the puffing of a pair of bellows, and  the two latter, the
rough grating of  a file and of a wood-saw.  They are attributed
to impediments in the current of blood,  which  may be either
temporary, as it would seem, or organic.  The latter; condition
is inferred from the intensity of the noises heard, from their con-
stancy or continuance, and from  the  other phenomena which
may concur.
   Laennec speaks of another sound, which he designates as the
"cri de cuir"—the creaking of leather; which he and others are 
croup.                        225
 disposed to ascribe to the roughness and friction of pericarditis,
 with effusion of lymph.
   8. I only mention here to reprobate, a method of exploration
 proposed by Marshall Hall, and which, nothing but his deserv-
 edly high reputation induces me to mention at all.   I allude to
 his proposition to "insert a small flat trocar between the ribs into
 the thorax, in order to ascertain, in doubtful cases, the presence
 of air, serum, or pus, in the sac of the pleura." I cannot hold it
 a  light matter, thus to inflict a wound upon this membrane,  in-
 flammation of which is so easily  excited, and productive of so
 much pain and danger; as we see when it is torn by the spiculae
 of a fractured rib.   I can only imagine one contingency in which
 I would consent to make this sort of examination :  where para-
 centesis thoracis had been resolved on as indispensable, and  re-
 quiring to be immediately performed,  in order to relieve the pa-
 tient from the presence of air or effused fluid, and  where the
 insertion of the trocar was only to be regarded as a preliminary
 step; like the sounding for stone after the patient is laid on the
 table, which, if unsuccessful in detecting its presence, shall ren-
 der nugatory, at least for the time, all the  preparations  already
made ;  but if successful,  gives confirmation and clearness to the
opinions previously entertained, and  sustains the surgeon with
the plea of present and urgent necessity.
                   CHAPTER XXXVIII.

 CROUP.--CYNANCHE TRACHEALIS.--LARYNGITIS.--TRACHI-
                        TIS.--HIVES.

   The subject of our present lecture, may be affirmed to be one
of the most common diseases of children.  Its aspect is alarm-
ing, and its ravages, when neglected or improperly treated, rapid
and terrible;  but it is consoling to reflect, that  when  opposed
with promptitude and judgment, it may  be  confidently ranked 
226
CROUP.
among those maladies, over which the powers  of medicine ex-
hibit most clearly their divine control.
  Croup, although known to the ancients, even as  early as the
time of Hippocrates, as has been proved by Coxe and Copeland,
until of late years comparatively, attracted little attention.   Dr.
Blair, (in Scotland, in 1718,) first described it under its present
name, which I prefer to retain ;  not only  because it is univer-
sally recognized and received, but because the very numerous
and more scientific appellations which have been substituted by
different writers, are all of them significant of some opinion enter-
tained as to its peculiar nature and locality.  You will find that I co-
incide with Home, in considering it a true inflammation of the
larynx and trachea, though this  is a point  far from being univer-
sally agreed upon.  Some have  regarded  it as possessing a two-
fold character—sometimes  spasmodic, and sometimes inflamma-
tory ; and hence the disposition  of certain writers to speak of it
as an infantile variety of asthma.  In France and in Germany, it
has indeed been confounded, strangely enough, with diphtherite,
and almost every species of angina and cynanche.
  Croup usually affects children—seldom before they have been
weaned, or after they attain the age of puberty.  Chronic laryn-
gitis is not uncommon, especially in more recent  times,  among
adults ; and the acute form of the  disease,  which I consider to
be  true croup, occurs, though rarely,  in  such  subjects.  Every
physician must occasionally  meet with an instance of this sort;
and every  American is familiar  with  the  fact,  that  this painful
affection terminated the lofty career of our beloved Washington.
Marshall Hall gives two cases occurring in eminent physicians—
Dr. Pitcairn and Sir John  Hayes.  Dr. Pitcaim had "an uneasy
feeling in the larynx," and "wrote that his complaint was croup."
It is not long since I  saw a very strongly  marked attack (in con-
sultation,)  in a lady of fifty years of  age; and a patient of mine
who is nearly sixty, has been subject to it all  her life.  I have
seen her frequently laboring under it.
   In our country, this disease is so well known, as scarcely to
need a detailed  description.   It consists  in a very distressing
difficulty of breathing.  The respiration is loud, hurried, anx-
ious ;  performed with evident  muscular effort,  and a struggle 
CROUP.
227
painful to witness.  There is cough,  attended with a peculiar
stridulous croaking and  ringing  sound, of which  words can
convey no adequate idea, but which, when once heard, will never
be forgotten.   It is described as resembling the barking of a dog,
the crowing of a cock, the vibration of a brazen tube.
  Croup is essentially pyrectic.   The symptoms of local disor-
der, the change in the voice, cough, etc.,  may either precede or
follow, at a short interval, the  febrile movement.  The eye is
brilliant and suffused, the skin hot and dry, and the cheek flush-
ed.  Some writers have divided the history of the attack into
three stages,  and although the  lines of transition cannot  be
always precisely drawn,  yet the distinction  should  be  kept in
mind, as useful in the treatment.   The incipient, or as some call
it, the catarrhal stage, is hardly to be discerned from the forming
stage of catarrhal fever, except  that, perhaps,  there is somewhat
more ringing or shrillness in the cough, and a less diffused rale
throughout the chest.  The age  of the  child should make  us
attentive to this  matter.  Croup is more to be dreaded while the
process  of dentition is going on, than at any other period of
childhood.
  The inflammatory stage offers,  when exquisitely developed, a
most impressive picture.   The  nostrils of the  patient are dis
tended by the struggle for breath, the eyes protrude,  inspiration
is attended with a harsh  whistling or wheezing, the face, at first
flushed, becomes irregularly livid, the child grasps its throat with
its hand, and complains of pain seated there, the pulse becomes
extremely frequent and chorded, there is incessant  restlessness,
and the little sufferer, by its expression of countenance, its moans
and its entreaties for help, with  every other sign that its age and
degree of intelligence admit of,  shows the  highest  intensity of
distress.   The cough is at first loud,  dissonant, and accompa-
nied with the peculiar sound formerly alluded to, but after a time,
becomes  lower and feebler;  and in the  third stage,  which  has
been regarded as a condition  of collapse, is little more than a
whispered or wheezing effort.
  The face now assumes a more livid hue, or is very pale and
swollen, the skin is covered with a clammy and abundant sweat,
and the extremities are cold.  The shoulders  are elevated,  and
the  chest heaves with the struggle for breath.   A muoous rale is 
228
CROUP.
heard throughout the thorax, and the action of the heart, though
convulsively frequent, grows weaker.   There are two modes in
which the fatal termination  may take place;  either  the  symp-
toms just recounted increase with rapid progression,  and suffo-
cation ensues,  from the clogging up of the larynx with its own
tenacious  secretions; or the signs of spreading inflammation
extend into the bronchi, and even affect the  pulmonary tissue;
while a certain amount of expectoration, which follows each
effort in coughing, protracts the case (even  though beyond the
hope of ultimate relief) it may be for some days.  During this
condition of things, respiration  is  unequal and irregular, some-
times very slow, at others exceedingly hurried—performed with
violent exertion of  all the muscles which can be brought  into
play;  the alae nasi are distended—the eyes  protruded;  the
whole scene calculated to inspire  the  parents  and friends with
the greatest horror, and the  physician with  the deepest sympa-
thy and solicitude.
   The Pathology of croup  has been  much discussed.   I have
never  seen  a  case  which was not  decidedly inflammatory and
attended with marked febrile symptoms.  There are  many prac-
titioners, however,  who regard the  disease  as presenting occa-
sionally  a purely  nervous  or  spasmodic character.   I  do not
doubt that  the laryngeal irritation may and does,  excite, and
perhaps  often, a degree of  spasmodic action of the  muscles of
the glottis, and others  concerned  in  respiration, and that this
secondary or sympathetic may outrun in vehemence the original
mode of irritation in nervous and  highly excitable individuals,
so as to  become a prominent and paramount condition; and
thus I regard  the alleged cases of nervous or  spasmodic croup.
   The inflammation of the larynx and  trachea, which  consti-
tutes this disease, frequently gives rise to the production of an
albuminous exudation of organizable lymph, rapidly condensed
into a pseudo-membrane lining  the tube.  This is  considered,
by certain writers of  France and England, as a test, or diagnos-
tic symptom.   Good makes it  an essential characteristic, and
Guersent and Bretonneau speak of the cases  in which it  does
not  occur as  "false croup."   The majority of writers agree,
however, that  this is  an error.    This membrane  or layer of
lymph does not always present itself  in  the worst  cases.  The 
CROUP.
229
 changes shown in post mortem examinations are two-fold.  The
 mucous surface of the  larynx  and trachea is, in  most  cases,
 swollen, reddened  and covered with  an effusion of tenacious
 mucus, which extends generally throughout the bronchi and air-
 cells ;  this is sometimes purulent, sometimes tinged with blood.
 In others, the false membrane is found in  various states.   In
 some,  tenacious and adherent; in some, loose and in mere shreds
 or flakes.  I have seen it but seldom.  Dr.  Chapman says,  he
 has failed to find it.  He mentions  a case, in which Dr. Dorsey
 found it so fixed in the larynx, as to occasion suffocation.  Bail-
 lie has described this tubular membrane, in the following terms,
 under the title of polypus, and as the consequence of a peculiar
 diseased state  of the vessels  of the  trachea.   "The  trachea and
 its branches are sometimes lined, with a layer of a yellowish or
 whitish matter, forming a sort of tube, which is applied to the inner
 surface loosely. It has not occurred to me," he says—and hence we
 must infer its  infrequency—"to see any instance of it in the dead
 bodies which I have examined; but I have seen several instances
 of it  in preparations.   This layer of adventitious membrane
 exactly resembles the coagulable lymph which is formed in other
 parts of the body,  and I have no doubt of its being that sub-
 stance."  He goes on to state, that  he has seen one instance, in
 which this coagulum  was solid instead of tubular.
   Nor are these diseased appearances confined to the larynx and
 trachea—the  minutest  ramifications of the bronchi, and  the
 smallest air-cell are found filled and clogged  up with the same
 tenacious mucus, or choked with a  similar membranous forma-
 tion.   In a case which I saw with  my friend, Dr.  Jervey,  the
 ramifications of the bronchi, as well as the trachea and larynx,
 were lined extensively with  this  pseudo-membrane, of so dense
 and tenacious  consistence, that it was  easy to draw it out in
 long tubes resembling the finger of a glove.  Dr.  Bard, in  his
 Essay on Croup, affirms that he. has found the lungs so dense
 and solid, that they exhibited the appearance of the structure of
 the liver.  Cheyne and Baillie have both made the same ob-
 servation.  To these morbid changes, Dr. Marshall Hall adds a
 third—oedema of the glottis.  Bland distinguishes laryngitis into
three kinds or  degrees, which he has designated from the Greek:
1. Myxogene, when mucus is expectorated;  2.  Puogene, where
      vol. n.—20 
230
CROUP.
pus  is effused;  and 3. Meningogene, when the membrane is
formed.  The idea is ingenious and plausible.
  The Causes of croup are numerous, comprising all the circum-
stances which give rise to catarrh,  sore  throat, etc.—such  as
exposure to sudden changes of temperature, or currents of cold,
damp air, wet clothing, wet feet, falling asleep in the  night air
or dew.  Easterly winds are, with us, among the most frequent
exciting causes, as being cool, raw and  sharp.   Familiar expe-
rience ascribes it to all such agents as occasion a suppression  of
the natural and healthy cutaneous transpiration.
  A predisposition  to it  is often hereditary, and  transmitted
through  many generations;  it is built up, undoubtedly, under
various conditions, arising from previous attacks, a  repetition of
which will most remarkably increase the degree of susceptibility
to the invasion.  This susceptibility became so great, in one
child under my care, that  she did not escape an access for any
entire fortnight, during a period extending from her being weaned
to her fifth year.  I have already spoken of the  coincidence not
being well  understood, between croup and dentition.  A greater
number of severe cases occur, certainly,  while the process  of
teething  is  going on.   But in  my own  experience,  children  of
about two to four years, are the worst sufferers by it.   It is rare
before weaning, but Duges says that he met with  it in a child
only a few days old.
  The gastric origin of croup is not mentioned, so far as I know,
by any author, but for own part, I am disposed  to  consider the
presence of undigested food, and other irritating crudities in the
stomach, as among the causes of the disease ; and the' remark
is a familiar one, in some  families subject to its frequent presence.
In one child  to whom I have been frequently called, the attack
was uniformly preceded by vomiting of acescent  matters and
undigested food, or by disordered or relaxed bowels, with green-
ish and highly offensive stools.. In another, I had  repeated oc-
casion to notice, that the emetics  administered failed to  give
relief, until the efforts  in vomiting brought away some crudities,
such as green fruit, or other  improper ingesta, when the re-
covery was rapid and  complete.
   Croup has been regarded as endemic, epidemic and contagious.
There are  no reasons that weigh with  me, for  attributing to it 
CROUP.
231
 those qualities.   It is more  definitely,  than almost  any other
 malady, the result of particular conditions of atmosphere and of
 special exposures.
    The Treatment of croup has become so generally understood,
 that notwithstanding the frightful rapidity of its access, and the
 evident tokens of imminent danger which attend from the first, it
 is in a great many families confidently believed to be under domes-
 tic control.  And, indeed, the domestic management of the early or
 invading stage of croup, is usually successful.  This stage, as I
 have already said, is marked by the symptoms of catarrhal affec-
 tion.  The child sneezes and coughs,  perhaps in a shrill tone.
 If of sufficient age and intelligence, it takes warning and com-
 plains of the approach of its tormentor, pointing out the  larynx
 as the seat of uneasiness.  At this period, I have never failed in
 the attempt to arrest the disease and prevent its farther progress,
 by the free use of opium.   I  prefer the familiar formula of pare-
 goric, (tinct: op: camphor:) of which I give a full  dose, putting
 the child to bed after a warm pediluvium, and applying a warm
 mustard poultice to the throat.  There is absolutely nothing in
 the whole practice of medicine, of which I can speak with  as
 much confidence, as this simple plan of treatment.  When this
 stage has passed by, however, and inflammation is fairly lighted
 up,  the respiration is attended with a distressing struggle and a
 loud croak, and the peculiar cough, with its characteristic ringing
 sound, incessantly harrasses the larynx, we must resort to other
 measures.   An emetic is now demanded.  While  many prefer
 the  antimonial, for  its specific  qualities in  reducing febrile and
 inflammatory excitement, others regard the ipecacuanha as es-
 pecially expectorant, and others still resort to the sulphates  of
 lime and of copper, which  act so surely and promptly, in  order
 that no time may be lost, in seeking relief from so much suffering.
   Venaesection is the next  remedy to be spoken of.  It is much
 disputed whether the use of the lancet should precede or follow
 the resort to vomiting;  but I should scarcely think it proper to
 lay down any precise rule on the subject.  In a very robust,
 plethoric child, when some hours  had been lost, and the  attack
 was advanced into a deeided  inflammatory stage, with marked
 febrile excitement, it might be well to let blood  without delay;
liut in general, the child will  be so much relieved by an active 
232
CROUP.
emetic, that the bleeding may be dispensed with.  If you detract
blood, you should be guided only by the effect—go as far as the
pulse will allow, and produce some relaxation or fainting.
  It is scarcely necessary to warn you against the excessive de-
pletion into which some have  been misled.   Nor can  I advise
you to trust, at this stage, to the topical  bloodletting so highly
eulogized.   Leeches annoy your little patient, and restrain the
movements necessary, in his eager struggles for breath.   A warm
mustard poultice, may instead, be kept applied to the throat and
the neck.
  If the child is not relieved by the first emetic and the lancet,
place him in the warm bath, and repeat the emetic.  Vomiting,
under these circumstances,  is attended with more relaxation and
expuition  of the tenacious  mucus from the air passages, and its
sudorific effect is greater and more continued.
  Having thus obtained a truce with  the oppressive dyspnoea,
we next attend to the condition of the bowels, on  which it will
be well to act promptly by some cathartic; this will  at  once
tend to reduce irritative excitement, and serve a good purpose as
a revulsive.  Calomel is regarded  by  many  practitioners,  both
in England and our own country,  as endowed with some  bene-
ficial influence of a specific nature, which adapts it to  our pre-
sent uses,  and a large experience has accumulated many facts in
confirmation of this opinion.
  Some, with Dr. Potter, give it in large dose alone; some com-
bine -it, adding an antimonial  or  other emetic,  to produce a
double effect.; some make it more promptly purgative, by  min-
gling it with rhubarb or castor oil.  For myself, I  will confess
that I prefer, at this juncture, the saline cathartics,  which I dis-
solve in one of the sudorific or expectorant infusions, as for ex-
ample, in  that of seneka or serpentaria, which are in this disease,
of admirable and acknowledged utility.
  The polygala seneka forms the basis of the hive  syrup of
professor Coxe, and of the  "anticroupal mixture" of Jadelot.  It
is an expectorant, if there  be one; a  sudorific also ; and tends,
in large dose,  to keep up an occasional vomiting.   The serpen-
taria possesses nearly the  same properties in a minor degree of
irritative activity.   When  croup is complicated with any visce-
ral affection, or  arises  from gastric disorder, the mercurial will 
croup.                       233
 be  found of great benefit, if indeed  it be not essential to the
 complete  relief of the patient.  It  may  be usefully  combined
 with Dover's powder, in  doses properly adapted to the urgency
 of the case and  the  age of the subject.  The employment of
 opium has been strongly objected to by some of the authorities.
 I  have already  spoken  of its  remarkable adaptation  to   the
 incipient or  invading stage—and regard it as also well suited,
 in the farther progress of the attack, after free depletion and full
 vomiting.  The formula I have just mentioned, in which it is
 united to  an equal  amount of ipecac:, is  an excellent one, and
 will effect much  in  behalf of the little  sufferer under the cir-
 cumstances  pointed  out.  It diminishes the frequency of  the
 distressing cough, and by determining strongly to the surface,
 checks the progress of pulmonary congestion and inflammation,
 and thus relieves the  urgent  difficulty of breathing,  and gives
 opportunity for rest and refreshing sleep.
  Squill and digitalis have been highly recommended for their
 nauseant, expectorant and  sedative  qualities.  I  have  some
 confidence in the former.  The latter I have never  employed
 here.  Dr. Godman  has in strong phrase eulogized the powers
 of tobacco, the Scotch snuff,  which he advises to be laid in  the
 form of a plaster upon  the chest.   It is uncertain whether it
 acts upon the skin or the nostrils, but in some it produces a re-
 laxing and nauseating operation, which  checks the progress of
 and removes a mild attack.  The alkalies have obtained a very
 extensive and firm confidence in the  domestic management of
 croup throughout our country.   Common ley, made from wood
 ashes—a solution of an impure  sub-carbonate  of potass, is fre-
 quently exhibited, and often with success.
  I am acquainted with  several families, in whose children at-
 tacks of croup are warded off or removed by the exclusive  ad-
 ministration  of the volatile liniment,—oil  and hartshorn being
 mingled, and  given  with some  syrup or molasses.  The influ-
 ence of these alkalies I do not pretend to account for ; the facts
are perfectly well known.  Some who believe in their specific
effect, prefer  to medicate  the  baths, using warm ley  water  for
the immersion of the  sick.   Among  these domestic  remedies,
indigo was once in great  esteem.  It was prescribed in solution
      20* 
234
CROUP.
or in powder diffused in water—in sufficient quantity to operate
actively, both by vomiting and purging ;  when the relief pro-
cured by it is said to be immediate and lasting.
   Should the case  seem disposed to protract  itself,  and the re-
mission  of the troublesome  and dangerous  symptoms remain
imperfect, or  alternate with  paroxysms of  renewed violence, a
very careful attention becomes necessary.   The inflammation is
exceedingly apt to  encroach upon  the bronchi  and pulmona-
ry tissue—a  result which is to be feared, when we have much
mucous rale in the lungs, with a loss of resonance on percussion,
a pale or livid  complexion, and gasping or panting.  A blister
should be put on the chest, large enough to cover a considerable
portion  of the surface.  The  emetic  may be repeated, if the
strength be not impaired; and it is best given while the child
is in the warm bath.  I never trust to the mercurial exclusively,
but have often derived from  it unquestionable advantage, under
the circumstances  now presented.   On account of the  very
striking insusceptibility to the use of medicines  so frequently
met with in croup, it will be necessary to exhibit it in full doses.
I have given from five to ten grains to a child little more than a
year old, repeating  it pro re nata—that is, until it freely moved
the bowels.   Dark  colored,  offensive  and ill-conditioned stools
are thus brought away, either greenish or approaching to black,
with decided amelioration of symptoms.  I have repeatedly seen
accumulations of undigested matters  of some  days  standing,
forming part of these stools.
   In  the meantime,  the use of the infusion of seneka or serpen-
taria, with some alkali in solution, may be continued.  If occa-
sional vomiting be still desired to relieve  the trachea from collec-
tions  of mucus—or  in  the hope of detaching and forcing away
the shreds of false  membrane or organized  lymph, when it is
formed, squill or ipecacuanha may be added.
   If collapse threaten—the  pulse sinking, and  other  signs of
muscular and general debility supervening,  I would  have re-
course promptly to the stimulant diaphoretics.  The vol: alkali
is particularly well suited, and may either  be prescribed with oil
as before mentioned, or in syrup.   Camphor  is also useful, and
so is  opium.   The two are united in the tinct: op: camph: which 
CROUP,
235
deserves your confidence, and should be freely administered. Si-
napisms should be applied  to the extremities, and the powers of
life supported by wine whey and wine.
   I must not close  the consideration of the treatment of croup,
without entering briefly into the  much disputed question of the
propriety of bronchotomy, as it is called—laryngotomy or trache-
otomy.  I have seen this operation performed but once ; in this
instance, the circumstances were unfavorable, and the results far
from gratifying; my opinions concerning it must therefore be
chiefly founded  on  reasoning.   No clear or  satisfactory effort
has yet been  made to distinguish the cases in which it is appli-
cable.  Hence it happens that while one declares it to be inexcu-
sable that any patient should be allowed to die without an open-
ing being previously made into the trachea, another affirms it to
be a frivolous and useless  attempt, uncalled for in curable cases,
and superfluous in such as are hopeless ;—productive of gratui-
tous suffering to the patient;  and protracted suspense to his
friends.
   The truth appears to me to be as follows.—Croup is  at  first
confined to the upper part of the  windpipe—the larynx  and
adjoining trachea.   If the  rapid effusion of  tenacious mucus
which attends the invasion of  the disease, cannot be got rid of
by the  sufferer—or, if the swelling of the lining membrane of
the part be so great, whether by oedema or inflammatory conges-
tion and tumefaction, as to occlude the opening of the glottis—
or if the false membrane so much talked of, be formed  in mass
sufficient to prevent the passage of air ; if, under either of these
contingencies, a sudden stop  be threatened  to  the  process of
respiration, and  the usual means of relief, promptly and freely
applied,  be unsuccessful,  then we are bound to resort to the
operation.   A patient should not be suffered to die of suffocation
in an early stage of croup; an opening  should be made in the
windpipe for the admission of  air.  But we  should satisfy our-
selves, by a careful examination, that the impediment to breath-
ing is confined to the larynx; the thorax should  be resonant on
percussion,  and the respiratory  murmur or loose  mucous rale
should be distinguishable.
   On the other hand, in the more advanced stages of croup, the
disease  is no  longer a local inflammation  of the larynx  and 
236                        croup.

trachea.  Post mortem examinations prove it to have extended
itself through the minutest ramifications of the bronchi and air-
cells, which are  gorged with mucus or occluded with organized
lymph, and even the pulmonary tissue has become solidified or
"hepatized."  This extension is inferred, in  the living subject,
from the peculiar complexion—ghastly pale or livid, and from
the loss of resonance on percussion, and respiratory murmur.
  We  have  to  contend with  bronchitis—and pneumonitis as
well as laryngitis and trachitis.  Suppose  the occlusion of the
upper  and large tubes capable of being  instantly and totally
removed by the operation, what will you have gained?  In this
state of things, you can readily perceive the absolute ineffi-
ciency of the operation ; and here it should never be performed.
Bronchotomy is not,  as you  must  be aware, in any sense, a
remedial means; it has no tendency to remove the  inflamma-
tory actions going on in the trachea, or to check their progress.
By  its success, we  merely  obtain time for  the  vigorous and
persevering employment of the proper measures,  and if these
should be neglected or carried  into  imperfect execution, the
extension of the disease into the lung will be as likely to occur
and to prove fatal, as  if the operation had  not been resolved on.
   Finally, let me urge upon you, in the treatment of this pain-
ful and formidable malady, the most assiduous attention—the
most unwearied perseverance.  Make it an inviolable rule, never
to leave your patient until relieved from the immediate danger
of  suffocation.   Whatever of success 1 have to boast of,  I  attri-
bute simply to my observance of this rule.  There should be no
 intermission of your efforts ; and when you have exhausted all
 your  resources, renew the application of your  remedies, and
 persist until success shall crown your sincere and  earnest  exer-
 tions.  Thus will you entitle yourself to the rich reward of a
 parent's gratitude, whose warmth none but a parent can con-
 ceive.   You will enjoy a sublime  pleasure in  snatching the
 victim from a horrible death—in restoring to a fond mother the
 offspring of her bosom—to  a  despairing  father the joy of his
 present, and the hope, it may be, of his  future existence.  Let
 me anticipate, that  these pleasures and rewards  may often be
 y0urs_the only adequate compensation for the severe privations
 and wearisome toils of our most  laborious profession. 
CHRONIC LARYNGITIS.
237
                   CHAPTER XXXIX.

       CHRONIC LARYNGITIS--LARYNGEAL PHTHISIS.

   Chronic Laryngitis.  As  croup,  the acute  form of this
 disease seems chiefly to attack children, though, as I have stated,
 by no means exclusively, so its chronic condition is met with in
 adults only.  It has attracted, of late years, much attention, and
 is referred  to in  the  books,  as one of  the  modifications  of
 Phthisis—P. Laryngea.  Some  have considered  it  as a new
 disease, but Trousseau and Belloc, authors of a memoir on the
 subject, which received a prize from the Academy of Medicine
 at Paris, have traced it in the writings of Morgagni—"perhaps,"
 they say, "in those of Galen and Aetius."  In modern times, it
 is described by Double, Cayol, and Louis.  The writers above
 mentioned, say they have  "never met with it but  in complica-
 tion with pulmonary phthisis," and attribute it altogether  "to a
 tuberculous diathesis."   It is certainly true, that it is much most
 likely to attach itself to this state of constitution.   It is farther
 true, that as in acute laryngitis, so in chronic—the inflammation
 has a remarkable tendency to spread itself by downward pro-
 gress  along the bronchi and into the lungs, and thus give rise to
 phthisis pulmonalis.  In a majority of cases that I have seen, I
 am ready to acknowledge, the patients were of scrofulous habit,
 and probably labored under tuberculous development either ob-
 scure  or discernible, but I have had three or four instances under
 my care, in which the laryngeal affection seemed entirely local,
 being treated as  such, and completely removed ; and, in others,
 this disease of the larynx and trachea preceded by  weeks—nay,
 by months, all the emaciation, and other constitutional symp-
 toms,  which, by their occurrence, form a pulmonary consump-
 tion.   In some of these, I  was satisfied, that the whole  evil was
 at first, and for a long time, exclusively local, and that it was
 through the persistent irritation, that the more extended malady
 was generated.   It is said  occasionally to cause death by suffo-
cation, but this I have not seen.   If unmanageable, it  runs on to 
238
CHRONIC LARYNGITIS.
Phthisis, under which head we shall discuss its second and last
stages.
  At present we  shall only regard the local affection,  which is,
indeed, so distressing, and in prospect so  full of danger, as to
require our special attention.  Its frequency has undoubtedly
been of late years increasing very notably.   A variety  of causes
are suggested to account for this, all of which will  be  found
unsatisfactory on examination.   Our Northern brethren  have
given some alarm by ascribing it to  the  influence of anthracite
used as fuel, because  since the introduction of that kind of coal,
we meet with it much oftener than  formerly.  The fact is so,
but the coincidence seems accidental merely.  In France, wheie
the same increase is observed, anthracite is unused ;  and I have
had several patients laboring  under  it, who  never saw a fire
made with anthracite.
   In our own country, it has been particularly often  met with
among clergymen, whose habits  have, therefore,  undergone a
close scrutiny.  Nothing new has been detected in their modes
of  life, and I cannot attribute their special  liability, therefore, as
some have done, either to their sedentary indolence, their hard
study, or their laborious use of their vocal organs.
   It is worthy of remark, however, that it has affected in great-
est number the clergy of those sects which admit of the custom
of  reading written discourses, and can hardly be  said to have
attacked any individual who habitually spoke extempore.  No-
body is ignorant of the difference in  effort and liability to  fa-
tigue, connected with the use of the organs of speech in reading
and in declamation;  the  same individual  will declaim loudly
for hours unfatigued and free  from  suffering, who cannot read
for more than a few minutes without uneasiness and distress.
Indeed,  I regard the frequent and free use of the voice in loud
speaking, as rather preventive  than otherwise, of affections of
the respiratory organs.
   Chronic  laryngitis is met with much oftener  in men than in
 women.  It arises chiefly, like the acute form, from exposure to
 some atmospheric change, to cold and moisture.  Its  complica-
 tions, as given by writers, I have not met with, except in tuber-
 cular or scrofulous subjects.  A cancerous, herpetic and syphili-
 tic modification, are  spoken of. 
CHRONIC LARYNGITIS.
239
  There can  be no  difficulty in  distinguishing the disease.
The patient  refers  all his sufferings to the larynx;  there is
aphonia, the voice being a  husky whisper, and the attempt  to
speak annoying and fatiguing.  The ear, or stethoscope applied
to the windpipe, detects a peculiar, harsh, rough, rushing sound,
mingled with more or less sibilation.  The cough is  hoarse or
weak, and  is apt to be dry and teasing.  Sometimes there is
expectoration of a tenacious  mucus—sometimes  of a purulent
matter streaked with blood.
  Dysphagia is, in some,  the most distressing  symptom, the
deglutition of the smallest  morsel giving great pain.  Marshall
Hall makes dysphagia, and the absence  of it,  the diagnostic
separating laryngitis from tracheitis.  In laryngitis, he also af-
firms, "there is the remarkable symptom of inability of snuffing
up the nostrils, or of drawing the alae nasi together by a quick
inspiration."  I have, however, lost a perfectly well-marked case,
in which  the  dysphagia was  extreme—the voice and cough a
mere whisper, but the patient could "snuff up."  There is pant-
ing, especially after any muscular exertion.  As  the  case pro-
gresses, the dyspnoea increases to orthopnoea.
  Autopsy.  The local changes found after death  are various.
1. Oedema of the  glottis.   2.  Inflammation of the mucous
membrane, with redness and swelling.  3. Ulceration of this
surface.  4. Ossification, caries and necrosis of the cartilages.
  The Treatment of chronic laryngitis is directed by the  same
principles which guide us in the management  of  other inflam-
mations. If the patient is strong and robust, and the case recent,
venaesection may be premised, and topical bloodletting resorted
to.  Leeches should be applied to the front  of the throat, or cups
to the back of the  neck.   Emetics  are  not generally  adapted,
but if the case present, at intervals,  paroxyms of dyspnoea  par-
ticularly severe, they may serve the purpose of procuring tem-
porary relief.
  Mercurials  have  been highly eulogized, especially by the
French authors above quoted, who explicitly declare that their
"cases—a great number," prove most decidedly the "advantage
of the mercurial treatment,  carried even to  salivation."  I  have
been disappointed in my hope of similar results.   Dr. M.  Hall 
240
CHRONIC LARYNGITIS.
gives an impressive case  of cure  by the mercurial,  even after
tracheotomy had become inevitable.
  Narcotics are of more uniform utility, and indeed, have seemed
to me essentially necessary.  The Dovers' powder is the best form
of prescription, if it be well borne;  if it give rise to headache,
or disorder the stomach, some of the salts of morphine must be
substituted.   The muriate may be taken without any ill effects,
for great lengths  of time.  Endermic  medication, by applying
to blistered surfaces opium  in some mode of preparation, or the
extracts of stramonium and belladonna, is recommended.
  Various topical remedies  are proposed.   The vapor of warm
water is inhaled, simple and diversified with  balsamic  and aro-
matic impregnations; these have sometimes appeared to give a
transient relief.
  Fumigations with resin,  cinnabar, chlorine, iodine, etc., were
much  employed, but are now abandoned.  The  inhalation of
aether in which  cicuta has been steeped, is spoken of as ser-
viceable.
  In cases of dysphagia I have found the solution of nitrate of
silver of great benefit, used as a gargle  or  applied by a mop of
lint on the end of a probe.  I have been entirely unable to in-
troduce it as Trousseau and Belloc have done, into the glottis with
a sponge, and by means of  Anel's syringe.   Any attempt of the
kind has threatened my patient with instant suffocation.  Unless
dysphagia has been present, or some pharyngitis observable on
examination  of the  fauces, which  should never be omitted to
be done carefully, I have seen no  advantage from the nit: ar-
gent: or the  corros: sub:, or sulph: cupri:, all which are recom-
mended as gargles.   I believe they are available only when the
glottis and epiglottis are involved in the laryngeal inflammation,
as now and then happens.
   The  same  authors refer to  many instances, in which they
affirm, that the  life of the patient has been saved by trache-
otomy—a canula, of sufficient size, having been introduced into
the opening  made,  and kept there as long as necessary, while
the proper measures for his relief were pursued. 
BRONCHITIS.
241
                      CHAPTER XL.

                        BRONCHITIS.

   Bronchitis, as the term imports, consists in an inflammatory
 affection of the mucous membrane which lines the  bronchi, the
 air tubes of the lungs, and the pulmonary cells.  Though sen-
 sible in all its extent, this  membrane is particularly so at its
 external extremity, where it runs into and is connected with the
 somewhat modified, but similar membrane, lining the fauces and
 pharynx  and aesophagus.   When irritated at the glottis, or in
 the larynx and trachea, the excitement rapidly spreads over the
 whole of the tissue.   The immediate consequence is a prompt
 increase of its peculiar secretion, which, in a state of health, is
 so moderate in quantity, as to be entirely exhaled or absorbed,
 there being then no  expectoration.  This augmented effusion
 shows little change in the condition of the membranous surface,
 but the next step in the series of effects produced by irritation,
 is indicative of a definitely morbid state of action,  the fluid
 poured out being thinner, and  resembling  in its acrid quality
 the coryza thrown from  the schneiderian  membrane in catarrh.
 Afterwards, it assumes a denser consistence, becoming of globu-
 lar form, and putting on  a  yellowish  hue, mixed occasionally
 with a tinge of green, or a brown or red color.
   The distinction between  croup  and bronchitis refers clearly
 to the locality of  the  original  affection.  There  is also a differ-
 ence to be noted in the nature of the diseased actions;   the
 formation of a  false membrane, which occurs in so decided a
 proportion of cases of croup, never happens,  I believe, in bron-
 chitis,  unless this  be  the  secondary effect  of inflammation
 commencing within the larynx and extending itself downward.
   It has been found less easy to draw the line  between bron-
 chitis and catarrhal fever, or as the phrase is, "catarrh."  "If the
 irritation," says Broussais, "exhibits no other  token of its exis-
 tence than a disordered mucous  secretion, it is called catarrh;
but if it manifest itself by a violent disturbance of the circula-
tion joined to an  alteration in the mucous secretion, we call it
       VOL. II.—21 
242
BRONCHITIS.
pulmonic inflammation."   There  is a  singular vagueness  and
obscurity in  this proposed  diagnosis; for inflammation almost,
uniformly commences, in these cases, in irritation, which modi-
fies the  secretions, the functional soon passing into the inflam-
matory or structural condition of disease.   According to Brous-
sais, then, we  should consider bronchitis as  merely a second
stage of  catarrh.   They seem to  me, to be better distinguished
by a reference to the  general or constitutional disorder in the
one case, catarrh being truly  an idiopathic  fever, (as I have
already treated it,)—and, in  the  other, the essential and unva-
rying  indications of local inflammation attacking a special tis-
sue; these local symptoms of pulmonary mucous inflammation
constituting bronchitis, properly so called.
  Bronchitis divides itself very naturally into the two forms of
acute and chronic, which, however, run readily into each other.
The latter, when protracted to the exhaustion of the patient, or
to the production of pulmonary disorganization, is familiarly
recognized as one of the varieties of phthisis, and known under
the title of Catarrhal Consumption.
  Acute  bronchitis  is  often spoken of as closely allied to  ca-
tarrhal fever.  It may, indeed, be said to be, in a  certain sense,
coincident with  it, the  inflammatory affection of the bronchial
mucous membrane being often the earliest and most  prominent
lesion attendant upon the general febrile disorder, and very fre-
quently remaining fixed after this has subsided.
  All  the known Causes of catarrh may give rise to it, such
as exposure  to alternations of temperature and  vicissitudes of
weather—to currents of cool air when the body is heated—get-
ting the feet wet—putting on damp clothes, or sleeping in damp
beds, and every  other  of the numerous  circumstances which
occasion sudden suppression of the perspiration  or suspension
of the  ordinary cutaneous actions.  Hence, it  often, though not
always, commences with a chill;  this is followed by some  un-
easiness in the  throat,  and a sense of  roughness  and tickling,
which excites a cough with efforts to expectorate.   The cough
becoming more frequent and harsher, is attended with  soreness
of the chest, increasing to pretty severe pain,  not often acute in
any one  point, but extensively diffused.  There is a feeling of
thoracic  fulness and tension, which restrains  the inspirations. 
BRONCHITIS.
243
 A wheezing and rattling sound is heard in breathing, occasioned
 by the amount of mucus in the air passages.  If this secretion
 exceed the quantity which can  be removed by coughing and
 expectoration, the air-cells and tubes are engorged by accumula-
 tion, the entrance of air is impeded, and suffocation threatened.
 The due performance of the  important function of respiration
 being thus impeded, the blood no longer undergoes the neces-
 sary changes—the organs are imperfectly stimulated—the brain
 and nervous system languish—the muscles lose their force, and
 the powers of life  are  rapidly exhausted.   This mechanical
 termination in which the patient  dies suffocated, by the mucus
 filling the bronchi and pulmonary cells, is the condition known
 among English writers as peripneumonia notha.
   In young and robust or plethoric subjects, bronchitis some-
 times  exhibits great severity in its symptoms, and follows a
 rapid  course.   The pyrectic  excitement runs high, with full,
 hard pulse, hot, dry skin, anxious  and hurried breathing, at-
 tended with a distressing tension or constriction of the chest,
 and much soreness in coughing.  The patient cannot lie down;
 his lips are livid—his  face flushed—his expectoration  scanty,
 with struggling for  air after  a fit of coughing.   If he be not
 promptly relieved  from  this condition, a total  collapse of the
 system, and irremediable prostration of the vital powers, must
 ensue within a short time.
   Post mortem inspection shows  the mucous membrane of the
 bronchial tubes and pulmonary air-cells notably thickened in
 fatal cases of bronchitis ; the surface of the membrane is turgid
 and high colored by the vascular injection of the tissue, so as to
 appear sometimes like a mere eongeries of  blood vessels.  The
 ramifications of the air tubes, and  the cells also, have  been
 found so filled with a tenacious  ropy mucus, or  an effusion of
 purulent or even sero-purulent matter, that  the lungs refuse to
 collapse when exposed.   In more protracted cases, all the  pul-
 monary tissues become affected with infiltration,  hepatization, or
 some other  mode of consolidation.   If  the  protraction  has at-
 tained a  chronic tendency, we  may meet  with more  or less
 ulceration of the mucous lining membrane.
  The Prognosis accords generally  with the state of the respi-
ration  If there be dyspnoea and orthopnoea—if the breathing 
244
BRONCHITIS.
be impeded by accumulations within the air tubes and  cells, as
shown by wheezing, rattling, struggling with sputa which the
patient cannot expectorate, while his livid  or pale countenance
announces that the due pulmonary changes in the blood are no
longer effected, suffocation impends and  may be  expected  soon
to occur.  Or, if the loss  of respiratory murmur and  of  reso-
nance be remarked  over any very large extent of the  thoracic
surface, the pulse  being  quick and frequent, with panting and
dry cough, we must fear the impairment of function, by consoli-
dation of the lung, to be at hand.  On  the contrary, when the
patient spits largely and freely after coughing, and can lie in the
horizontal posture, or shift from side  to side, as  he pleases, his
inspiration, with whatever rale  attended, being  full  and  deep,
and his muscular strength little impaired, we may anticipate his
recovery.  The disease is most fatal  to infirm  subjects, and  to
the extremes of age—infants and very old persons being alike
liable to  mucous engorgement, of the  pulmonary tubes  and air
cells.   In delicate women, and  in constitutions  predisposed to
phthisis, it may run on tenaciously into  the chronic  condition,
known as catarrhal phthisis.
  Of the Treatment.  There is little doubt or difficulty in the
management of the  early  stages of  acute bronchitis.   In the
majority of cases, such as  happen in  the young and robust,
prompt and fearless  depletion is indispensably requisite.   The
pulse being full and hard, and the breathing short and painful,
blood must be freely drawn from a large orifice, and in quantity
proportioned to the violence of the attack.  An emetic should
then be administered without delay; and here I  have found the
combination  of tart: antimon: with ipecac: preferable to either
separately, and to every other article of the class.  This should
be the  first, as it  is  the  indispensable  remedy, in the  cases of
infants and old and infirm people.  We  shall thus disgorge the
air tubes of the suffocating mucus thrown out in such prodigious
quantity, and so rapidly, as very often to  require, at but short
intervals, the repeated excitement  of the  efforts at  vomiting.
"The benefits,"  says Dr. Hastings, "which arise from  emetics
are two-fold ; they unload the primae viae, thus removing causes
of irritation ; and  they increase the expectoration, on which the
favorable issue so much depends."  In young children they are 
BRONCHITIS.
245
 especially serviceable in  the former mode, as there is presented
 here, almost uniformly, the complication of a highly  disordered
 state of the stomach and bowels.
    The  combination  above mentioned, of the  antimonial  with
 ipecac: will very generally act as a cathartic also very benefici-
 ally.  It may require to  be aided, however, and we should pre-
 scribe moderate doses  of sal:  epsom, in an infusion of serpenta-
 ria or decoction of seneka.  Thus we  shall promote a full deter-
 mination to the skin with free diaphoresis.   The attack is some-
 times ushered in with great oppression at the pit of the stomach,
 the tongue being  much furred, with  nausea and an unpleasant
 taste in  the mouth.  The tokens of gastric and hepatic derange-
 ment, if not relieved by the emesis above advised, will require a
 mercurial  purgative.  Calomel should be given in  full doses,
 either alternately or mixed with some  more ready laxative, and
 some  diaphoretic—as in the old  and  favorite antimonial or ni-
 trous powders, in which the pulvis antimonialis or  pulv: jacobi,
 or nitrat: potassae, with a certain portion of jalap or  rhubarb, are
 added to the mercurial.
   It is necessary that  I  should express myself decisively  as to
 the propriety and advantage  of thus  exhibiting a purgative  in
 the  commencement of the pulmonary inflammations ; for there
 is not an older nor a stronger prejudice, nor one which has ob-
 tained a more general  currency, from  the earliest times  of our
 science,  than that  which denounces the use of cathartics in pec-
 toral  affections universally.  For my own  part, I am disposed,
 on the contrary, to rank the judicious employment of  our reme-
 dies of this class as a means of reducing inflammatory  action
 wherever seated, second only to the lancet,  and in a great num-
 ber and  variety of cases, as even preferable to that powerful in-
 strument of depletion.  Upon this  view  I have founded my
 practice  for more than twenty years, and have seen much good
 and no evil in  any shape result  from  it.   You  must observe
 however, that I am speaking only of the first stages  of pulmona-
 ry inflammation, and as it occurs in subjects of ordinary muscu-
 lar strength and vigor of constitution.  But when arterial ex-
citement is reduced or has subsided ;  when a free diaphoresis  is
 going on, and abundant expectoration attends the paroxysmsof 
246
BRONCHITIS.
coughing, our purgatives are not  only unnecessary but perni-
cious. Generally speaking, all that is necessary in the advancing
stages of bronchitis, is merely to keep the bowels regular and so-
luble.   This should never be neglected.
  I have already spoken of diaphoretics, which are much relied
on in the treatment of bronchitis.  At first, the sedative articles
are to be preferred.   Many depend almost exclusively upon the
tartarized antimony, which they administer in aqueous solution,
and in doses properly adapted to  the state of the stomach.   The
tolerance of it in different individuals, and at different times in
the same individual, varies .very much.  The Italian  school
press this matter very far, increasing the dose almost indefinitely.
Others  add to it  opium in some form, to reconcile the stomach
to its free use.  It has never  been with me a favorite prescrip-
tion.   I have seen it  more than  once give rise to such  prostra-
tion and debility as quite to counterbalance the good effects an-
ticipated from it, in  the reduction  of  arterial action, and the
establishment of a salutary sweating.  Some have alleged  that the
peculiar or specific curative effect of the antimonial, is lost when
it is carried to the extent  of producing nausea.  I do not clearly
understand this notion, but allude to it here merely to show that
others  beside myself have  become  aware of the inefficacy of
nauseants, or their want of adaptation in the case before us.  The
pulvis antimonialis, James' powder, seems to me more managea-
ble than the  tartrite—and  I therefore prescribe it oftener  as a
diaphoretic.   Its efficacy is much increased by adding the nitrate
of potass, which is of itself often a very available sudorific, and
possesses the remarkable property  of co-operating well  with
both varieties of diaphoretics—the  sedative and stimulant.  It
is  very usefully given  with serpentaria  and  seneka, either in
 powder, infusion or  decoction—and with  the Dovers' powder or
 the acetate or carbonate of ammonia.  The  Dovers' powder is
 indeed one of our happiest formulae.  It is peculiarly well adap-
 ted to the condition  of our patient, when  the arterial action has
 been moderated  by  the  depletory measures above  recited; the
 fulness and hardness of the pulse being  lessened, and  the heat
 of skin somewhat abated.  Among the most trustworthy of our
 febrifuges, it is singularly well calculated  to relieve the tracheal, 
BRONCHITIS.
247
 laryngeal and  bronchial irritation, and thus subdue the cough
 which so incessantly harrasses our patient, and prevents his enjoy-
 ing even a transient repose.
   If  the local thoracic affections with which this disposition to
 cough is connected—the soreness and  pain of the chest, dysp-
 noea, etc., continue obstinate, or but little  relieved by the con-
 stitutional treatment above enjoined, it is advisable to resort in
 the next place to topical  depletion.  In  very young subjects,
 leeches may be applied ; but when it is in my power to choose, I
 very much prefer the cups, which should in the first instance be
 laid as  near the seat  of pain or greatest degree  of soreness as
 convenient; but  should be shifted so  as  to  take blood, in an
 unyielding attack, from the whole surface of the thorax.
   Warm and soft poultices should be kept on the chest, to solicit
 a free discharge from the  leech bites  and scarifications, when
 cups  and leeches have been used, and as fomentations when they
 have not.  In the latter case, mustard should be added, in order
 to  produce a revulsive effect.   Patients are very often highly
 delighted with the relief thus afforded them.  When these means
 have failed us, and the first vehemence of febrile excitement has
 passed over, we shall find  it proper to resort to vesicatories.  A
 large blister should be laid on  the side, or in front, and if one
 give no definite benefit, several of them in succession, on differ-
 ent parts of the surface.   They very  rarely fail  to  subdue or
 palliate very notably, the symptoms of pulmonary inflammation,
 whether concentrated on one point, or diffused  widely through
 the lung.
   To relieve the  cough, which is often  very troublesome, a va-
 riety of demulcents have been employed.  The basis of all these
 is mucilage, of which we have abundant diversity, in the solu-
 tions  of gum arabic and the infusions of flax seed, barley,  slip-
 pery elm, etc., etc.  These are made agreeable to the patient by
 numerous additions ;  they  are acidulated with vinegar and with
 lime juice, and sweetened with sugar, or honey, or some syrup
 each of which is  supposed  to exert a peculiar efficacy.  We may
 medicate them usefully, too, with squill, or ipecacuanha,  or tart:
antimon:, or opium, in very small  doses, so as to bear indefinite-
ly frequent  repetition.  They  thus become serviceable adju-
vants  in  our management  of bronchitis, but must  not  be  too 
248
BRONCHITIS-.
much trusted to, or  too  largely indulged  in.  The cough, it
should be recollected, is a mere  symptom, which is best got rid
of by the removal of  the  condition it serves to indicate, and is
not, therefore, likely to yield to the exclusive use of expecto-
rants, so called^   When the pulse is full and hard, and the skin
hot and dry,  the best relief for the cough is to be found in venae-
section ;  cathartics relieve it, by reducing the general vascular
excitement, and thus diminishing the pulmonary  irritation  of
which it is a token;  and  emetics and diaphoretics conduce  to
the same end, by the relaxation and revulsive determination fol-
lowing their  action on the stomach.
  The administration of opium, in  the treatment of acute bron-
chitis, has been made  the subject of much dispute.  The ob-
jectors to it allege, that when taken early, its action as a stimu-
lant is improper and hurtful;  and that at a  later  stage, it has a
tendency to check the expectoration upon which so much stress
is laid, both as a favorable symptom  and a  means of recovery.
Its advocates contend, on  the other hand, that  there  is nothing
which so directly and powerfully controls  the irritation of the
trachea and bronchi, forming  so important a constituent of the
malady  under our care, and consequently, that nothing tends so
much to abate both the violence and the frequency of the cough;
and they distinctly deny its injurious  influence upon expuition,
declaring that if it seems  to lessen the expectoration, it is by
diminishing the unduly abundant and morbid secretion.
  I will freely aver, that I have never met  with an example  of
the. evil influences, above  ascribed to opium.  No one would be
so absurd as  to  trust to its exclusive administration.  Time and
circumstances must be taken  into view.  It is usually  best  to
premise the ordinary means of depletion, and to  combine  with
it some  of  the relaxing or sedative diaphoretics.  There is no
occasion, however, for any long or indefinite postponement  of
its use.   The Dover's powder  may be prescribed  safely and
beneficially, on the first night  of the attack, in a very large ma-
jority of ordinary cases ;  and the camphorated tincture, or some
other of  its numerous formulae, mingled from the very begin-
ning, in small quantities with our demulcents.
  Full doses of opiates, as I have  more than  once repeated  to
you, should be  reserved for  the accustomed  bed-time of the pa- 
BRONCHITIS.
249
tient.  Their anodyne and sudorific operation, (which though
but a part of their remedial efficacy, is a very important part,)
is much aided by the influence of habit.  The day doses should
be smaller, depending upon repetition for their good effect.  Yet
there is a class of cases, in which writers of great authority and
experience, urge upon us  the observance of special caution,  in
the administration of opium.
   In the bronchitis of aged people, and of infants, and of some
very infirm subjects, there is never any marked access of pyrec-
tic excitement;  the  inflammatory  symptoms never  run high,
and the danger to life consists apparently in the mere engorge-
ment of the lungs, and the filling up of the air cells and  tubes
with abundant and morbidly  tenacious mucus.  The  pulse is
soft and weak, the strength impaired,  and the countenance pale
or livid.  Depletion is scarcely required and badly borne.  Emet-
ics give, seemingly,  most relief, the majority of  practitioners
preferring those which, like seneka, possess some  stimulant and
expectorant properties, or  at any rate, like the sulphates of zinc
and  copper, do not  exhibit any  prominent power to nauseate
or relax.  A similar  caution is observed,  in regard  to  pur-
gatives ;  the saline and  sedative being shunned,  and the oily,
resinous, or stimulant selected, as turpentine, with or  without
castor oil, calomel, aloes, etc.  Here, the employment of opium
is considered a matter of no little delicacy, and its effect must
be attentively watched.  If too largely prescribed,  it may by the
stupor it induces interrupt the necessary  efforts  to expectorate
the effused  pulmonary  secretion,  and thus prove dangerous.
Another form of injurious action is  described, as  shown in the
excitement of restlessness, with some febrile  irritation,  perhaps
some light delirium,  the cough changing from loose and rattling,
to a harsh, dry form, with a ringing sound, etc., a loud  asthma-
tic wheezing.  Here they advise a discontinuance of the opiate,
and the substitution  of the emetic and diaphoretic.   I will not
deny the possibility of these deleterious results, from the exhibi-
tion of our most valuable drug ; but in general, I am disposed
to think that there is little reason to dread them, and agree with
Johnson  and Eberle, that  in pulmonary effusions, opium rather
checks the  secretion, than the expectoration in the mode alleged.
I  employ it freely, in all its various  modes  of preparation, pre- 
250
CHRONIC BRONCHITIS.
ferring the Dover's powder and paregoric;  and every day I see
pain relieved by it, cough mitigated, and the harrassed patient
losing all remembrance of his sufferings, in a deep soft slumber,
attended almost uniformly by a most salutary diaphoresis.
  When the strength of  the  patient is much impaired, and he
seems exhausted, either by the violence or the protraction of the
attack, the impending prostration must be averted by the judi-
cious use of stimulants.  Among these, ammonia is supposed to
be peculiarly well adapted, on account  of  its  obvious expecto-
rant properties.  The carbonate may be given in an  infusion of
serpentaria or seneka;  the dose being proportioned,  in  amount
and frequency, to the  urgency of the  case.   We may add to
such a mixture, a proper quantity  of the  nitrous aether,  or of
camphor, which tend to fulfil the same indications.  Vesicato-
ries should be applied to the chest, and sinapisms to the extremi-
ties, and wine and brandy offered, as the occasion requires; per-
severing the more tenaciously in the effort to re-excite the  sick
man and recruit his exhausted energies, because in so large a
proportion of these instances  of peripneumonia notha, there is no
reason to apprehend  any fatal disorganization, or modification of
healthy structure of  the parts affected.
  During the convalescence from acute bronchitis, the habits of
the patient must be carefully regulated.   He must be clothed in
flannel, and protected from all exposures.  His diet should be
light, consisting of  farinaceous  matters, with milk and  eggs.
His drink should be  water, tea and  coffee.  Lemonade may be
allowed as an occasional  luxury.  All excesses must be avoided,
and special prudence enjoined forcibly upon him.

  Chronic Bronchitis very naturally results from the tenaci-
ty and protraction of the acute form, but you  will meet with it
not unfrequently, as  an original and primary affection.  In such
instances, it begins as an ordinary catarrhal attack—a "common
cold," which adheres obstinately,  and gradually increases in the
severity of the local or thoracic symptoms.  There is often sore-
ness of the throat, with roughness and  tickling in the  larynx,
provoking a frequent teasing cough, at  first dry and harsh, or
attended with expectoration of a  tenacious mucus, brought up
with difficulty.  This becomes easier in a short time, and  more 
CHRONIC BRONCHITIS.
251
  abundant, and assumes a yellowish hue, being  mingled with
  purulent or puruloid matter.  There is some stricture and  op-
  pression of the chest, with a feeling of diffused soreness, increased
  on coughing and in making a deep inspiration.  The respiration
  is hurried, attended with panting and wheezing, and a loud mu-
  cous and crepitous rale.  In long protracted cases, we hear, in
  exploring the thorax, a purring or cooing sound,  at  particular
  points, and sometimes a distinct  sibilation or whistling.   These
  noises are referred to thickening of the tissue which lines the
  tubes and cells, thus straitening the passage through  which /he
  air is respired.  The voice is usually more or less hoarse, and
  may, indeed, when the upper part of the  trachea or the larynx
  is much affected, be reduced to a mere whisper; the cough being
  also rendered feeble and sibilant.  Hectic fever rarely fails to
 supervene, upon this chronic inflammation of the bronchial mem-
 brane—with hot and dry skin, most  generally in  the  evening,
 flushed face, pulse frequent, from one  hundred  to one  hundred
 and twenty or one hundred and  thirty, slight, headache, thirst,
 red tongue, etc.  The expectorated matter increases in quantity,
 is brownish, bloody, foetid;  the respiration is hurried and embar-
 rassed by all muscular exertion, even on  turning  from  side to
 side in bed;  there is much debility, with langour  and emacia-
 tion.   Night-sweats supervene, to  the great annoyance  of the
 patient; apththoe cover his cheeks, gums, lips and  tongue ; his
 feet and legs swell;  and a diarrhoea, at first easily checked, but
 promptly recurring and obstinately unmanageable, at last carries
 him off.
   In Autopsies of chronic bronchitis, the mucous membrane lin-
 ing the respiratory apparatus is found deeply injected, inflamed,
 thickened, and even occasionally ulcerated.  The pulmonary
 substance is in a certain degree solidified ;  the air cells and tubes
 are filled  with  muco-purulent  fluid, mingled with a frothy and
 bloody serum.  Broussais asserts that in the campaign of the
 French armies  on the European continent, the almost universal
 pathological  characteristic of chronic bronchitis, was the indu-
 ration of the parenchymatous structure of  the lungs themselves.
  From what has been said, you will readily infer the difficulty
of drawing the  line between chronic bronchitis and true phthisis
in some of its modifications.  Indeed, there are certain familiar 
252
CHRONIC BRONCHITIS.
symptoms which are common to both.   "Early in the disease,"
says Hastings, "the absence of pain during inspiration—the ca-
pability of resting  on either side in bed—the wheezing noise in
respiration—the leaden color of the lips—the pallidity of  the
countenance—the  appearance of the sputa,  consisting  almost
entirely of mucus  streaked occasionally with  blood, are symp-
toms sufficiently well-marked to distinguish chronic  inflamma-
tion of  the  bronchi  from tubercular  phthisis."   It is scarcely
necessary to observe to you, that in this list he has not included
any phenomena that deserve to be at all regarded as character-
istic.  The  distinction required of us  here, is not of much
consequence, it is true, in  the  practical  management  of  the
cases ; but it may  be important in forming the prognosis, which
of course will  be  demanded.  This, it is  evident, will be  far
more unfavorable in true phthisis than in bronchitis proper.
   In the early  stages of mere bronchitis, percussion of the tho-
rax will show a general impairment of resonance on the side
affected, proportioned to  the  degree of thickening of the lining
membrane  or  infiltration of fluid from  its surface within  the
cells; more notable still, when pulmonary congestion has  oc-
curred, or consolidation of the parenchymatous substance super-
vened.   Auscultation will always detect some  imperfection of
the vesicular sound or the  respiratory murmur, with mucous,
crepitous, or sibilant rales, according  to the various modes in
which the access of air is impeded.
   Treatment.  In the discussions concerning the management
of chronic  bronchitis, though there has been little dispute as to
the propriety of cautious depletion, yet the modes of depletion
proper  to be  instituted, have been warmly debated.  We  can
hardly go wrong in taking for granted, that the primary indica-
tion of cure is the reduction  of morbid vascular excitement both
local and  general.  Venaesection may occasionally be required
as a means of  fulfilling this indication,  and deserves to be re-
garded as  a very useful  preliminary measure, though its influ-
ences will often be found less impressive and striking, than we
 had hoped  for.  Yet the lancet will be, in our hands,  an instru-
 ment of no contemptible efficacy, when employed with prudence
 and judgment.  Large quantities of blood must not be taken
 away at once ; for the engorgement of the pulmonary organs,  is 
CHRONIC BRONCHITIS.
253
  of such a nature, the congestion so passive,  that the loss will be
  sensibly felt in the production of general debility, before any
  notable local changes are brought  about by it.  A well  timed
  repetition of small or moderate bleedings, will be found most
  serviceable, as unloading at intervals the  distended bronchial
  vessels, and  gradually  equalizing the disturbed and  irregular
  circulation.  When venaesection is of doubtful propriety, or the
  strength of the patient will not admit of it, we should  substi-
  tute for it topical bloodletting.  Cups should be freely applied to
  the chest, at first near the part of the lungs most  affected, and
  afterwards revulsively to the whole thorax,  with or without the
  scarifications, as we remark the tolerance of loss of blood to be
  exhibited.   The  flow  of blood and the determination to  the
  thoracic surface, may be well promoted by the  assiduous  appli-
  cation of warm poultices, which seldom  fail to give great relief.
  They may be put on from time to  time with advantage, during
  the whole protraction of the case;  and when made more stimu-
  lant and revulsive by the addition of mustard, are truly efficient
  and valuable remedies, which we shall lose much by neglecting.
  They may be made of any convenient material, moist or dry
  as the patient  prefers.                                       '
   It is unnecessary to repeat what  was formerly said  of the
 value of emetics.   They are among our most indispensable and
 useful prescriptions, disgorging the air tubes and cells of the
 accumulated  mucus  which oppresses them, and  determining
 powerfully to the cutaneous surface.  They render the expecto-
 ration by coughing, freer and more satisfactory, and relieve the
 stomach and bowels of their morbid secretions.  In many cases
 their frequent and persevering repetition is imperatively called*
 for, with these views.  Ipecacuanha is generally preferred, and
 enters into many efficient combinations  with other articles of
 the same class.  With the sulphate of copper, it forms the dry
 vomit so highly eulogized by Dr. Maryatt.   During its action
 he prohibited the administration of warm  water, or any other of
 the usual diluents, under the impression that its effect as an ex-
 pectorant, was  thus greatly increased.
  Purgatives are little  adapted to  the management of chronic
bronchitis, but the bowels must not be neglected.   If not kept
soluble by the laxative and light diet  upon which  our  patient
      vol. ii.—22 
254
CHRONIC BRONCHITIS.
must be made to live, and the occasional use of taitarized  anti-
mony,  ipecac,  etc., when  administered  pro re nata,  we must
interpose from time to time, a moderate dose of rhubarb or ep-
som salts,  or such other articles as he may prefer.  Nor should
we long delay, in  threatening cases, the resort  to an  alterative
course of mercury.  Small doses of calomel should be prescribed,
at proper intervals, and the system slowly impregnated with the
medicine, kept for  some time under its influence, avoiding, how-
ever, the production of any definite degree of ptyalism.  As a
general remedy  for inflammations  of the  mucous  membranes,
mercury is unrivalled ; this is often shown in croup,  the close
analogy between which and bronchitis, would lead us to expect
similar  benefit from it in the latter, as in the  former disease;
and accordingly, I have repeatedly seen it subdue the inflamma-
tion and restore the patient to health, after the long continuance
of the malady, the incessant soreness and pain of the throat and
chest, and the purulent appearance of the  sputa had threatened
the most fatal results.
   We must not neglect, at this juncture, the exhibition of our
expectorants and diaphoretics.  The seneka and serpentaria must
be employed; the former, preferably in powder,  and in  very ser-
viceable combination  with the nitrate of potass; the latter, in
infusion with sudorific doses of antimony, or  ipecacuanha, or
the alkalies, of which the acetate and sub: carbonate of potass,
are the best.  To allay the pulmonary irritation and palliate the
cough, we  must have early and  constant recourse to opium.
Authors urge upon us, even here, the cautions r formerly dis-
cussed,  and advise us  to  abstain from its  use in the  invading
stages of such instances as present much arterial excitement, and
in the cases of very aged persons,  very young infants,  and sub-
jects specially debilitated.  I am  willing  to  admit always, the
propriety of a nice and prudent attention to the influence of any
efficient remedy, and have, therefore, recited  to you these warn-
ings ; but I have seen  none  of the  dreaded  evil consequences
thus alluded to, as following the  exhibition  of anodynes.  We
derive unquestionable advantage  from them, in  what may be
termed  the second stage of bronchitis, whether acute or chronic,
when the lancet and our other antiphlogistic measures for the
reduction of undue excitement, have been properly premised. 
CHRONIC BRONCHITIS.
255
    "In chronic catarrhal  affections,"  says Eberle, "or  in recent
  cases, unattended  with any considerable phlogistic  diathesis,
  opium is a remedy of great value.  It is particularly useful when
  there is  too abundant a secretion of bronchial mucus.  In cases
  of this kind, small doses of opium check the inordinate  secre-
  tion and allay irritation, not  only by their direct narcotic influ-
  ence upon the mucous membrane, but also by  diminishing the
  secretion of the irritating matter in the bronchi." Dover's pow-
  der and  the elixir paregoric, are invaluable formulae—the combi-
  nation with ipecac in the first, and with camphor and balsamics
  in the latter, producing most useful results.   Where crude opium
  obstinately disagrees, giving  rise to  vertigo,  nausea,  and other
  familiar  sufferings,  it will be  proper to make trial of its several
  extracts  and the preparations formed from it—as morphine and
  its salts,  McMunn's ext: opii:, etc.
    I have not yet failed to find some one among  these  which
  proved available in any given case, without counterbalancing dis-
  advantage.  Should any such instance offer itself,  where all
  these formulae are  intolerable or annoying,  we  may  substitute
  some other narcotic,  as  lactucarium, hyosciamus, dulcamara,
 cicuta, etc.  I have, however, very little confidence  in any  of
 them. Duncan  recommends very  highly, the lactucarium; the
 others have each their advocates, and may be experimented with.
    For the farther alleviation of the cough, and  to promote the
 expuition of the  bronchial mucus, the inhalation  of several spe-
 cies of medicated airs and vapours, has been proposed.  Among
 these, the vapour of boiling tar was extravagantly extolled, and
 there  were  not wanting striking histories  of instances of cure
 performed by this means alone.   The hopes of relief thus gene-
 rated, led great numbers of  sick to the  dock yards in England,
 but the results have been far less favorable  than was anticipa-
 ted.   In some few cases of long standing, unquestionable benefit
 was received; but in the majority of instances, the  tar vapour
 was either absolutely inert, or did positive harm,  by  increasing
 the irritation already existing  in the air tubes.   This objection
 seems to be removed by diluting the tar with a sufficient amount
 of warm  water, and taking care that in boiling it does not burn.
 The aqueous  vapour thus  formed, is free from  any injurious
quality, and seems often to promote and render easy  the  tena- 
256
CHRONIC BRONCHITIS.
cious expectoration.  Some  medicate it  still farther with the
fumes of vinegar.
  Alcoholic inhalation has been found of advantage.  Brandy,
mingled with vinegar, has been used.   Cicuta steeped in brandy
or in aether, and aether alone, have been  recommended.  The
factitious airs or gases, the nitrous oxyde, mixtures of hydrogen,
carbon, iodine,  chlorine, in various states and proportions, have
been respired.  I have found them all  either useless or injurious.
The inhalation of some of our  astringent  and tonic drugs, in
the form of powder in a  state  of fine levigation or infinitely
minute division, has been tried with varying results.   Some pa-
tients cannot bear the intrusion of these powders into the lungs;
while others find  benefit  in  thus breathing  cinchona and the
acetate of lead.
  A very common  modification of chronic bronchitis, is met
with in persons of thin, spare form, and originally weakly con-
stitution.   The febrile symptoms never in these run high; they
are not, perhaps, confined to  their beds, or even their chambers,
for weeks after they are attacked.   The skin, in  such  cases, is
dry and constricted, the pulse small, but hard, frequent and ab-
rupt, the tongue clean and fiery red ;  the cough is not violent,
but harrassing, short and dry ; at night, its returns are repeated
so often as to disturb the rest very much, and are attended occa-
sionally with oppression of the chest or constriction ;  the breath-
ing is much hurried by slight  exertion  of any  kind,  and the
patient easily fatigued.  He  gradually loses  flesh, and at last
become strikingly emaciated, although his appetite may be but
little or not at all impaired, and his digestive powers give no sign
of being weakened, or disturbed in any degree.
  It is in this condition that  we shall  witness the most decided
benefit from digitalis—a remedy so extravagantly eulogized by
some, and so strangely misused  by many.   Its  ill judged and
almost promiscuous administration, has done much  harm; but
if you will select carefully, the cases to which it is adapted, you
will have reason to be well pleased with  its effects, in diminish-
ing the frequency and hardness of the pulse,  removing the ten-
sion of the chest, and  abating the harrassing cough.  Whether
these results  depend upon its  operation as a diuretic, I will not po-
sitively decide; but I  have not been satisfied that it occasions, 
CHRONIC BRONCHITIS.
257
  when prescribed in such cases, any increase of the urine dis-
  charged.   Under similar circumstances, the lobelia  inflata has
  been exhibited with advantage, in doses less than nausea tin o\
  The squill is serviceable here, too,  and may be  resorted to in
  turn.
    The colchicum autumnale, or meadow saffron, has of late
  years risen regularly in reputation and extent of use.  The tinc-
  ture certainly displays very remarkable powers, in many cases
  of chronic bronchitis.  It allays the  cough,  promotes a flow of
  urine, and keeps up a very  manageable degree of determination
  to  the  bowels,  without exciting irritation or impairing the
  strength; these latter properties adapt  it to  our purpose,  even
  when considerable febrile excitement is present, which indeed
  it will often relieve promptly by augmenting the various secre-
  tions and excretions.   The  sanguinaria canadensis deserves also
  to be mentioned here.
    It is my custom to prescribe the five remedies last  spoken of,
  in various combinations, the specific  efficacy of  each becoming
  more obvious and certain by the addition of any one or more of
  the others; and the  modifications of their influences thus ob-
  tained, will be often found capable of ready and  nice adaptation
  to the varying condition of  the patient.
   Since the favorable  notice of it taken  by Dr. Armstrong, in
  his treatise of consumption—copaiba has been much employed
  in chronic  bronchitis  and, has obtained some confidence.   It is
 by no means a  new remedy here, having been  long known in
 these regions as a cure for colds and chronic coughs—even
 among our domestic animals.  Its analogous efficacy in gonorr-
 hoea, an inflammation of another mucous surface with purulent,
 and mucous effusion, perhaps denotes some specific adaptation
 to  such contingencies.  Its application is limited both by its
 peculiar offensiveness to most stomachs, and its tendency to act
 too much on the bowels.
   Other balsamics have been from  time immemorial administer-
 ed in the case before us.  Myrrh  and tolu are among the most
 familiar.  Tar water is recommended as a constant drink.  The
 fir balsam  and the balsam  of Canada, are  much lauded; pills
are made of what our country people call pine-gum, a terebin- 
258
CHRONIC BRONCHITIS.
thinate  exudation from incisions in the bark of the pine tree ;
and there is not a little reliance still  placed, in  the domestic
management of protracted pulmonary affections, upon lightwood
chips steeped in rum or other  ardent spirits, taken mixed with
honey.
  Much has been  said  by Hastings, Broussais and others, con-
cerning the exhibition of cinchona in chronic bronchitis. Brous-
sais advises it to be given in infusion, "lowered with a little mu-
cilage," in the lingering inflammations of the membrane affected;
being decidedly  preferable, as  he affirms, to  all  other tonics.
Hastings, in  speaking  of the utility of cinchona,  tells  us that
the benefits arising from its exhibition are sometimes very appa-
rent—chiefly, he goes on to say, "in those instances that succeed
to acute bronchitis when  the debility thus brought on is consi-
derable.  The profuse  perspirations  and  other discharges are
not only restrained by it, but it appears occasionally to alter the
secretion  from the mucous membrane of the lungs."  To pro-
mote these effects, he  proposes to combine it with diluted sul-
phuric acid, which also tends to restrain the colliquative sweats.
   A few words may be added to what  has been  said above, of
the topical applications adapted  to the treatment of  chronic
bronchitis.  I have declared  my preference for the cups; others
resort to leeches.   I  make no objection to this choice in warm
weather ; but in winter I am unwilling to expose the thorax in
the mode required.   I have spoken of the benefit of the poultice
and sinapism.   In protracted attacks, numerous modes of coun-
ter irritation are resorted to.   Of all these, the vesicatory is the
most efficient and useful;  and  of  the two  modes of employing
the  blister, the keeping it open as a large superficial issue, by
stimulating dressings or the successive  application to different
portions of the surface, allowing  one  to  heal while  another is
acted on, the  latter seems to me by far the best.   Nay, I do not
doubt that I have seen  cures affected under this plan of repeated
blistering, exclusively  followed without any internal medicine
whatever.
   I must not, however, omit to mention the remedial  efficacy
of the  croton oil  and tartarized antimony, employed as counter
irritants.   They produce,  when rubbed on the  surface, each a 
CHRONIC BRONCHITIS.
259
 peculiar mode of inflammation ;  that of the latter being of pus-
 tular form, very closely resembling the pustule of variola.  This
 state must be kept up for a considerable time, bringing under its
 influence, from period  to  period, successive portions of the skin
 of the chest.  One  advantage  of  these irritants is, that  their
 full effect does not  materially interfere with the ordinary habits
 of a patient.
   Setons and deep issues, made with caustics of various kind-
 pure potass, nitric acid, etc.,  and even the actual cautery,  have
 their advocates.  Broussais  tells us he has  succeeded with the
 latter.  Ammonia and capsicum have been used  more recently.
 Some invalids consider the  latter  particularly manageable and
 quite efficient.  It may be applied as  a plaster, in powder or in
 strong tincture.  Invalids may be  well indulged in making ex-
 periments for themselves, of  these several irritants, in protracted
 cases.
   During the treatment of chronic bronchitis, it will be proper
 to guard the patient with the utmost  care against the influence
 of atmospheric vicissitudes.   For  this purpose, in the severer
 cases he must be confined to his chamber, in which an uniform
 temperature—say about 60°  of fahrenheit, must be kept up. He
 should wear  flannel next  his person, and take every means to
 keep his feet warm and dry.   Convalescence having fairly com-
 menced, exercise will constitute the most important partof his
 further management.  Sailing and riding, as passive modes of
 exercise, must at first be exclusively permitted ; but when he is
 able,  he may walk moderately, and mount  on horseback.  A
 journey in the saddle, with change of air, are the true specifics
 where they can be applied.   No combination  of remedies, no
 remedial management will serve as substitutes for them ; none
 can even be considered as second to them in efficacy.
  If your patient continue too debilitated to bear exercise, so
 rude as he must suffer on horseback, you must advise a sea voy-
 age—and he should seek  the benefit  of a warm and  equable
 climate.   The atmosphere of islands has  been  almost unani-
 mously regarded as peculiarly fitted to the irritable pulmonary
organs of sufferers from bronchitis.  Among these the West In-
dies, especially Santa Cruz and Cuba, and Madeira next  per-
haps,  have been preferred by the majority; and I have indeed 
260
PNEUMONIA.
known many instances of relief and  even of cure, sought and
obtained by a visit to these general  and highly favored shores,
whose softened air seems to have exerted some balmy influence
over cases long protracted and aparently hopeless.
                     CHAPTER XLI.

      PNEUMONIA—PLEURO-PNEUMONITIS--PLEURITIS.

  Under the present head—following the example of Cullen, I
shall  treat of all the inflammatory affections—whether of the
parenchymatous  substance of the lungs,  or of the  membrane
which invests and contains these organs ; whether of that por-
tion of the pleura lining the thoracic  parietes on the sides—the
pleura costalis, formerly regarded as the exclusive seat of pleuri-
sy strictly so called ; of that which covers the lungs; or of
that which extends itself over the upper surface of the dia-
phragm.   To each  of these  limited  localities of inflammation,
specific symptoms have been alleged to belong;  and even Good
is found retaining the particular distinctions referring to them.
Thus he speaks not only of empresma pneumonitis—empresma
pleuritis, separating not  unreasonably  the parenchymatous from
the  membranous  inflammations,  but  he sub-divides the latter
into pleuritis vera, mediastina, and diaphragmatica.  Now, though
I will not deny that a careful  and minute examination may ena-
ble  us to distinguish the peculiarities of position and circum-
stance which appertain to each of these cases, yet this diagnosis
will afford us no practical advantage whatever.
  Inflammation of the pleura, if  it exist but a very short time,
will  necessarily give  rise to a similar affection of the  pulmo-
nary  tissue  immediately beneath it,  and of the  membranous
surface  directly  opposite to  it;  and  thus, these local condi-
tions, however cognizable at  first, are soon  confounded by ex-
tension, and run into each other, a remark long since made by
Baillie, and one which you will  perpetually see verified in the 
PNEUMONIA.
261
 dissecting room.  "Inflammation of the substance of the lungs,"
 says Baillie,  "seldom takes place without some similar affection
 of the pleura;" and this holds good even  in  the most  chronic
 and least violent cases.
   Pleurisy is  one of our  most common and well-known dis-
 eases.   It is usually met with in the winter and spring months,
 and the number of attacks will bear a definite proportion with
 the  severity and  suddenness of  the  atmospheric changes  in
 these  inclement and unsettled seasons.   It  is seldom  seen  in
 mild winters.   Its causes are obvious.—Exposure of the person
 to damp and cold  air—all  the contingencies which have been
 enumerated as giving rise  to catarrhal  affections—all such vi-
 cissitudes of weather as act upon the cutaneous surface, check-
 ing  the ordinary functions of the skin  and  obstructing the
 natural transpiration.  It is said sometimes to have been  occa-
 sioned by external violence, as by blows on the chest, falls, etc.,
 but nothing of this sort has happened under  my own notice,
 except where the pleura is wounded by the  sharp spicula of a
 fractured rib, or by a penetrating instrument of some kind.  A
 fatal case is recorded, in which the pleura had been wounded by
 a  needle employed  to pass a ligature  round the subclavian
 artery.
   It is evident, that in cold or variable  climates, as the causes
 above  recounted are in constant  action during a considerable
 portion of the year,  pulmonary inflammation  will be  a very
 frequent disease.   "The pleura," observes Dr. Baillie,  "is more
 liable to  inflammation than other membranes investing  cavities
 which have no external opening.  This  is so  much  the case,
 that we  can  hardly  examine the chest of any person who has
 arrived at  the adult  state, without perceiving more or less the
 traces  of a present or former inflammation."
   Pleuro-pneumonitis is known to exist where the patient  is
 attacked with  pain in the side or chest, under  the ribs or scapula,
 fixed, circumscribed, sharp, and increased by inspiration, so  as
 often to render the taking a full breath impossible.   After this
 pain has lasted a  short time,  fever comes on, with a full,  tense
 pulse ;  the face is flushed—the  skin  hot  and dry, and there is
cough  or inclination to cough, resisted  on  account of the pain
the effort occasions.  It has been doubted, whether the pain and 
252
PNEUMONIA.
fever invade simultaneously.   I  have seen  the  former precede
the latter by various intervals—in one  instance as long as an
hour.  So also of the cough, which  seems an  effect  partly of
the embarrassed respiration checked by the acute pang attending
the expansion  of the  lung—partly by  the  congestion  which
must  result  from the imperfect transmission of blood through
the undilated  cellular  tissue, and  partly by the irritation ex-
tended not only (as I have before inferred must happen) to the
parenchymatous substance of the organ in immediate connection
with the affected  membrane, but even through it  to the bron-
chial  mucous  lining within.   The results of this engorgement
and inflammation of the respiratory organs  are  various and
highly interesting.   The most common  is  the  pouring  out of
plastic or organizable lymph upon the surfaces  affected,  which
connects by adhesions,  more  or  less extensive, the  pleura cos-
talis and pulmonalis—the sides of the pleural sac.   This effect
may not at the time be  noticed, but it entails on the subject a
greater  or  less degree of impairment of  freedom of respiration,
and a liability to pain and uneasiness in the side or chest.
  Suppuration  sometimes happens in place of  the  effusion of
lymph.   I have  not been  so unfortunate as to meet with it in
any case ; but in  many of your books, it is  spoken of as by no
means unfrequent.   The signs  of the presence of  pus within
the pleural sac, differ little from those which have been detailed to
you as denoting hydro-thorax—the same loss of resonance  on
percussion, and of respiratory murmur, changing their relations
with the changing  position of the patient—the  same dyspnoea,
and orthopnoea.   We distinguish empyema by the connection of
these  symptoms with recent pleurisy, and  the  absence  of the
usual appearances of the hydropic diathesis.
  Serous effusion is another consequence of pleuritis, which,
when unconnected  with dropsical tendencies, it  seems  to  be
impossible  to  separate from empyema—perhaps  its access is
later ;  it is more connected with chronic  than  acute pleuritis;
its increase is slow, and it is more free from the association with
cough, pain, and other modes of pulmonary irritation, than em-
pyema is, for the  most part, apt to  be.
  Chronic  pneumonia,  to  be hereafter  particularly described
under the head of phthisis, is a sequela of the acute malady of 
                         PNEUMONIA.                     263

 which I am now treating, but too frequently met with.  It mat-
 ters not  at what  point the affection may begin—whether the
 central point of inflammation be in the substance of the lung or
 its  investing membrane, the congestion and vascular  irritation
 which result, unless promptly arrested, run on into a  series of
 the  most destructive alterations—solidification by deposition of
 organized  particles, induration  and ultimate formation of ab-
 scesses, with great danger, and probably fatal consequences.
   "Pneumonic  inflammation,"  Cullen tells us,  § 346, "has  a
 termination peculiar to  itself—that  is,  by  the effusion  of  a
 portion of the entire mass of blood  into the  cellular texture of
 the lungs, which soon interrupting the circulation  of the blood
 through  this viscus, produces suffocation."   In this brief  des-
 cription, the illustrious Scotchman has anticipated the  notice of
 the  "pulmonary apoplexy" of Laennec, and of the other French
 pathologists.  From  my own experience, I should judge, that
 they have both overrated the frequency of its occurrence as a
 consequence of  pleurisy.  Indeed, Cullen  affirms it to be  "the
 manner in which this disease most commonly proves fatal," and
 declares, that "upon the dissection of almost  every person dead
 of the  disease, it  has appeared  that such an effusion had  hap-
 pened."  Occasionally,  though, as it would seem, comparatively
 very seldom, the violence of this mode of inflammation deter-
 mines  the  occurrence  of gangrene of the lung.   I have  seen
 but  one instance  of this kind.   It is known by the  extreme
 foetor of the breath, and of the sanious and offensive expectora-
 tion.   It is attended  by great and rapid sinking of the pulse
 and  general prostration, though some, Dr. Gerhard, of Philadel-
 phia, among them,  assert, that it is not necessarily  a fatal  con-
 tingency,  and report recoveries after it had supervened.
   I have  thus gone into a recital of the local changes resulting
 from pleuritic inflammation, because they form an essential  part
 of its history, and because it is  chiefly by means of these local
 lesions, and their indirect effects upon  the  constitution, that it
proves fatal in cases that terminate unfavorably. Acute  pleurisy
is  very rarely directly  fatal.  The febrile excitement  is often
very great, and  perhaps, in a few examples proportionally, may
run  so  high, as  by its  irritation of the general system, to pro- 
264
PNEUMONIA.
duce the usual evils attendant on fever, or to exhaust the vital
powers, and bring on a species of typhoid condition.
  Post-mortem examination exhibits the changes above alluded
to, as being capable of detection during the life of the patient,
by proper exploration of the chest, and deliberate enquiry into
the history and symptoms of the  case.  The frequency of adhe-
sions of the opposite surfaces of the pleura  has been  spoken of.
The sero-purulent effusion, empyema, represented by Law, and
other writers, as so common a consequence of chronic pleurisy,
is by no means  an  ordinary result of the disease with us.
"When pus is formed in the chest,"  says Baillie, "the pleura is
found entirely free from ulceration, but covered with a layer of
coagulable lymph."  Far more frequently we meet  with solidifi-
cation or hepatization of the lung thus described by Laennec—
"The lungs are somewhat  livid,  exhibiting in their  interior a
red color more or less deep.  An  incision  shows it to have lost
the cellular structure, and to have acquired a granulated appear-
ance."   This gives it a resemblance, not very close, perhaps, to
the liver, whence the use of the term.  This granulation Laen-
nec looks  upon as the proper and  distinguishing anatomical
characteristic of inflammation of  the pulmonary tissue.
  The Diagnosis of pleurisy can hardly present,  any difficulty.
It has been confounded, however, with  intercostal  rheumatism,
and  with  hepatitis.  A careful  exploration of the chest will
detect always more or less loss of resonance and defect of respi-
ratory murmur, independent of the position uf the body.  These
do not attend either of the affections above mentioned.
  The general Prognosis is favorable in our climate.  I have
said that acute pleurisy is scarcely ever fatal, except by protrac-
tion, and the ultimate supervention of certain  local changes.
The degree and importance of these can be very well estimated
by ascertaining their effects upon the function of respiration and
upon the constitution of the patient in the  production of hectic,
atrophy, and the other tokens of phthisis.   Cullen has strangely
set down a shifting of the pneumonic pain from one side of the
thorax to the other, among  the prognostics of evil.  An exten-
sion of  this pain, so as to affect both sides  at once, is obviously
unfavorable; but  the metastasis or shifting that he speaks of, I 
h  PNEUMONIA.
265
have always found, when it has  occurred, to precede recovery
and produce more or less  relief.  We dread to  meet with any
exhaustion of strength  or failure of the pulse, while the breath-
ing continues embarrassed and painful.   All typhoid symptoms,
low muttering delirium, starting and picking in the air, coma,
with  dry tongue, and dry, hacking cough, portend a fatal issue.
Expectoration of considerable  quantities  of mucus  or muco-
purulent matter  are attended with relief; a slight, tinge of red
blood coloring it, betokens no evil, and seems sometimes indeed
productive of benefit;  but a brownish, rusty, and  foetid expec-
toration, is a gloomy presage.   A sudden gush of blood fol-
lowed by loud rale, a feeling of suffocation, and a sinking pulse
show the termination in pulmonary apoplexy.
   Serous effusion—hydro-thorax, and  sero-purulent effusion—
empyema, are to  be detected by their characteristic signs as above
described.  It has been suggested, as farther assisting us to dis-
tinguish between these two modes of effusion, that the suppura-
tive termination  of pleurisy is attended by a notable  remission
of pain, with rigors or  shivering fits, a sense of weight in the
thorax,  and often an observable fluctuation.  The  supervention
of abscess, chronic pneumonia, apostematous consumption, with
previous solidification  of the tissue, is known by the loss of
respiratory murmur  and resonance,  with  fixed  uneasiness in
some part of the chest.
   In the Treatment of pleurisy, it is to be  remembered, that our
purpose is single, and we must effect it promptly, or suffer the
alternative of local lesion and structural disorder.  The resolu-
tion of the existing inflammation—the subdual of irritation—the
removal of the attendant congestion :  these must all be accom-
plished  without  delay.   Each  of these indications  happily is
best fulfilled by  a single means ;  and by almost the unanimous
consent of the profession, venaesection is placed first on the list
of our remedies, both  in point of time and of importance.  If
called early to a patient of ordinary  strength and vigor, open a
large vein and suffer the blood to flow freely and  rapidly until
the quick interrupted breathing becomes fuller and deeper and
the pain subsides.   The  rule is clear  and plain.  The amount
to be  taken away is  limited by no considerations  but the effect
of such  depletion upon  the disease or  the  patient.   To prevent
       vol. n.—23 
266
PNEUMONIA.   »
syncope, seems to be an  object with  some practitioners, who
recommend the subject to be kept in a horizontal  position and
with his head low, in order that a greater quantity may be  ab-
stracted before fainting is induced.  For my own part, I observe
none  of these precautions.  I am not  aware  of any special
reason for seeking to take  away blood  aside from  its influence
on  the condition of the patient, nor of  any disadvantage to
result from syncope ; on the contrary, I should  rather suppose
this transient cessation or languor of vascular action, is favora-
ble to the diminution of the inflammatory excitement.  But you
will rarely meet with much disposition to faint  in any case of
pulmonary inflammation.   Marshall Hall has made  the  "tole-
rance of blood-letting" a test of inflammation generally ; it may
more  safely be regarded  as  such  in  thoracic  affections.  An
apparent exception may now and then present itself in a consti-
tution of highly  nervous  susceptibility, or as an  effect of per-
sonal  idiosyncrasy; but this is transient, and interferes with you
only on the first  attempt to bleed, after which you may repeat
the operation as soon and as often as you please.   It is not from
loss of blood, but from mental  emotion, that such  persons faint,
and therefore I would not hesitate, in the case of a delicate,
nervous woman,  to open the vein during her syncope, permit-
ting the blood to  flow when the circulation is restored.
  There was  formerly much  discussion  as to the preference of
one arm or the other for V. S. in  pleurisy; and  even Cullen,
§ 362,  is found  affirming, "that  the operation  will  be per-
formed with most advantage in  the  arm of the side affected."
"Perhaps," says the learned and somewhat pedantic Good, "per-
haps there is no disease in which profuse bleeding from a large
orifice may be so fully depended on, or has been  so  frequently
acceded to by practitioners of all ages  and all  nations—the only
question on  the  subject  being, whether the blood  should be
taken from the side affected, or from  the opposite.  The earlier
Greeks recommended the former—the Galenists and Arabians
the latter ; and the dispute, at  one time,  ran  so high, that the
medical colleges themselves not  being  able  to determine the
point, the  authority of the Emperor  Charles IX.  was whimsi-
cally appealed to, who, with much confusion to the controversy,
died himself of a pleurisy before he had delivered his judgment. 
PNEUMONIA.
267
  He, too, had been bled, and his death was immediately ascribed
  to the blood having been drawn from the wrong side."
    A more recent  controversy has  arisen as to the degree  of
  value, the actual efficiency, of the remedy.   Louis, in applying
  the "numerical method" of observation to therapeutics, came to
  the tabular result,  that very little  influence was exerted by the
  lancet in  subduing the symptoms  of pulmonary inflammation,
  or, at any rate, in shortening the duration of the disease, although
  so  far  as it had  any effect, it was favorable.   This startling
  conclusion is combated by Bouillaud, who accounts  for Louis'
  want of success with  this most  important therapeutical agent,
  by the  timid  and  insufficient mode in which  he  employed it.
  On the other hand, he declares vehemently, that the abstraction
  of blood, promptly, energetically, in  such amount and with such
  frequency as circumstances may require, will not only shorten,
  but arrest the disease,  and put an end, in many cases, at once to
  the  sufferings and risk of the patient.  I do  not hesitate to
  repeat these assertions of M.  Bouillaud.   I have many times
 arrested pulmonary inflammation, in its incipient stages, by the
 use of the  lancet  alone;  and have, more  than once, in more
 advanced cases, given  entire relief from  pain, and removed all
 danger, with  the  same instrument.—And it is by these and
 similar  remarks, published  by Louis,  much as  I  respect  his
 scientific knowledge and his persevering research, that my con-
 fidence  in the therapeutical  inferences to be drawn from  his
 numerical  or statistical method of enquiry has been shaken, if
 not  altogether overthrown.  You will find this question dis-
 cussed ably and forcibly by  Professor  Martyn  Paine, in  his
 "Commentaries."
   Not  only, then,  should we  bleed freely, as  above  directed,
 when called at the commencement of a pleuritic  attack, but we
 must repeat  the depletion as  often  as the pain and dyspnoea
 return or become pressingly urgent, and the pulse does not posi-
 tively forbid it.  This  may be twice, thrice, or even oftener, in
 the first twenty-four hours of the  disease;  the principle is per-
 fectly well-settled,  and the case  does not admit  of delay or
 vacillation.
  I must carefully  admonish you, however, that I am speaking
only of the  earlier  stages of the  malady.  When  some hours 
268
PNEUMONIA.
have elapsed, and the  pulmonary vessels have, by  distention
lost a portion of their tone and  elasticity, and  by the interrup-
tion  of the respiratory function, and the severity of his suffering
the patient has lost some of his strength and  vigor, it would be
unreasonable  to expect the  same prompt and salutary effects
from the use of the lancet.  Here it is not possible to correct, at
once, by it, as a revulsive, the established determination to the
lungs, or subtract, immediately, by it, as a means of depletion,
from the accumulation of blood in the thoracic vessels, without
drawing off so large a proportion of the vital  fluid as shall affect
the general system with prostration, and  perhaps the organs of
circulation with a failure of the  powers of action.  Under these
circumstances, we  open  the vein  and take away a moderate
quantity of blood, attentively watching the  effect.   If the loss
be well-borne, and the pain and  dyspnoea  still  continue severe,
we repeat, the  operation at an interval of  an  hour or two.  In
the meanwhile, we resort to topical depletion  by cups or leeches,
the former of which  I much prefer—and, in  this way, we shall
benefit  our patient very greatly  with little  risk.   The cups
should be applied over and near the seat of pain, and the appli-
cation may be renewed, from time to  time, as long as any acute
addition of suffering recurs on inspiration.  As soon as the arm
is bound up and the cups  removed, large warm poultices should
be laid over the chest, which indeed should be kept constantly
enveloped in them.   Next to  blood-letting, they constitute the
most ready means for diminishing pain and procuring comfort;
by the unremitting employment of them,  an  obvious  advantage
is almost always gained ;  they are doubly useful both as revul-
sives and diaphoretics.
  The next step to be taken, is the administration of a full dose
of Dovers' powder as an anodyne and sudorific.  Should the
patient sleep, I would  leave him  to his repose; when  he is again
disturbed, I would follow up the endeavor  to determine  to the
skin, by the  exhibition  of some  antimonial  preparation.  Of
these, the common tartar  emetic is the best.   It may be com-
bined, at first, with a cathartic,  calomel or the epsom salt, and
after  the bowels have  been  freely opened,  with  tinct: opii, or
alternated  with Dovers' powder.  I cannot,  indeed,  speak  too
highly of the latter  formula.   I  am  convinced, that there is 
PNEUMONIA.
269
 something peculiarly happy in  the  union of the ingredients of
 which  it is  composed, which  renders it not  only one  of  our
 most certain  and most valuable diaphoretics, but also one of  our
 safest.  Such was the  opinion, and such the  practice of Post,
 one of our most justly  esteemed physicians.  Such also  is  the
 judgment of  Paris,  who  says,  "it  may  be given with perfect
 safety and advantage  in  inflammatory affections  accompanied
 with increased vascular action.  It  would seem, that while  the
 opium  increases  the force of the circulation,  the ipecacuanha
 relaxes the exhalent vessels, and causes a copious diaphoresis."
 Whatever  may be its  modus operandi, its influence is, indeed,
 most salutary, especially when exhibited at bed-time and in  the
 night.  It determines to the surface, gives relief to pain, allays
 the  troublesome cough which harrasses  the  patient, and pro-
 cures for him quiet and refreshing sleep.
   Among other diaphoretics, I have already given a preference,
 in the first stage of the attack, to antimonials ; but I am not fond
 of using them  in  the contra-stimulant  mode in  ultra doses,
 whether we procure what is called a tolerance  of these doses, or
 excite, as some aim to do,  protracted nausea and occasional vom-
 iting.   Good, for example, advises the use of emetics in pneu-
 monia, and speaks  highly of the beneficial results of keeping
 up full vomiting for an hour or two at a time.   I should not be
 willing to subject a patient to a process so annoying  and  ex-
 hausting ; though I do  not imagine it to be so dangerous as Cul-
 len has pronounced it, unless in»cases of great debility, or nota-
 ble weakness of  constitution.
   If the stomach, as will  sometimes happen, refuse to bear any
 preparation of antimony,  we must  resort to other formulae.   A
 combination of jalap with the nitrat: potassae is much used, and
 seems well adapted to the  case.  A solution of  sal:  epsom in  the
 infusion of seneka or serpentaria, is a very common and excel-
 lent domestic prescription.  You have not, I hope, forgotten  the
remark made upon a  former occasion, of the propriety and  ne-
cessity  of  exhibiting  cathartics in  diseases of the thorax, so
much deprecated by the prejudices  of the olden time.   And  in-
deed we find writers, as well since as before the time of Cullen,
warning us solemnly against purgatives in pulmonary complaints
as having a tendency to check the expectoration, which in their
       23* 
270
PNEUMONIA.
views constituted the natural and exclusive solution of such in-
flammations.  Nay, we are cautioned, and by writers of some
authority too, against free bleeding in pneumonia vera, though
they are willing to permit it  in pleurisy, in which latter, they
suppose expuition or expectoration  to be  of less consequence.
You will find  their  speculative notions groundless, and their
distinctions  unworthy your notice.   These  evacuations,  as the
sagacious and experienced Cullen has satisfactorily shown, have
not in themselves, as thus assumed, any disposition to check the
salutary process of expectoration—but on the contrary, rather
promote  it when properly timed and  judiciously advised.  By
reducing the vascular excitement  and readjusting the disturbed
circulation, by equalizing the  various local determinations, they
relieve the  pulmonary vessels of an  oppressive load, and thus
 enable them  to resume their natural actions  and appropriate se-
 cretions.   The asclepias  decumbens of our country affords a
 very useful domestic prescription, and indeed has been supposed
 to possess  so partial an  adaptation to  the case before us, as to
 have obtained the name of "pleurisy root."   In strong infusion
 or decoction, of which  two ounces may be  taken three or four
 times a day, it proves an efficient sudorific.  Eberle speaks of it
 as "exerting a peculiar and almost specific action on the organs
 of respiration, powerfully promoting  suppressed expectoration
 and thereby relieving the breathing  of pleuritic patients."  It
 seems like  the seneka, to be best suited to that stage of the case,
 in which the arterial excitement  being in great measure sub
 dued, there still remains pain in  the  side or tension across the
 chest, with inability to draw a free or full inspiration, and a dry
 teasing cough.  Of the more stimulant diaphoretics, which become
 necessary  when any obvious degree  of exhaustion  or debility
 ensues, while the local irritation continues, the carbonate of am-
 monia is  the best.   The dose employed should be proportioned
 to the circumstances ; from  three  to  five grains will generally
 suffice.  If necessary, the camphorated  mixture will add to its
 efficiency in every way, or they may be alternated.  The nitrous
 aether is of similar  utility—but requires to be employed  in free
 doses—from one to two drams.
    The application of local revulsives and counter-irritants, must
 by no means be neglected.  I have already strongly advised the 
PNEUMONIA.
271
 assiduous application of large warm poultices in the first instance.
 To these, after a time, mustard may  be added; but when the
 constitutional irritation and febrile excitement have been suffici-
 ently brought  down, vesicatories  deserve  a decided preference.
 A large blister should be placed as nearly as possible over the
 seat of thoracic pain, and as soon as this begins to heal, another
 and then another  applied in succession, in  the neighborhood of
 the point affected.  I prefer this  method of employing them to
 the plan of keeping open  the first blister by means of stimula-
 ting dressings, so much in vogue.
    To relieve the troublesome and annoying  cough, which  so
 uniformly attends upon pulmonary inflammation, increasing  it
 and aggravating the sufferings of the sick man, it is  customary
 to administer a great variety of expectorants and cough mixtures.
 Some mucilaginous solution  is generally made  use  of as the
 basis of these—such as the infusion of slippery elm, of flax seed
 and of gum arabic ; such  also as  the solutions of liquorice and
 of lac ammoniac.   To these may be added,  with advantage,
 antimon: tart:  in small  doses, squill, ipecac: and colchicum.   I
 have seen little effect from  them  all, however, unless opium in
 some form be   mingled in the combination.  Spermaceti, which
 was until recently much  trusted to as a demulcent, has of late
 fallen  into disuse ; very unjustly I think, as it is one of the best
 of the class.   Powdered with a little nitrate  of potass and sugar.
 and with the  addition of a  little Dovers' powder, I  have seen it
 prove  as serviceable as any of them.
   Should the  attack be protracted,  much care  and  attention
 will be necessary to prevent the  supervention of some of the
 local lesions formerly described  as the sequelae or terminations
 of pleurisy.  In the transition from  the acute to  the chronic
 form of the disease, mercurials have been strongly recommended.
 I have seldom found them necessary; but if judged proper, cal-
 omel may be exhibited in small doses, combined with opium in
 some form—or this latter  may be  administered nightly in full
doses,  while during the day, we advise a formula consisting of
nitrat:  potass: and  digitalis  and calomel.  Here I rely much on
the good effect of blisters, which may be laid not only all around
the thorax but to the arm and forearm with obvious  benefit.
  The antimonials are also applicable here.   I prefer to add to a 
272
PNEUMONIA.
solution of tart: antimOn: such quantities of tinct: opii: or pare-
goric, as may prevent  any nausea or vomiting, and assist in de-
termining efficiently to the surface.   Under such circumstances
too, the colchicum, lobelia and digitalis are highly useful. They
may be given alternately, or in combination, a mode of adminis-
tering them that seems to increase very often the efficacy of each;
and in such dose as shall not disturb or oppress the stomach.
   I often  use with advantage a compound formula, containing
the tincture of sanguinaria  canadensis, with the squill in some
of its preparations ; generally preferring the ordinary syrup of
the shops.
   Should serous or purulent  effusion occur, constituting empy-
ema, or hydrothorax, it will be necessary to resort to the trocar,
and  evacuate the fluid contained within the sac of the pleura,
and mechanically impeding respiration.
   I have thus gone through, at some length, the  history and
treatment of acute  pulmonary inflammation, in its simple form.
It now remains for me  to say  a few words of a modification of
it, which you will probably often meet with.   In our low coun-
try, influenced probably by our warm climate and our miasmatic
atmosphere,  pleurisy frequently  occurs, complicated  with the
familiar symptoms of gastric and hepatic disorder, which have
obtained for it, with no impropriety, the name of "Bilious Pleu-
risy," and which imperatively demand a corresponding modifica-
tion of the management to  be pursued.  It is more especially
met with in our colored population, the mulatto rather than the
blacky and in  the cold  days of late  autumn, and early winter,
and in spring.  It is usually ushered  in with a distinct chill,
preceding or accompanying the  pain in the side, cough and
dyspnoea, that mark the access of respiratory disorder.  There
soon follows headache, with  gastric oppression, nausea, pain  in
the back and limbs, red eyes, turgid countenance,  quick full
pulse, and great thirst.  The tongue is furred and yellow; there
is a bitter taste in the mouth, with vomiting of bilious matter;
pain  in  the  epigastrium;  delirium.  Williamson,  the  historian
of North-Carolina, tells us that "bilious intermitting fevers are
Very prevalent during the autumn, in the level country near the
sea coast.   These intermitting fevers disappear as the winter sets
in, and are succeeded by fevers of a different type, that are more 
PNEUMONIA.
273
 fatal.  The fevers of this colder season are commonly attended
 by  symptoms of partial inflammation, whence they  are de-
 nominated pleurisies of the eye or of the head.  At other times,
 they affect the side.  In these several  forms,  they are equally
 dangerous."
   Cooke describes a winter epidemic  of this character, which
 prevailed in Greenville, on Tar River,  in February, March  and
 April.   "Some physicians," he says, "called it 'bilious peripneu-
 mony.'  The attack was made by chill or ague; before this was
 entirely worn off, a pain in the head, breast, side, or back, seized
 the patient.  These increased in violence as the fever came on."
   Of the Treatment.  The use of the lancet is by  no means
 so clearly or so uniformly demanded here,  as in simple pleu-
 risy, but I have found it, in a great majority of  cases,  highly
 serviceable to take away some blood, if the case were seen early.
 The pulse will generally be found to yield to a moderate bleeding,
 and a repetition of it will rarely be demanded ; but I  would not
 shrink from it. if the arterial action still ran high, and the dysp-
 noea and pain in the chest, or other  local disorder,  continued
 severe.  I am in the habit, in the  next place, of administering
 an emetic, preferring to unite the antimonial  with  ipecacuanha,
 rather than depend on either  separately.  We thus  relieve the
 stomach of its foul and oppressive secretions,  determine  power-
 fully to  the surface, and excite the pulmonary exhalents to a
 free expectoration.   The emetic should be followed by, or  per-
 haps combined with an active cathartic, which is absolutely in-
 dispensable.   "Purgatives," says Cooke, "were found  to be as
 necessary here, as in the summer and autumnal fevers, and the al-
 vine evacuations were of the same color, consistence and appear-
 ance."  The mercurials deserve a preference.   I employ calomel
 with rhubarb, or alternately with a solution  of epsom  salts—
 watching its effect and keeping a safe interval between the doses,
 so as to avoid the occurrence of ptyalism, to which inconvenience
 in these  winter diseases, it is seldom, if ever,  necessary to sub-
ject the patient.   We may in the meanwhile,  interpose the ad-
 ministration of the diaphoretics and expectorants, advised in the
 simple form of the malady, with this caution—that opiates are
 to be used in smaller amount, if there be much determination to
 the head; and if found to increase it, should be abstained from. 
274
PHTHISIS.
   Vesicatories must by no means  be  neglected;  they may be
applied early, and persisted in as long  as any thoracic  pain re-
mains.  Laid upon the epigastrium, they aid us in quieting the
irritation of the stomach; if  there be much pain in the eye or
head, the back of the neck, the skin behind the ears, the ankles
and wrists may be blistered.   In protracted cases, cinchona may
be used with benefit, both in infusion  with serpentaria, and in
the solution of sulphate of quinine,  which I often prescribe, add-
ing very minute doses of the acetate or muriate of morphine.
   Convalescence requires special care  and attention.  The  diet
should be light and nourishing.  The  patient should be well
guarded against all the influences of cold, moisture, and vicissi-
tudes  of weather.  He should wear flannel next  his skin,  and
for some time after his recovery put on  additional clothing, on
the occurrence of every change of temperature.   To a neglect
of these brief and simple precautions,  must we attribute a large
proportion of the cases of pulmonary consumption, which we are
called to prescribe for.  This remark applies more  particularly
to our slaves and colored population, generally, whose  thought-
less recklessness subjects them in a peculiar degree, to all the
physical evils that result from inconsiderate exposure.
                     CHAPTER  XL1I.

     PHTHISIS PULMONALIS.--APOSTEMATOUS PHTHISIS.

  We enter now upon the consideration of a subject which has for
ages vexed the minds of physicians of every country, and upon
which volumes have been written,  whose  contents consist in a
great measure of perplexed inquiries, unsuccessful experiments,
and disappointed hopes.  A full and complete discussion of this
important topic,  would consume an undue proportion of the time
allotted to us in  this place;  it must suffice  to bring before  you,
in as comprehensive a manner  as is consistent with perspicuity,
the views of such authorities as are most worthy  of our conn- 
PHTHISIS.
275
 dence, and to investigate  concisely,  the  several questions con-
 cerning the nature, history and treatment of this most formida-
 ble malady.  You will not wonder at the serious earnestness of
 these inquiries, nor  at the  number and weight of the names
 which are to be found in the list  of writers  on consumption,
 when you are informed of the extent of its frequency, and its
 proportional mortality.  According to an estimate made by Dr.
 Young, who has not been accused of exaggeration, one fourth
 of the inhabitants of Europe are carried  off prematurely, by the
 pulmonary diseases included under this  title.   Dr. Woolcombe
 calculates the annual victims to its  ravages in Great Britain at
 fifty-five thousand.
   All agree in  attributing to it a singularly unmanageable obsti-
 nacy ;  most pronounce it, in its genuine or exquisite form, be-
 yond the control of medicine.  Bayle declares  it to be impossible
 for any one to recover from it;  Laennec, while he coincides in
 the opinion, as founded on just and correct views, yet believes,
 that in a few rare cases, to use his own expression, it is curable,
 and has been cured.   Parr affirms, that in an  extensive experi-
 ence of thirty-five  years, he had  "seen but  six  instances of re-
 covery from phthisis, and these were spontaneous," in his own
 words, "perfected  by nature."  Good avers, that he "has seen
 phthisis terminate  favorably once or twice," whether from the
 treatment pursued, or a remedial exertion of nature, he does not
 undertake to determine.
   Phthisis pulmonalis has long held the first  place  among the
 opprobria medicorum, and every  effort of the  profession to re-
 move this stigma, has been hitherto in vain.  Every year, how-
 ever, some new remedy is proposed, which is for a while ex-
 pected to perform  wonders in our favor, but  each  in turn is
 abandoned or neglected, and we fall again into  the  gloomy de-
 spondency which must always attend upon repeated failure.
   Yet the prospect has  been somewhat brightened  within the
 last quarter of a century.  Not to speak of the  essays of living
 writers, of whose value time will bring the  true test, I refer to
 the labors of Bayle, Duncan, Laennec,  and our own country-
man, Rush, whose  eager enthusiasm and sanguine benevolence
 were always devising schemes for the improvement of our art'
and the advantage  of mankind—whose ardent zeal and hopeful 
276
PHTHISIS.
anticipations, no difficulty could check, no disappointment darken.
It requires little of the spirit of prophecy to predict, that if ever
we acquire a knowledge of means, by which phthisis shall be
transferred  to  the  catalogue of  curable  maladies,  it will be
through the exertions of some future practitioner, no  less zeal-
ous and enthusiastic than Rush, and endowed,  like  him, with
an almost unlimited confidence in the resources of nature against
physical evil.
  With him, indeed, I believe that we  have as yet possessed
ourselves  of but a small proportion of these resources, and I am
so far an optimist, as to expect that  the period will come  when
all diseases  shall be numbered among  the curable.  At the same
time I cannot but smile  at the vain imaginations of those, who
dream of  the arrival of an  era when the only outlet of life shall
be the decay of old age.  Men die now, in vast numbers, every
day, of diseases actually in their  own nature curable, as may
readily be seen by reference to any bill of mortality, and  as has
been noticed and discussed by Rush, himself, in an interesting
little essay.
  It is of the first  consequence to distinguish  accurately, how
we are to limit and apply the term Phthisis.   Under this dreaded
name, have been included  diseases of the most heterogeneous
nature and  tendency.   Simple catarrh,  bronchitis,  chronic he-
moptysis, chronic pneumonia, the  climacteric  disease so ably
described by Sir Henry Halford, syphilitic affections of the chest,
and tubercular or scrofulous  disorganizations,  are  all alike de-
nominated consumption, decided on under the  same  prognosis,
and treated by the  same remedies.
   Rush, deluded by his peculiar notions of the  unity of disease,
talks loosely of phthisis, as distinct and separable from any local
affections or lesions of the  lungs, such as cough, abscess,  tuber-
cles, etc., which  he numbers, to use his own language, "among
the effects of consumption."  There has, however, been no want
of  divisions and subdivisions on this subject;  on the contrary,
 they have been multiplied by nosologists, to an almost indefinite
 extent.   Portal, for example, gives fourteen species of phthisis,
 Sauvages, no less than twenty.
   From this mass of  error and confusion, we have of late been
 extricated by the labors of a few distinguished pathologists, to 
PHTHISIS.
277
whom must be offered the gratitude of our  profession and of
mankind.   One of these,  the venerable Dr.  Duncan, of Edin-
burgh, in the seventieth year of his age, published a treatise on
pulmonary consumption, containing many valuable observations.
In it he suggests the  distinction of phthisis into three species—
the catarrhal, apostematous,  and  tubercular.   These  present,
when fully developed, a great number of symptoms in common,
cough, dyspnoea, purulent expectoration, hectic fever,  atrophy,
emaciation, etc.  Yet there are many points of essential dissimi-
larity, which, as he says,  may be known and discerned without
difficulty, during the life  of the patient, and serve, therefore, as
better bases of distinction than such as are discoverable only on
examination after death.
   The first named of these, catarrhal phthisis, is, as you were
formerly told, nothing more  than  chronic  bronchitis,  and has
been numbered among the forms of consumption, for the  obvi-
ous reasons, that after a certain duration of the disease,  purulent
or muco-purulent matter is expectorated,  and hectic fever is de-
veloped, with atrophy, etc.  The importance  attached  to the
first of these conditions,  caused an earnest  search  to  be made
for tests by which pus could be clearly distinguished—that by
its presence it might be known when catarrh had become con-
sumption.   Among the great number of these,  which  you will
find proposed in the  books, Sir  Everard  Home's and Wilson
Philip's are best suited to practical purposes in  a  sick chamber.
The latter tells us, that he judges from the  cream-like appear-
ance of the matter, and its sinking in water, when so agitated as
:'to separate it from the tough mucous with which it is mixed."
To these, Home  adds, that it is not homogeneous,  but "com-
posed of globules, contained in a transparent  liquid, and that it
does not coagulate by heat, and is  only condensed by  alcohol."
While the expectoration of pus was regarded as conclusive evi.
dence of the existence of an ulcer or abscess in the lungs, these
experiments were deeply interesting; but at the present day, when
purulent secretion is  known to take  place,  from  the unbroken
surfaces of membranes, and even within the vessels  themselves,
they are little attended to.
   It remains then, for us to speak in due  order, of  the second
       vol ii.—24 
278
APOSTEMATOUS PHTHISIS.
and third varieties of consumption recognized by Duncan, the
apostematous and the tubercular.

  Apostematous Phthisis  derives its  designation  from  a
Greek word, (apostema,) signifying abscess, and is intended to ap-
ply exclusively to those cases in which the disease depends upon,
and is obviously connected with the formation of  one or more
abscesses, or (to use a phrase of Celsus, which has become, in
later times, technically appropriated to the  lungs,)  "vomica;," in
the pulmonary substance.  Of the tubercular, the name of which
carries with it its own  explanation,  we shall treat  hereafter.
Suppuration of the lungs, the formation of true  abscess  within
these organs, was mentioned among the  occasional sequelae, or
terminations of pneumonitis and pleuro-pneumonia; and though
less frequent, no doubt, than the other varieties of  consumption,
so called,  is now and then met with, chiefly as the consequence
of neglected, ill managed, or imperfectly relieved attacks of acute
pulmonary inflammation.  It is said  to  have occurred, as the
effect of external violence,  from a blow, a fall, etc.; it may be
brought on by a penetrating wound of the thoracic cavity.  Its
comparative frequency, is matter of positive contradiction among
pathologists.   "It is  very common,"  says  Baillie,  "to find ab-
scesses  in the lungs.  These sometimes consist of small cavities,
containing pus; and at other times, the cavities of the lungs are
very large, so that the greater part of the substance of the lungs
has  been destroyed.   These cavities sometimes  communicate
only with branches  of the trachea, which  are destroyed in the
progress of the ulceration."  Duncan also  affirms,  that "an in-
flammation of the thoracic viscera terminating in a state of sup-
puration, is, perhaps, as  frequent as a similar termination from
inflammation of any other part."  Contrast with these, the opin-
ion of  Cullen, who  declares, that  "a phthisis from  a suppura-
 tion, in consequence of  pneumonic  inflammation, is that which
 most rarely occurs in the  climate of Great  Britain"—and the
 testimony of  Laennec, than whom no single  authority carries
 more weight, on any point of pathological anatomy: "The forma-
 tion  of an abscess," he  tells us, "or a collection  of pus in the
 substance of  the lungs,  as a consequence of inflammation, is an 
apostematous phthisis.
279
  extremely rare case, at least a thousand  times rarer than a case
  of empyema."   I do not intend to  represent apostematous
  phthisis, as a form of  disease ordinarily  to be encountered; but
  as far as my observation goes, Laennec's expression contains a
  great exaggeration.  It has not been my fortune, in more than
  twenty year's  practice, to meet with more  than  a very few in-
  stances of empyema.   I have witnessed the origin, progress
  and termination  of many cases of pulmonary abscess, some of
  them of the most unequivocal and well  ascertained character.
    Rush, who  confuses together  all the  forms of phthisis, de-
  clares "the two  diseases, pneumonia and phthisis, differ from
  each other, only by the shorter or longer operation of the causes
  which induced them, and by  the greater or less violence and
  duration of  the  symptoms.  The pneumony appears  to  be an
  acute consumption, and the consumption a chronic pneumony."
  Limit the application of his remark to the instance now  before
  us, and its correctness will not be denied; but even Hippocrates
  recognized a distinction here, and considered the  disease, which
  consisted simply in the formation of abscesses  in the lungs, as
  something different from true phthisis.
   You are already aware in what manner, and  how  much it
 differs from  chronic bronchitis—Duncan's  catarrhal consump-
 tion, and the characteristic peculiarities which separate it from tu-
 bercular, or true phthisis, emphatically so termed, are, if possible,
 still clearer and better defined.   Apostematous consumption, or, if
 you will, chronic pneumonia, is, in its origin, a merely local affec-
 tion,  gradually involving by its continuance the general system,
 which ultimately sinks  under the lesion of one  of the most im-
 portant organs, and the  constitutional irritation, exhaustion and
 injury consequent thereupon.   On the other hand, tubercular
 phthisis is, as we shall show you, but a  partial development, a
 secondary manifestation in the lung of an all pervading diathe-
 sis, or mode of predisposition, which,  indeed,  in a very  large
 majority of instances, is well known previously, having been in
 early life developed, and manifested by other tokens, and in other
 organs and tissues.
  Chronic pneumonia, with the actual formation of pulmonary
abscess, may be occasioned  by the  application of some transient
cause, and the escape of pus from the cavity, when expectora- 
280
APOSTEMATOUS phthisis.
ted, may be at once followed by the restoration of perfect health.
The formation of tubercles, on the  contrary,  never being the
result of any temporary contingency, we are not allowed to look
for sudden or quick recovery, but rather as they are almost uni-
formly deposited in groups, large numbers, or considerable masses,
the melting down or elimination  of any  one, affords  us very
feeble hopes for  our patient;  perhaps,  indeed, always giving
reason to expect a successive growth and development for inde-
finite periods.
   Apostematous  phthisis, the  consequence generally  of acute
pneumonitis, is most usually caused by the circumstances form-
erly enumerated, as giving rise  to  pulmonary inflammation;
exposures to cold, moisture, or vicissitudes of temperature, among
which,  I must not omit to specify the habitual imprudences com-
mitted by the young and gay, during the  winter, the season of
social pleasure, in encountering the keen air of midnight, when
warm from the dance, or from confinement in the close limits of a
heated parlour or a crowded drawing room.  The delicate slip-
per and thin silk stocking, permit the lower extremities almost
instantly to become of an icy coldnesss, while  the throat and bo-
som are but half protected; the bronchial membrane is irritated by
the sharp,  chill breath inspired, while  congestion of the blood
repelled from the limbs, is solicited to the thoracic viscera; and
the victim of merciless fashion or of misguided taste, becomes a
 ready prey to the destroyer.  "An abscess in the lungs," says Rush,
 "is generally the consequence  of a neglected or half cured pneu-
 mony."  I would rather consider it, as in  truth it is, itself a half
 cured or less than half cured pneumony.
   It is, however, and not very rarely, I think,  to be met with as
 occurring  primarily, in  the chronic form, and  unpreceded  by
 acute pulmonary inflammation.  Loud or long continued speak-
 ing or singing, and playing habitually  upon  any  wind instra-
 ment, will gradually bring it on.  A variety of mechanical irri-
 tations will develope it; millers, cotton ginners, coal diggers and
 heavers, needle grinders, knife, scissors and scythe grinders,  are
 all liable to it, on account of the  inhalation and  gradual accu-
 mulation of particles of dust from grindstones, steel, grain, motes
 and coal, within the cells of the lungs.  Authors enumerate on
 this list of causes, the sudden suppression of eruptions, as of the 
APOSTEMATOUS phthisis.
2S1
 itch, etc.  Good declares, that it has  more than once  happened
 in his own observation, that the lungs have been  attacked du-
 ring the cure of cutaneous affections, even when no hasty mode
 of treatment had been pursued.   Chronic pneumonia is fairly to
 be reckoned among the sequelae of measles and small pox;  in-
 deed, in all the deaths I have seen, of this last pestilence, the
 pulmonic symptoms became ultimately  of paramount  import.
 I  do not, however, regard this as a metastasis, but as an extension
 and progressive development of disease.
   The stoppage of any habitual  or periodical discharge, has
 been supposed to give  rise to it, as of the menstrual secretion
 and the hemorrhoidal flux.  The same is  asserted  of the irrita-
 tion of particular diseases, as asthma, worms,  and syphilis, he-
 patic and gastric  disorders.  Indeed, Wilson Philip considers
 the latter as so directly active in the production of pulmonary
 disease, that he has designated, as deserving the title, a large class
 of such cases, under the name of dyspeptic phthisis.  An elongated
 uvula, by keeping up an annoying irritation in the throat, with
 a tickling and violent cough, has been suspected of becoming a
 source of chronic pulmonary inflammation.   To our illustrious
 countryman, Dr. Physick, is due the credit of directing  the no-
 tice of the profession to this evil and to its  remedy—the ampu-
 tation of the uvula;  although it has been  unjustly claimed  in
 France for a Mons. Cuynat.
   "One of the most frequent causes," says Duncan, "from which
 an abscess in the chest derives its origin, is an haemorrhage
 taking place from the  lungs."  Influenced by a similar  notion,
 Cullen has arranged phthisis, in his System of Nosology, not  as
 a proper genus of disease, but as a mere  sequela of hemoptysis.
 It is alleged,  "that suppurative inflammation more frequently
 happens as a consequence of haemorrhage from the lungs, than
 from any other part  of the  body, probably because of the con-
 stant  state of  action  to which these organs  are subjected  in
 respiration."
   Now it is  not found that wounds  in the lungs are peculiarly
difficult to heal—nay, the contrary is asserted by some of the
best authorities.  Rush did not recollect a single  instance in
which consumption followed a wound in the lungs, either by a
bayonet or a bullet, during the revolutionary war.   He quotes a
       24* 
282
APOSTEMATOUS PHTHISIS.
British officer as stating that the Surgeon General had reported
twenty-three cases cured, out of twenty-four of soldiers admitted
into the hospital with wounds of the lungs.   I have myself seen
two instances  in which phthisis  followed  gun-shot wounds of
the chest.   One died, after  lingering nearly a year;  the other
recovered at last from a still more protracted illness.  Hemorrh-
age from the lung is by no means, in a majority or even in  any
laro-e proportion of instances, followed by abscess.  The King
of Prussia was subject to it during his famous seven years war,
yet he lived in  good health  twenty years after.  In the lecture
on hemoptysis, I have  spoken of many similar examples.  My
own opinion on the subject is, briefly, that even when abscess
does follow pulmonary  hemorrhage, they do not stand in  the re-
lation of cause and effect to each other ; both being more proba-
bly coincident effects of some common cause.  When pneumo-
nitis supervenes suddenly, and  with violence, the engorged  ves-
sels distended by the disproportionate quantity of blood deter-
mined to them during the early periods of irritation and conges-
tion, will be apt,  especially  in  plethoric subjects and in a mal-
formed thorax, to yield and pour  out  their contents.   Under
these circumstances, the hemorrhage  is certainly not to be re-
garded as the source of the attendant or consequent inflamma-
tion ;  nay, it may even  prove salutary,  as a mode  of local
depletion, in a  constitution vigorous or not otherwise  defective.
   As to the suggestion that the respiratory motions prohibit the
healing of a ruptured blood vessel, I reply, that hemorrhages are
not generally the result of  any laceration  or solution of conti-
 nuity ; that abscess is always preceded by the solidification  of
 the pulmonary  tissue ;  and that the lungs, being capable of  con-
 taining ten times  as much air as is received by an ordinary ef-
 fort of inspiration,  each portion of the pulmonary tissue, among
 the cells of which it is  diffused, must undergo very little motion,
 and the hepatized or consolidated portion least of all.  •
    I formerly described this condition from Laennec.   Baillie
 tells us, that "the lungs round the boundaries of an abscess  from
 common inflammation, are  rendered more solid in their texture,
 in consequence of coagulable lymph being poured out during
 the progress of  the  inflammation.  When blood vessels are
 traced into an abscess,  I have found them very much contracted 
APOSTEMATOUS PHTHISIS.
283
 just before they  reach  it; their  orifices have  been closed up
 entirely ; so that it will require a probe to be thrust with a good
 deal of force, to open again their  extremities.  In these contract-
 ed  vessels, the  blood is  coagulated, as  it is in similar circum-
 stances in other parts of the body."
   One of the first symptoms of apostematous  consumption,
 when it is not the  mere  protraction  of acute  pneumonitis, is
 usually a sense of uneasiness, soon amounting to a fixed heavy
 pain,  in some part of the chest.  Acute lancinating pangs are
 occasionally felt in the spot, in most cases ;  and not unfrequent-
 ly a pulsation or throbbing.  A full inspiration cannot be taken
 without difficulty, and the dyspnoea is increased in the horizon-
 tal posture. Some patients cannot lie on the side affected ; others
 cannot turn upon the sound  side, without coughing and uneasi-
 ness in breathing; others lie only  on the back. I have noted these
 facts simply  as such, and  confess myself unprepared to account
 for the selection of different positions in the different cases.  The
 exact seat  of disease is known,  not only  by the  complaints of
 the patient, but definitely  by accurate exploration ; there is want
 of resonance on  percussion, and  loss of respiratory murmur in
 the earlier stages.   After the abscess  is ruptured, auscultation
 shows want of murmur, and pectoriloquy;  and percussion ex-
 hibits restored and even undue resonance.  There is cough, the
 paroxysms of which are severe though not frequent, and accom-
 panied with no expectoration, or  with  the spitting of but  little
 mucus, until the vomica has burst.   This ev^nt  is usually
 brought about by some  violent fit of coughing, and attended or
 preceded by  acute pain in the chest, and some slight discharge
 of bloody  mucus.   The  quantity of pus discharged will vary
 from ounces  to pounds—not unfrequently threatening, and some-
 times actually occasioning suffocation.  I have seen a quart(lbij)
 of pus brought up from the lungs in the course of an hour, with
 much  difficulty and danger.   I have also seen two patients die
 exhausted, in the vain struggle thus to discharge the contents of
 a newly ruptured abscess.
   This free  and large  expectoration  commonly gives  a good
degree of relief to  the  pain, dyspnoea, cough and other symp-
toms, for a time at  least;  and  in  some few, effects their entire
removal, the patient recovering  without further impediment. In 
284
APOSTEMATOUS PHTHISIS.
the great majority,  however, there continues cough with ex-
pectoration of similar purulent matter, which gradually degene-
rates, becoming of a thinner, more serous consistence, assuming
a reddish tint, and an offensive odor.  The sputa are now and
then tinged for a while with  a little blood ;  but this soon disap-
pears.   It is about this period that hectic fever supervenes ; the
voice becomes hoarse and weak ;  the  patient loses  strength ; is
evidently emaciated,  and is liable to sweat much at night.  For
the most part, his digestive  powers continue unimpaired until
near the close of life ; his appetite is  good and his bowels regu-
lar ; towards the last, an irritating diarrhoea attacks him and
prostrates him rapidly.
   The tongue corresponds  with  the  digestive system in condi-
tion.  Until diarrhoea appears, it is natural;  it is then preterna-
turally smooth and red,  as if covered like the lip, with a  deli-
cate epithelium.   It often chaps, and is covered, as are the cheek,
the lip and all the lining membrane  of the mouth, with white
aphthous ulcers.   The pulse is usually small, corded, tense and
frequent, from one hundred and twenty to one hundred and fifty.
   The duration of this form of phthisis varies according to the
degree and extent of the pulmonary inflammation, and to the
powers of resistance  of the patient's constitution.   It  sometimes
terminates fatally in  four to  six weeks; this the  vulgar call ex-
pressively "a gallopping  consumption."  More commonly, how-
ever, it is protracted for  months;  it may be for years ; the sys-
tem gradually yielding to the permanent injury inflicted on an
organ whose  functions  are  so necessary to health, or sinking
under the irritation of extending inflammation and the formation
of successive vomicae.  It should be added, that after a time it
almost  always happens  that the  bronchial membrane becomes
diseased also, and  the sufferer has to contend with the complica-
tion of chronic bronchitis.
   Rush  relates the case  of a  lady who was seized in 1785, but
who lived two years.  This case was  remarkable  for the  fact,
that for some months  immediately  preceding  death,  neither
cough nor fever were present, the pulse being natural  to the
last, a circumstance which, indeed, he records  in  four cases of
phthisis.  Post-mortem examination of this   subject showed the
right lung almost  totally destroyed, and its space  occupied  by a 
APOSTEMATOUS PHTHISIS.
2S5
 large abscess.  It is difficult to account for the absence of cough
 under such circumstances, yet Rush gives us  another example
 of it, and I shall have occasion to speak of a case of tubercular
 phthisis, the true nature of which, from the total absence  of
 cough and dyspnoea, was never suspected until the death of the
 patient gave us  an opportunity of ascertaining the state of the
 lungs, which were mere masses of disease.
   Prognosis.   In point of curability,  the  apostematous form  of
 consumption may be said to hold a middle station between the
 catarrhal and tubercular.   Yet it is not easy  to give a reason for
 the acknowledged fact, that the proguosis is  so generally unfa-
 vorable.   We have already considered the chief alleged difficul-
 ties  in  the way, of recovery—the unceasing movement of the
 lungs in respiration, and  the  peculiar laxity of their  tissue.  I
 would ascribe more influence  to the  nearness of the point in-
 flamed, to the centre of circulation, and the vehement force with
 which blood must therefore be driven  into the diseased vessels.
   The individual prognosis will depend much upon the previ-
 ous state of health of the subject affected. If young and robust—
 if attacked after sudden exposure, or the application of any tran-
 sient cause—if well-formed  about  the chest, he may probably
 recover.   On the  other  hand,  if his  thorax be contracted or
 misshapen—if he have shown previously a particular liability to
 pulmonary disease, cough or catarrh—if he have been subject to
 hsemorrhagies,  epistaxis especially—if he be of weakly habit, or
 defective in muscular vigor, he will scarcely be able to sustain
 the attack, though he may linger long.
   It is usually considered, that a strong predisposition to any of
 the forms of pulmonary disease, is found in persons whose tho-
 rax is narrow, or  flat, or in any manner ill-shaped, or contracted
 in original capacity, or who have brought on a similar artificial
 contraction by  habits of stooping, slouching  the  shoulders, sit-
 ting in a bent position, etc.  I have mentioned above, the  true
 influence, I think, of such conditions.  It is doubtful whether
 they render the subject more liable  to  the attack of pulmonary
 inflammation, but they obviously diminish his chance of reco-
 very from it, when it has  occurred.   No unfavorable prediction,
you ought to be aware, is  to be founded upon the expectoration
of pus or purulent matter  only.  Nay, this is, perhaps,  a  means 
286
APOSTEMATOUS PHTHISIS.
of relief, and, it may be, the first step of convalescence.   Some
patients die before the bursting of the abscess, in which case we
derive warning of their fate from the extent of the local disease
as ascertained on exploration—from the degree of impairment of
the respiratory function,  the dyspnoea and  pain  suffered, and
from  the effects  on the general system, as  displayed in fever,
diarrhoea, and colliquative sweats.  Cullen estimates the danger
of the patient sagaciously, when he tells us, that "from a certain
degree of emaciation, debility, profuse sweating and diarrhoea,
no person recovers."
   I take  this occasion to remind you of the risk of error in
depending exclusively upon the results of physical exploration
of the thorax.  Some constitutions are fatally irritated and ex-
hausted  by an  extent of local lesion from which others may
readily recover.
   The Diagnosis of apostematous phthisis does not appear to
me to be difficult.   In the first stage, the extent and intensity of
the impairment of resonance and respiratory murmur will mark
it specially—in the second, the sudden escape of notable quanti-
ties of purulent matter, and pectoriloquy, may be common to it,
with  the  tubercular variety; but  in the latter, there is little
relief or apparent improvement immediately following, whereas,
if the case be simply one of suppurative pneumonia, the effect is
striking,  and the patient seems almost at once to become conva-
lescent upon the bursting of the apostema, if he possess strength
enough—that is,  to expectorate  completely  the effused  fluid.
Besides this, the suppuration around a tubercle rarely accumu-
lates to any large amount.
  Autopsy.   The  appearances  on  examination,  post-mortem,
have  been already incidentally described.  The  consolidation
or hepatization of the pulmonary tissue—the deposition of or-
ganizable lymph;  its vascularity, shown in its red and granula-
ted aspect—the cyst or lymphid lining of the abscess—the ob-
literation of the vessels—the thickening of the mucous bronchial
membrane in the neighborhood—the melting  down  or  absorp-
tion of the  substance of the  lung, have all  been spoken  of.
Sometimes,  as Baillie affirms, the cavity of the abscess will be
found communicating with  the sac of the pleura, thus compli-
cating apostema with empyema.  In cases of recovery, the pul- 
APOSTEMATOUS PHTHISIS.
287
 monary  excavation  seems to  be filled up  with  organizable
 lymph, which assumes a fibro-cartilaginous structure and firm-
 ness.
   I have mentioned,  that both  Laennec and Andral declare the
 occurrence of circumscribed abscess in the lung to be rare.  In-
 filtration of pus within the consolidated or hepatized mass, and
 its diffusion through the  pulmonary tissue, they represent  as
 more common, and suggest, that  the vomicae described by pa-
 thologists, Baillie and  others, were chiefly tubercular.  Be this
 as it may, the formation and deposition of pus, as the result of
 mere inflammation, constitutes the essential characteristic of the
 case before us, as contra-distinguished from the deposition  of
 tubercle or tubercular  matter—the latter  indeed being, as we
 shall hereafter see, met with, like  pus, in  both conditions, dif-
 fused and circumscribed within  cysts.
   The Treatment of apostematous consumption is fairly and
 naturally divisible into  two stages;  the first, comprising the
 whole duration of the attack previous to the effusion of pus in
 the lungs, and  the rupture of  the abscess containing  it; the
 second, consisting of  the management necessary after the burst-
 ing of the vomica and the discharge of its contents have  oc-
 curred.
   The indication, in  the first instance, is to prevent,  if possible
 the formation  and maturation of abscess—in  other  words  to
 resolve the present inflammation ;  and this will be best accom-
 plished by the prompt and assiduous employment of  the means
 calculated to reduce local excitement  and general vascular ac-
 tion.   But, in the use of these means, we must be guided and
 restrained by a due consideration of the condition of our patient.
 The pulse is, in chronic pneumonia, often small and contracted,
 but at the same time tense, corded  and  frequent, and will bear
 depletion well.   When it can be borne—and in  almost every
 case it will be proper to make the trial—venaesection is one of
 our most appropriate and  efficient remedies.   You will find
 interspersed throughout the writings on consumption, numerous
cures by blood-letting, almost every one of which may be fairly
 inferred, from the records, to have been of this apostematous or
simple  pneumonic form.  Dr.  Dover,  the inventor of the cele-
brated powder which bears his name, carried this practice to a 
288
APOSTEMATOUS PHTHISIS.
great extent, repeating the operation, as Good tells us, in certain
cases, not less than fifty times in succession.   Rush mentions a
case in which it was urged  still farther by a physician of Con-
necticut, who bled his patient, with ultimate success, eighty-five
times in six months.  He himself used the  lancet, in one  in-
stance, fifteen times in six weeks, with similar benefit.  He also
affirms, that he had seen two cases in which "large haemorrh-
ages from the lungs were followed by perfect cures of the pre-
viously existing consumptions."  I do not propose these frequent
venaesections and abundant abstractions of blood  as  examples
for your  guidance ; but I would be understood to say distinctly,
that the evidences of  debility must be clear, indeed, and urgent,
to justify me to myself in withholding the lancet, in the disease
under discussion.  Even where all hopes of  a  cure are denied
us, blood-letting will often relieve, in a  singular manner, the
sufferings of our patients, who become so  sensible of this, that
I have known more than one instance in which the last words
uttered expressed  a  desire to  be bled.  Moderate bleedings,
repeated at intervals, have seemed to me best adapted here, and
may be aided very much in their good effects by the application
of cups to the chest, or leeches.
   The cups,  which  may be employed safely and usefully in
cases where general depletion is forbidden, should be placed as
near the seat of the disease as possible, and are farther servicea-
ble, as  revulsives, when used without the scarifier—dry cupping.
We carry out this effort at revulsion still more effectually by the
successive application of repeated blisters.  These  I  regard as
among the most promising remedies in chronic pneumonia in all
its stages ; the whole thorax  may be vesicated, portion by por-
tion—the upper part of each  arm, the back of  the  neck, the
forearm  and wrist.
   I have seen chronic pneumonia, exhibiting  every tendency to
the formation of pulmonary abscess, arrested, in many instances,
by these means alone, and hence have learned  to place very
great  reliance on the  constant  action of  repeated  vesicatories,
after proper venaesection has been premised.   Issues and setons,
so highly eulogized by many physicians, seem  to me by no
means  so efficient  or trustworthy—a remark which  applies
equally to the pustular irritation of tart: emetic—of Croton oil, 
                 APOSTEMATOUS PHTHISIS.              289

etc.  I would resort to these inferior applications  when the
occurrence of obstinate strangury  prohibited the use of the
blister, or when  the want of fortitude of the patient  denied me
its free employment.   In the meanwhile, an occasional cathartic
or mild laxative  may be administered to keep the bowels in an
open and soluble condition, though no advantage is to be gained
by active purging.  If the light diet  proper to  be exclusively
taken, do not answer our purpose, a small dose of sal: Epsom
may be exhibited, or a little castor oil, or a blue pill, at distant
intervals.
  Emetics have  been very generally prescribed in apostematous
phthisis—in different stages  and by different practitioners with
different views.—At first to procure  the resolution of pulmonary
inflammation ; next,  to rupture the cyst and discharge the con-
tents of a  mature vomica;  and, lastly,  as  an  expectorant,  to
promote the free expuition of  the secreted matter after the ab-
scess is open.  Ipecacuanha, the tartarized  antimony, and the
sulphate of copper,  are preferred.    I  spoke formerly of the
contra-stimulant use  of tartar  emetic in large doses by  Laennec
and  the Italians, as powerfully promoting absorption and resolu-
tion.  The sulphate  of copper is selected by those who  wish for
the concussion of vomiting with  little nausea or depression—
and  ipecacuanha is regarded as peculiarly expectorant and dia-
phoretic.   The  "dry vomit"  of Marryatt, compounded  of the
two  latter,  and so called because during its operation  all fluid is
forbidden, has been  very strongly  recommended.  To  derive
the full advantage from emetics, we are advised to repeat them
almost daily for some weeks.   Chapman speaks well of the plan,
and  affirms, that he has seen it productive of cures.  Rush, on
the other hand, declares his belief, that "vomits have  done more
harm than  good."  Diaphoretics are almost universally admin-
istered, and are capable of doing good service.   At first we use
the sedative, as the antimonials, with  or without the nitrate  of
potass:—next, the infusions  of  seneka and  serpentaria—then
carbonate of ammonia and camphor.  The Dover's powder is the
best  of them all, however, and should be taken nightly in full,
free  doses; it is  sudorific, expectorant, and pleasantly anodyne.
  The use of mercurials in any of the varieties of pulmonary
inflammation, whether  acute or  chronic, has been vehemently
      vol. n.—25 
290
APOSTEMATOUS PHTHISIS.
deprecated by many practitioners.  I have already announced
an opinion favorable to their  slow and cautious exhibition in
chronic bronchitis, and the more recent authorities, both French
and  English, promise us  much  advantage from them in the
kindred affection, known under the title of Laryngeal Phthisis.
In the  case under discussion, simple chronic pneumonia, their
value is the same.   It is observed by  Wilson Philip, speaking
of what he calls dyspeptic phthisis, which is almost universally
apostematous, that "there is no case in which the benefits arising
from the exhibition of mercury, in minute doses, are more con-
spicuous."  I would  advise, however,  that they be prudently
administered, so as to avoid the excitement of an irritating and
annoying  ptyalism.  I  usually prescribe half a grain of mere:
dulc: night and morning, with such other medicines as circum-
stances require, commonly combining it with opium.
  In the second stage of apostematous consumption, when pu-
rulent effusion has taken place, and expectoration of pus shown
the rupture of  an abscess, it  is not easy to lay down  specific
rules for the management of the case.  You must be careful not
to infer the existence of a cavity merely from  the fact, that the
sputa consist of muco-purulent matter.  There may be present
nothing more than bronchial inflammation.   It  is true, that
where a large amount of such matter is suddenly and at once
thrown out,  an accumulation must have  been taking place.
But  the abscess  may be  small,  or  the  opening from  a  large
cavity to the air-tubes  may be such as to admit of but a slow
escape  of its contents,  a case actually  described by  Duncan,
and  the judgment, from quantity, may  be very indecisive.  It is
asserted by Laennec, that even when  an abscess exists, the
purulent  sputa  are furnished in greater proportion from the
mucous membrane of the bronchi, than from its cavity.
  The partial escape of matter from a vomica renders it easy to
ascertain  the condition of the patient by careful exploration ; it
is not  so clear where  the mere infiltration of the pulmonary
tissue has taken place.  In the  first instance, a  return of reso-
nance will be  noted, and  pectoriloquy will be heard.  In the
latter, if expectoration of the  matter poured into the tissue go
on faster than it is filled, a cavity will be formed with the above
phenomena.   If the fluid fill the cells or the consolidated tissue, 
                   APOSTEMATOUS PHTHISIS.              291

  of course there will be neither resonance, respiratory murmur,
  nor pectoriloquy.
    The indications now presented are, to obtain a free expecto-
  ration of the effused matter—to promote the  filling up of the
  secreting cavities and the healing of the ulcerous  opening, and
  to obviate the evil influence of the pulmonary lesions upon the
  general system.  In a large proportion of the cases, the  sponta-
  neous expectoration is sufficiently free, and the cough, though
  frequent, unattended with  pain.  If the local inflammation con-
  tinue or progress, however, there will be complained of  a sense
  of tension or constriction across the chest, and the cough will be
  dryer  and  more harrassing;  or  if, on  the  other hand, the
  strength of the patient  fail greatly,  he will  not cough  with
  sufficient force to spit up the  mucus and pus  from  the lungs,
  and will be threatened with  suffocation from debility.  This
  catastrophe I have witnessed  in two cases,  and have  seen, in
  others, a horrible struggle—not to  be looked upon without the
  most distressing sympathy.  These opposite  conditions require,
  it  is evident, directly opposite management.  In  the first, we
 must still farther deplete,  though  cautiously.  A small loss of
 blood, say 5 to  10 oz., will  often prove of immediate benefit.
 Cups may be laid to the side also, and  this  topical abstraction
 will be doubly useful by its revulsive influence.  Blisters should
 also be applied without delay and in quick  succession.   An
 emetic of ipecac: and sulph: cupri may also give great relief.
   Stimulant emetics which combine an expectorant quality, are
 also advised in  feeble and  debilitated subjects, such as seneka,
 squills, etc., but the  practice is of doubtful  advantage, as the
 patient may  sink under their operation.  I prefer to administer
 the stimulant  diaphoretics—the vol: alkali,  camphor,  nitrous
 aether,  with  wine whey, wine or  hot  spirits,  while poultices
 containing mustard are laid about the chest and  to the extremi-
 ties, and a blister applied near the diseased  point.  Stimulant
 inhalations have been found efficacious, as of the steam of warm
 water medicated with aether, with alcohol—the vapor of burnino-
tar  or of resin, and the fumes of nitrous acid.   Pearson advises
to macerate 3ss. of the powdered leaves of the cicuta in sulphuric
aether fi.; one or two teaspoonsful being poured  into a tea-cup or 
 292              APOSTEMATOUS PHTHISIS.

 wine-glass, are  held up to the mouth and breathed over  until
 the whole is inhaled.
   I have confessed already the difficulty of assigning a satisfac-
 tory reason for the acknowledged fact, that pulmonary abscess
 heals  so slowly and reluctantly.   That  this does  take place,
 however, we know as well from post-mortem inspection, as
 from the recovery of patients after the sudden discharge of such
 quantities of pus  as must have  been collected in an abscess of
 considerable size.   "This healing process," says Duncan, "re-
 quires that state of action of the vessels  of the  part, which, in
 contra-distinction to the suppurative, has  been termed the adhe-
 sive inflammation."   Laennec denies the occurrence of  any  such
 adhesion of the sides  of vomicae, but describes the  curative
 efforts of Nature in the case  before us, "as terminating- in the
 formation of a semi-cartilaginous  membrane as  a  lining to the
 empty, ulcerous cavities, left on  the rupture and evacuation of
 an abscess, or the filling up  of the excavation by a deposit of
 fibro-cartilaginous matter."
   I  am  very doubtful,  whether we are in  possession of any re-
 medies by which we can aid or further in any degree this healing
 process.   I think our best hopes  are  founded on the measures
 directly adapted to preserve or restore the proper  tone and vigor
 of the general constitution.  A slow and gentle mercurial course
 is, by several authors, strongly recommended.  "In recent cases,"
 says Rush,  "it generally succeeds, which  is more  than can be
 said of any or all other remedies for this disease ;  in the hectic
 state it frequently cures, and even in its typhous  and last  stage,
 I have more than once prescribed  it with success."  My experi-
 ence will not enable me to employ such language  as this; for the
 mercurial has often failed, with me, to do  any service, and,  as I
 have already said, I endeavor to avoid the  irritation of ptyalism.
 I prefer to all other formulae of mercurial prescription, the happy
 combination recently prepared for  us, and known as the deutio-
 dide of mercury and potassum, through which we can derive all
 its remedial  and alterative  influences  with little or no risk of
 salivation, while we add  the peculiar and  specific effects of the
other ingredients  of this valuable compound.   From iodine
 itself I have derived much advantage.  It is most safely used in 
APOSTEMATOUS PHTHISIS.
293
d ilute  aqueous solution, or in the natural combinations so often
found  in  mineral waters.
   The balsams have been, from the earliest times, regarded as
well adapted to the class of cases now under consideration, and
each of the agents included within the  application  of the term
has found its special advocates.   Copaiba—the exudations from
many  species of fir—tolu—camphor—tar, and myrrh, are most
in  vogue.   Tar-water,  long  a favorite with  the  vulgar,  was
highly eulogized by the celebrated Bishop  Berkely. The vapour
of  tar, first brought to the notice of the  profession by Crichton,
has been  commended  also by Paris.   It must be made to boil
slowly, when the patient may inhale it; but it must not be al-
lowed to burn.   Simmons and Fordyce  speak highly of myrrh,
and Griffith has combined it with iron into a mixture which has,
for a great while, been much relied on.  I derive as much benefit
from tolu as from any other of this class of  drugs.
  It still remains to inquire, how we shall best obviate or remove
the ill effects upon the general constitution, arising  sympatheti-
cally or otherwise, from the pulmonary disorganization.  Hectic
fever scarcely ever fails to be developed, as the disease progresses,
and soon becomes a prominent evil.  From its analogy in habits
of periodical recurrence, with intermittents, it has been attacked
with the whole list of remedies useful  in  that class  of fevers,
and formerly enumerated to you, but with no flattering success.
Cinchona does seem, however, to have some influence over it;
and I have  more than once succeeded  in  obtaining a truce  of
various duration, with the  combination  of piperine and sulph:
quinine, so eminently efficient as preventive  of ordinary tertian.
Arsenic andiron have been alleged to be also of service.  It has
been supposed, that the inhalation of very finely levigated bark, or
of alum or acetate of lead in impalpable powder, may act as astrin-
gents on the vessels of the suppurating cavity, checking  their
vitiated secretion and favoring the healing process.   The same
has been asserted of chlorine gas, and iodine volatilized by heat.
All these  I have  tried without  benefit, and in some instances
with obvious injury, and have therefore  abandoned them.
  It was more reasonable  to expect advantage from  breathing
the sedative airs or gases—hydrogen, nitrogen, carbonic acid, in
combination with smaller proportions  of oxygen  than go to
      25* 
294
AP0STEMA10US PHTHISIS.
make up our atmosphere.  They were conceived  to be less ex-
citing to the irritable lung, and less likely to foster or arouse the
annoying cough.   A similar notion led to the "stabling with
cows," so fashionable for a short time in  Great Britain.  I have
no confidence in the favorable reports concerning these remedial
measures, and indeed, they are now fallen into disuse.
  The  night  paroxysm of hectic terminates with that distress-
ing and debilitating sweat, so much dreaded by consumptive pa-
tients.   It has been debated whether or not we should make any
attempt to control this distressing symptom, which some practi-
tioners are unwilling to interfere with, as one of the natural and
regular stages of the febrile paroxysm.   "I have sometimes suc-
ceeded  very decidedly," says Dr. Young, "in checking  these
sweats by Dover's powder, but I do not know that the progress
of the disease has been much retarded by this palliation."  How-
ever this may be, I am certain  that the patient is not only bene-
fitted by the removal of great inconvenience, when we have been
able to  relieve him  of this  cutaneous discharge ; but that his
proportional loss of strength  and emaciation have  both been
diminished.   But one exception to this rule has ever occurred to
me.   The prussic acid, strangely enough, had the effect, in one
case under my care, of regularly stopping the night-sweats ; the
patient,  however, complained  that the  protracted heat of skin
which was  substituted, was far  more intolerable ; and begged
earnestly that I  would withhold the medicine,  and  allow the
sweats  to return. Sulphuric acid, in the form  of the vitriolic
elixir, is in common use for the purpose of which I am speaking,
and will sometimes succeed  very well.  I have seen these cuta-
neous discharges arrested by the occurrence of a mercurial pty-
alism, the accession of hectic seeming hardly less regular or less
violent.  Dover's powder, mentioned by Dr. Young, appears to
me to act indirectly—but in the  most favorable mode ; in dimi-
nishing the force of, or  altogether preventing the hectic parox-
ysm, it  did  away its  ultimate result, the relaxation of the sur-
face.  If this explanation be correct,  it removes at once the im-
putation of inconsistency in prescribing  for the relief of night-
sweats, one of  our most certain sudorifics.  Besides this, we can
readily  imagine the colliquative transpiration to be associated
 with or dependent upon a loss of elasticity or contractility in the
 exhalents of the skin, which  it  is  the  well-known property of 
APOSTEMATOUS PHTHISIS.              295
 opium to  excite and stimulate, as is shown by the glow which
 follows its use, and the itching and  eruption which it not unfre-
 quently produces.
    It is in this relation that I prefer to speak of the exhibition of
 digitalis, which has so long enjoyed a high repute as a remedy
 in pulmonary disease.  If beneficial at all, which you are aware
 is a question warmly contested, it must be as a sedative, a nar-
 cotic, an anti-irritant; and its agency must be directed upon the
 general constitution,  to protect or relieve it from the sympathetic
 influences of local disorganization.   It should be acknowledged
 that its eulogists have not agreed in defining the contingencies
 in which it is best adapted to be of service, and it continues to
 be  employed in almost every  case of  phthisis—tentatively  or
 experimentally.
   Accurate and nice  observers (Sanders  and More) have affirmed
 that digitalis is not destitute of stimulant powers ; but its effects
 in this way are so  slight and transient,  that we may consider it
 practically a sedative of the  most  definite character,  and may
 safely attribute to its influence in repressing the action of the
 heart and  arteries, all its usefulness in  the present case.  "It is
 well known," says Ferriar,  "that bleeding is in some cases inad-
 equate to the lessening of  the velocity of the  circulation, unless
 it be carried to a dangerous excess.   The foxglove furnishes us
 with the means of regulating the pulse to our wish, and of sup-
 porting a given state  of velocity as long as we judge it proper."
 In conformity with this view of the subject,  we find Magennis
 affirming, after a large experience, "that he had met with several
 instances in which  the digitalis, given freely  and fully, effected
 not the smallest reduction  of the pulse, and  that in these the
 patients uniformly derived  no  advantage  from  its use."  Drs.
 Darwin, Fowler and Drake—upon  what grounds, I am unable
 to explain—refer its beneficial  agency to an  asserted power of
 diminishing  secretion and  augmenting  pulmonary absorption.
 Others again  of its advocates, and perhaps a majority, regard it
in the light of a specific, whose influence is peculiar, inexplica-
ble, and as it were antidotal.   Some  very extraordinary testimo-
nials in its favor may be collected among the authorities.  Dr.
McLean tells us that it will sometimes succeed when all other
remedies fail.   Dr. Kinglake declares that he cured seven cases 
296
APOSTEMATOUS PHTHISIS.
out of fourteen with it.  Drake gives an account of fifteen cases
treated with it, of which  nine recovered.   Magennis lays  claim
to still more astonishing  success.   Out of seventy-five patients
at the Naval Hospital of Plymouth, of which  he was phy-
sician general, he reports  forty-four  cured, twenty-two relieved,
and but ten deaths.  Dr. Beddoes gives utterance to his exulting
confidence in  it, by the following enthusiastic expressions: "I
daily see  many patients in  pulmonary consumption  advancing
towards recovery  with so firm a pace, that I hope consumption
will henceforward be cured as regularly by foxglove  as ague by
the Peruvian bark."
  After making due allowance for the evident exaggeration of
such incredible statements, and considering too that in these re-
ports all forms and stages  of chronic pulmonary disease are con-
founded, much will  still  remain  which must  not be lightly re-
garded.
  Digitalis seems to me  to promise most benefit in patients of
irritable or excitable constitution ; too weak to bear any further
depletion, but suffering too much from pain, dyspnoea and fever
to admit of the  free use  of tonics ; the pulse  being small, fre-
quent and irregular; the cough troublesome, and often recur-
ring, with imperfect  expectoration, and perhaps  occasional he-
moptce in  small amount.  In phthisis, it is best given, I think^
in powder or  tincture ; some, however, prefer the infusion. Its
long-continued administration has never failed,  as far as my ex-
perience goes, to depress and injure the tone of the stomach and
impede digestion.  After  bringing the pulse fairly under its in-
fluence, I advise to intermit its use for a few days, resuming it
again when the frequency of the pulse returns.  Or if, after a
proper trial, it produces no  effect  upon the circulation, I would
abandon it entirely and substitute some safer remedy.
  The prussic acid deserves to be mentioned, also, as a narcotic
and sedative.   It does not affect  the pulse as digitalis does, nor
induce sleep and tranquillity like the opiates ; but it nevertheless
diminishes the violence of hectic  irritation, and is particularly
useful when the attendant cough has assumed the character of a
habitual nervous or convulsive  paroxysm.  It  will be found in
such cases to repress both  its frequency and its vdhemence. Gene-
rally speaking, I prefer the formulae in which it is  much dilu- 
APOSTEMATOUS PHTHISIS.
297
ted—as the water of bitter almonds, infusion of peach leaves and
kernels, etc.; but sometimes the concentrated acid must be cau-
tiously employed.
   Opium, however, is most incomparably superior  to  all  seda-
tives,  anodynes and antimonials.  Its valuable  influences are
no where more sensibly or strikingly exhibited, than in directly
controlling irritation by its power of diminishing irritability,
and in soothing  and allaying  the disturbances  of the general
system, when we are unable to remove the local  cause which
has sympathetically excited them.  I would not be understood,
however, to limit its beneficial effects to mere palliation of suffer-
ing, though this is its most  obvious  and immediate operation.
Sydenham recommends it in the strongest terms, and is followed
by Rush, who advises it not only to be given at night, to procure
sleep,  but early in the morning and throughout the day.  If not
capable itself of effecting cures of confirmed phthisis, we  may,
at least, be always sure of doing something with opium to the
advantage of our patient.  Nay, I regard it, for  my  own  part,
as so essential to the proper  treatment, of the case, that I  have
never  seen an instance of cure  without it.   It lessens the fre-
quency and violence of  the cough; bestows upon the exhausted
sufferer quiet slumber and pleasant dreams; checks the  colli-
quative sweats and diarrhoea; and when all hope  has  deserted
us,  "assuages the pangs of parting life, and smooths the pillow
of dissolution."  When the diarrhoea is obstinate, the acetate of
lead, in proper doses, should be combined with  opium.   Kino
and other astringents, may also be used, as recommended under
that head.
  As substitutes for opium, when  from  any circumstances, its
administration is  inconvenient,  hyoscyamus and  lactucarium
have been proposed.  I have no confidence  in either of  them,
and have never failed, by proper experiment of appropriate doses,
to find among the numerous formulae in which opium is mingled,
some one entirely unobjectionable.  Of these, the  denarcotized
laudanum, the acetate  and muriate of morphine,  the new in-
vented elixir  of opium, and though last, not least, the tinct: opii:
camph:, the elixir paregoric, deserve  special  mention,  and are
of inestimable value.
  I have been long of opinion, that we  make too  little use of 
298
APOSTEMATOUS PHTHISIS.
tonics, in the latter stages of phthisis, and especially in its apos-
tematous form.  It is well observed by  Abercrombie, that "the
lungs are not exempt from healthy" (or common) "phlegmonous
abscess, which like other such abscesses," elsewhere, "may heal
kindly, or according to circumstances, protractedly, wearing out
the patient with hectic fever."  Here it is evident, that we may
occasionally gain much, by the persevering use of such remedies
as give tone to the system, and thus support it  until the slow
process of healing is finished in the lungs.  And I take the op-
portunity of again urging the exhibition  of cinchona, as very
often adapted to prove eminently serviceable.  I would, however,
time it carefully.  I would not employ it when the tension across
the chest, dyspnoea, and other symptoms continued to denote
the presence of active pulmonary inflammation,  nor where the
cough was violent and hard, and the expectoration scanty.   But
where the pulse is weak and soft, the patient  much debilita-
ted, the cough loose, and the  expectoration thin, serous, sani-
ous or foetid, with abundant colliquative night sweats, it will pro-
bably be of as much advantage as any thing we can offer.
   Morton made  much use  of it.  Hastings and  Broussais em-
ploy it freely,  and recommend it highly,  in the  corresponding
stage of chronic bronchitis, or catarrhal consumption.  Duncan
thinks it better adapted to the apostematous than to any other form
of phthisis, and declares that he has reason to believe, "that from
its influence the adhesive inflammation is induced, and an ulcer in
the lungs has been thus healed, when that event would not other-
wise have taken place."  I prefer a watery infusion of cinchona;
others, however, use the decoction, and  perhaps a majority, the
sulph: quinine.  When the bark cannot be borne, some of the
simple bitters, as quassia or Colombo, may be substituted.
   "I  have lately  seen three persons," says Rush, "recovered
from the lowest  stages  of consumption, by  the  use of animal
food and cordial drinks, aided by frequent doses of opium,  taken
during the day as well  as night.  A diet of oysters is said to
have effected cures of consumption; so  of grapes, sweet apples,
and the juice of the sugar maple tree, when taken in large quan-
tities.  These all appear to  act," he continues, "by filling the
blood vessels, and thereby imparting tone to the whole system."
   The facts thus stated, surely deserve  to be remembered, and 
TUBERCULAR PHTHISIS.
299
to have a place and exert an influence  in all our future reason-
ings upon the management of this very formidable and fatal dis-
ease.   In conclusion, I need hardly again remind you, that our
best hopes for our patient, must be founded on such measures as
shall tend to restore his lost vigor, and preserve whatever  is left
to him of strength of constitution.  He should take a long jour-
ney, on horseback if he is able; or a sea voyage to some distant
quarter of the globe.  Meanwhile, let  him protect himself, by
every care, from a return or renewal  of pulmonary  inflamma-
tion.   Let him wear flannel constantly next his skin, and seek
for  his residence, a warm and equable climate.
                    CHAPTER  XLIII.

            PHTHISIS.--TUBERCULAR PHTHISIS.

   Phthisis, consumption, decline, are terms from  time imme-
morial applied to denote a condition of disease, in which a steadi-
ly progressive atrophy, shown by marked emaciation of the body,
formed  the prominent symptom;  the picture  being rendered
more complete if a cough, hectic fever, and great debility con-
curred.   Such, indeed, are the well known and striking features
of the malady, now about to engage our attention—tubercular
phthisis, from which all the  other  forms of consumption have
derived their names and most of their terrors.
   It may be regarded not only as the  most insidious and dan-
gerous among  the pulmonary affections, but perhaps, as excell-
ing in its destructive tendencies, all the other disorders, hydro-
phobia only excepted, to which  the human constitution is liable.
As its title  imports, its characteristic peculiarities are ascribed to
the  presence  and irritation  of bodies, called tubercles, or of
tuberculous matter deposited in the air tubes or substance of the
lungs.   The formation of these bodies, the deposition  of this
peculiar matter, are supposed  by many, to depend upon an origi-
nal defect in the organism, which if not identical with, is closely 
300
TUBERCULAR PHTHISIS.
allied  to  the strumous diathesis.  Proofs of this association
abound, and have been commented on by authorities of the great-
est weight in our science.  It is in subjects who have  exhibited
the most obvious marks of scrofulous disease, such as were for-
merly recited to you, that tubercles are most frequently  found;
whether in the mesentery, lungs, or elsewhere;  and the  ten-
dency to their development in the pulmonary tissue, is  so strong,
that Louis affirms positively, as the result of a long series of ob-
servations, "that whenever we find tubercle in any of the other
organs or tissues, we may surely infer its existence  in the  lungs."
Phthisis is familiarly noted as a hereditary malady, in scrofulous
families, as attacking  the children  of scrofulous   parents,  and
supervening in the advancing lives of those who, when children,
had suffered from scrofulous  enlargement of the  glands of the
neck, white swelling, etc.; to which we should add  the com-
mon remark, that the physical and physiognomical characteris-
tics of the strumous diathesis, have been universally regarded as
prophetic  also, of future phthisis ; the fine, clear skin; the deli-
cate, blooming complexion; the full, large  vein;  and the pro-
jecting, ruddy lip.
   Tubercular phthisis differs, then, from the  other pulmonary
diseases classed with it,  under  a common name, and  spoken of
as consumptions, inasmuch  as  they are originally local affec-
tions—lesions simply  of the lungs and  their appendages, in-
volving by their consecutive  irritation,  general disturbance  and
disorder of the body;  whereas, in the present case, the primary
derangement is general or constitutional,  the  lung being  only
one among the organs and tissues involved in  the progress of
its successive developments.  I must not be understood  to say,
that phthisis  consists in the mere presence of pulmonary tuber-
cle.  The predisposition thus pointed out, requires to be excited
and urged into action,  before we have the symptoms of phthisis
to contend with.   A tubercle, we know, may exist in  the  lung
without creating any disturbance  or  uneasiness.   In this state,
it is said to be indolent.   It is only when the parts about it are
irritated or inflamed, and become the seat of congestion,  that its
malignant qualities are  notable.  Its growth undergoes quick
increase, probably by  the determination  to neighboring parts,
and the engorgements of neighboring vessels;  and by this hy- 
TUBERCULAR PHTHISIS.
301
pertrophy it reacts, becoming a new centre of irritation, and  at
last producing abscess in the surrounding tissues.   This process
being repeated and renewed, by the  successive growth of one
tubercle after another, for they are  rarely found  but in groups
and masses, incurable inflammation and atrophy are  the result.
Observe, too, the distinction between the causes of the original
production of tubercle and the agencies just alluded to, which
arouse it into a state of increase and  hypertrophy, and make it
a centre of uncontrollable irritation.  These latter comprehend
all the sources of bronchial, laryngeal, pleuritic and pulmonic
inflammation; nay, catarrh, bronchitis, haemoptysis  and pneu-
monia, acute and chronic, almost inevitably bring into play the
consumptive predisposition, if it exists.  But  these diseases do
not produce tubercles, or create tubercular deposition.  It is true,
that Andral, whose name should  never be mentioned without
respect, has advanced the opinion that pulmonary inflammation
may, in any constitution, give rise  to tubercle.  In  this belief)
however, he stands alone,  and as I  conceive, unsupported by
facts, when correctly examined.
  I have already spoken of the association between tubercle and
scrofula.  The former can, no more  than the  latter,  arise  sud-
denly, but  equally depends upon changes long acting and slowly
contaminating the whole organism.  1 would not make it exclu-
sively hereditary;  for I think the changes in which it consists
may be traced during the successive  steps of  their progress, un-
der circumstances calculated  to foster them.   A healthy child,
placed in a close, ill ventilated manufactory, and there confined
during the long years  previous to, and  just  consequent  upon
puberty, will be very likely, when  adolescent,  to  exhibit a con-
sumptive disposition, as the very first open development of scrofu-
lous deterioration of  constitution,  and if such a subject be at-
tacked with pulmonary inflammation, a rapid formation of tu-
bercles, will very probably occur—a result of mere  pulmonary
inflammation, which I hold  to be  absolutely impossible  in  a
young rustic previously healthy, whose fluids are pure and  his
constitution sound.
  Another source of tuberculous predisposition has been suggested,
and some of the writers on phthisis have ventured to enumerate
contagion among the causes of the disease.  This opinion is pre-
       vol. n.—26 
302
TUBERCULAR PHTHISIS.
valent on the continent of Europe, not only among the common
people, but with the best informed medical men ;  and the wards
of the hospitals, in many parts of Italy, at least, are arranged
conformably.  We may  add the  testimony of  Morton,  Darwin
and Good, in Great Britain, the  latter of whom  declares  une-
quivocally, that he has met with  numerous cases that could not
be ascribed to any other  cause.  I would use the  more cautious
language of Cullen, and say that "I dare not assert that it never
is contagious."   We know  that it  very frequently  attacks the
several members of the  same family—the  husband and wife, as
well as the brother and sister, and that many  nurses die of it,
after a protracted  period of assiduous attention and close con-
finement in the chamber of the  consumptive.   These facts are
attempted to be explained, it is true,by references to other agencies,
as exposure to the same  local causes—air, diet,  grief, etc., but
not satisfactorily.
  When treating of scrofula, it was observed that its several de-
velopments or determinations, are influenced by  age.  The pul-
monary  derangement of tubercular phthisis, is apt to show itself
a few years after puberty, in early maturity, from the eighteenth
to the twenty-fifth year of life.  Exceptions to  this rule may
occur, but it is very generally correct.  It is rare that tubercular
phthisis  first shows itself after the thirtieth year.   Home and
Alison agree in the remark, that  "in the upper ranks of society,
there are more females than males  attacked, owing to the  more
impressive variations of dress, but in the lower classes, the male
patients  are more numerous, in  consequence of  their more fre-
quent and severe exposures."
   Every writer on this  form of consumption, has commented
on the peculiarly  insidious manner of its invasion.  The feel-
 ings of uneasiness and ill health, which the patient may suffer in
the early stages, are  indeed often so ill defined,  that they can
 scarcely be made topics of conversation or complaint.  Perhaps
his friends  may, in the first instance, notice some falling off in
 condition, some hollowness of eye or cheek, that gives warning
 of obscure and latent disease. You may trace the coming of
 the destroyer,  to use the beautiful language of Mrs. Ward,  "in
 the clear, transparent skin, in the bright eye, and ever brilliant
 cheek, in the delicate lip, the drooping, slender form,  the  damp 
TUBERCULAR PHTHISIS,
303
  and shining hair, and the  heavy breathings after  slight exer-
  tion."  Or there may be a short, hacking cough,  recurring fre-
  quently, as if habitual, but without pain.  In walking or ascend-
  ing a stair, he pants and is  easily fatigued.   On making a deep
  inspiration, some constriction or uneasiness may be felt.   These
  symptoms often abate, especially if the season  and  temperature
  are favorable, and they are  forgotten.  They  return, however,
  on some exposure, and the cough increases in force and frequency,
  harrassing the patient at  night  or early  in the morning,  when
  there is scanty mucous expectoration, perhaps tinged with a little
  blood occasionally.   Authors say, that hemoptoe is seldom con-
  siderable in tubercular phthisis,  but I have seen  some striking
  examples to the contrary.   The dyspnoea  and  thoracic  uneasi-
  ness grow more permanent; fixed, and  sometimes  acute  pains
  are felt in different parts of the chest, with a  sense of weight
  and tension.  The expectoration becomes gradually more copi-
  ous—muco-purulent, sometimes sanious and offensive ;  there  is
  great weakness, with emaciation.  Hectic, which supervenes ear-
 lier in some cases, and later in others, without any direct relation,
 as I have thought, with the local  disorganizations, is now ex-
 quisitely developed, with double diurnal paroxysm,  ushered in
 or commencing frequently  in the morning  with chill, and usu-
 ally followed at night by the so much dreaded  and  debilitating
 night sweat.
   "In the female sex, as the disease advances,  and  sometimes
 early in its progress,  "the menstrual discharge  ceases to flow;
 and this circumstance," as Cullen rightly observes, "is to be con-
 sidered as commonly the effect, although the sex themselves, are
 ready to look  on it as the sole cause of the disease."   You will
 find this error especially  prevalent among  our  colored popula-
 tion, and you will be incessantly teased by  your consumptive
 female patients of this class, for  emmenagogues to remove the
 evil.   They are, indeed, very much in the habit of  prescribing
 for themselves, by stealth, articles of that kind.
   The pulse is usually, from the first, quick, tense and jerking,
and attains, as the case goes on, a remarkable frequency—count-
ing from one hundred to one hundred and sixty in a minute.   The
sclerotica  of the eye  becomes of a pearly white, owing,  as is
supposed,  to the disappearance of the red  vessels,  and the ab- 
304
TUBERCULAR PHTHISIS.
sorption of animal oil from the cellular tissue; the same explana-
tion being offered, of the  lustrous whiteness  of the  teeth; the
whole body is shrivelled and  extenuated, the  nails even  becom-
ing adunque or bent inwards, for want of the usual fleshy cush-
ion at the ends  of the  fingers.   Until  this period, nay, some-
times to the very last, the  appetite of the patient remains good,
and his digestive organs  preserve  their tone; he is cheerful,
lively, and full of hope, and  flatters himself with a confident
expectation of recovery.  This  remark, which has, with the
usual neglect  of proper distinctions, been  extended to all the
forms of consumption,  is strictly true, only as regards tubercu-
lar phthisis, and by no  means applies to the other varieties of
the disease.  Rush tells us, he "never  met with but one man
who  would acknowledge  that he was in a consumption."  I
have witnessed the  long illness and the deaths of many  subjects
of catarrhal and apostematous phthisis, who were neither de-
ceived themselves, nor  at all  disposed to deceive others, as to
the actual hopelessness of their condition.   On the other  hand,
 in many such patients, I have had to contend with extreme de-
jection of spirits.   Dyspeptic  phthisis, and indeed, all cases
 associated with functional or organic derangement of chylopoi-
 etic viscera, seem to me regularly accompanied by deep gloom
 and  depression—a state of mind almost invariably produced by
 gastric and hepatic disorder.   And in the latter stages,  even of
 tubercular consumption, when the  irritating and  disturbing in-
 fluences of the disease are extended to the stomach and bowels,
 the spirits of the unhappy patient will often be  found to sink
 into extreme anxiety and despair.  I have seen many instances
 of this.
    To complete the melancholy description of this last and cure-
 less  stage—the patient is harrassed with frequent, loose, and often
 painful stools; the colliquative  sweats and  diarrhoea,  show at
 first, a disposition to alternate with  each other, but  soon go on
 together,  making rapid inroads on his little remaining strength;
 his voice is hoarse and weak; his mouth and tongue, lips, cheeks,
 throat, inflame  and ulcerate with aphthous sores, which ren-
 der  deglutition difficult; oedematous swellings distend the limbs;
 he is too  feeble to  expectorate the matter effused in the lungs
 and bronchi, and dies at last suddenly suffocated; or as Young 
TUBERCULAR PHTHISIS.
305
fifnrms, "the expectoration in some instances  ceases, as if the
capillaries had lost their secretory power, or as if the fluids of
the system were exhausted;" and he languishes for a greater or
less period, in an almost lethargic condition,  sinking gradually
into the long, long sleep of death.
   The duration  of the terrible malady, of which I have  thus
endeavored to give  you a  faithful picture, differs exceedingly in
extreme cases;  varying in accordance with the original or inhe-
rent powers of resistance  in the constitution,  the force of here-
ditary or idiosyncratic  predisposition, the  habits  and mode of
life, the prudence exerted in avoiding the exciting causes which
tend to arouse pulmonary inflammation and promote the growth
of tubercles ; and lastly, in no small degree, the skill and judg-
ment with which the remedial management is directed.  For we
shall hereafter see that however well founded may be the doubts
so generally entertained of the powers of medicine to remove or
cure phthisis, no one can deny our ability to check the progress
of the disease, and put off, to an almost indefinite limit, in many
cases, the fatal  termination.  A few months—a  period which
shall include a  second winter—may be mentioned  as the time
occupied by a majority of instances.  Yet it is  probable that a
greater number live beyond this date than perish within it. Ex-
amples are recorded of its protraction through five, ten,  twenty,
thirty, sixty, and even seventy years;  that is to  say, its symp-
toms ran through  the whole lives of the  subjects, with greater
or less intensity, yet without shortening life.
   It is in these protracted  instances, generally speaking,  that
the anomalies—so  much dwelt on by writers—occur, in which
the pulmonary disorganizations exist and progress ultimately to
a fatal result, without  having aroused  the sympathetic disturb-
ances which  have  been  described as belonging to their usual
history.  Nay, the local derangements of function are sometimes
deceptive and obscure.   In 1819, I attended with two other me-
dical gentlemen, a patient whose case (already alluded to in a
former lecture) deserves  to be noticed.  He had no cough, and
complained of no dyspnoea.  He  had no pain except at  the epi-
gastrium, but kept  his bed for  nearly three months, at the end
of which  time he died, apparently exhausted  by continual low
fever, My friends called it typhus mitior; I thought it a chronic
       26* 
306
TUBERCULAR PHTHISIS.
gastritis.  Examination after death, showed the lungs a  mere
mass of tubercles, in various states and stages of development.
  For our present knowledge  of the true Pathology and Patho-
logical Anatomy of Phthisis, we are chiefly indebted to Bayle,
Laennec, Andral, Louis, Clark, Baron, Morton and Gerhard. The
nature of tubercular formations  and depositions  has been ear-
nestly  investigated by these  writers—and perhaps still  more
closely  by Carswell and Cruvelhier.  Tubercular matter  is ge-
nerally found in a solid condition, and of consistence somewhat
caseous ; but Cruvelhier has detected it in a fluid or gelatinous
state.  Besides the  encysted form, so well known as tubercle, it
is seen in  small  granular  masses, called  miliary  tubercle and
tuberculoid granulation ; it also insinuates itself into the tissues,
the grey infiltration of writers.   Carswell says it takes the shape
of, or is moulded by the air  cells and  bronchial  tubes  ; it is
found every where in the body, in  the parenchymatous  struc-
tures, glands, etc., but chiefly upon the mucous surfaces. Chem-
ical analysis finds it composed of albumen, gelatin, fibrine, chlo-
rate of soda, phosphate and carbonate  of lime, with a trace of
oxyd of iron.  It is variously colored—whitish, yellowish, gray-
ish, and it is said darkly tinged sometimes by the pigmentum
nigrum.
   It has been much  disputed whether encysted tubercle is or is
not organic.  It  is certain that it possesses very little vascularity.
From its singular  independence of surrounding  connections it
has been supposed to be parasitic in its nature—a sort of hydatid,
 if I comprehend rightly.  Harvey, Bremser, Blainville and Cru-
 velhier seem disposed, like Linnaeus, to attribute many diseases
 to animal parasites.  Even Laennec, though somewhat vaguely,
 speaks of tubercles as possessed of independent vitality. His  words
 are, "tubercles  are accidental  productions;  that  is,  real foreign
 bodies which  spring up  in the lungs, and may be developed in
 any other part of the body."
   The cause of tubercular deposition I have  already said is ob-
 scure ; I believe it  to be dependent  upon, or closely connected
 with, a strumous vitiation  of the fluids, and consequent degene-
 racy in the nutritive function, which occasions  the fixation by
 the minute vessels engaged in the  office, of imperfectly animal-
  ized or vitalized solid particles.  This may happen any where— 
TUBERCULAR PHTHISIS.
307
but during adolescence is particularly apt to occur in the pulmo-
nary tissue.  For  what reason 1 know not,  but it is noted that
the right lung is  more frequently affected—and  especially its
apex.
   It usually takes place slowly :—Morton affirms that it may be
deposited rapidly—Andral thinks the process not only hastened
but  actually produced by inflammation.   It is a  question how
the growth of tubercle goes on ; whether from within outwards,
or by additions on the external surface of the mass.   It is  also
difficult to understand clearly how it is  softened and broken
down ;  whether by mere maceration  in the  fluid with which it
is surrounded, pus, serum, etc., or as Laennec maintains, from a
change commencing  in its own centre.   If  Morton—all whose
observations are entitled to very respectful attention—and whose
"Illustrations of Pulmonary Consumption" merit a place in all
your libraries—be  right in .believing each  tubercle "to be inter-
sected and all its granules separated by their appropriate tunics of
cellular tissue"—this tissue may soften them by sero-purulent se-
cretion.  These difficulties, which present themselves in the way
of both hypotheses, that which pronounces tubercular matter to be
entirely inorganic, as well as that which assigns to  it a parasitic
origin, are easily resolved, if  we suppose it as I have above sug-
gested,  to be partially or imperfectly organized, and gifted with a
vitality degenerate and defective.  Such a condition may admit of
the growth and change which actually take  place, while it ren-
ders it to a certain extent foreign, and independent of the parts
in which it is deposited.
   The Diagnosis of tubercular consumption  is somewhat  deli-
cate.   A careful exploration of the  thorax, in the early stages,
will  detect little beyond an irregular distribution of the natural
sounds, the respiratory murmur being, in  some points, percep-
tibly  defective,  more  usually at the  apex on  the  right side,
while, at others, it may be louder  than usual—puerile or bron-
chial.   A  slight  purring or a sibilant  rale may occasionally be
heard.  As the case progresses, the  chest will expand less, and
the breathing be  shorter  and  more  frequent;  consolidation
around the tubercles will increase the defect of respiratory mur-
mur, and resonance will become impaired.  At a stage farther
advanced, some  tubercle will have  been softened, forming  the 
308
TUBERCULAR PHTHISIS.
centre of an abscess of greater or  less extent, and  pectoriloquy
may be noticed; and this will occur at another  and another
point, and  so  on.
  After all, however, it is only by a due  consideration of all the
several circumstances of the attack, and the history of the  sub-
ject__his predisposition—the absence  of violent or acute symp-
toms in the earlier stages, and the disparity between  the consti-
tutional  exhaustion and  irritation on  the one hand, and the
apparently undefinable and unimpressive local disease and le-
sion on the other, that we are able to  distinguish the tubercular
from the other forms of phthisis.   And  the distinction is very
important in reference to the Prognosis,  if in  no other point of
view.
  As to the grave question of the curability of tubercular  con-
sumption, I have already given you an unfavorable opinion, and
the almost inevitable tendency to  a fatal termination is now, I
believe,  universally  admitted.   The delusive hopes of  those
enthusiasts who fondly imagined  themselves the discoverers of
antidotes, and specifics, and modes of treatment curative of this
disease, have vanished before the sad  realities of practice, and
their recorded successes may be  fully accounted for by the too
prevalent  confusion of  several  forms  of  pulmonary affection
under one name.   But it would be worse  than folly, to allow
our exertions  in behalf of suffering humanity to  be paralyzed
by our admission  of the difficulty, or,  even if this were fully
established, the impossibility of curing  phthisis.   Much maybe
done to diminish  these irremediable evils—much to prolong a
life cheered  and  enlivened by  the  bright gleams  of a  never
 sinking hope of ultimate recovery.   Bayle,  while maintaining
 the incurability of phthisis, admits the  possibility of its  indefi-
 nite protraction.  Rush prescribed for  his pupil.  Dr. Edwards,
 in  1769.   He lived until 1802, and seldom passed a year during
 that interval without hemoptoe, or a week without  cough.
 "While we  concede," says  Laennec, with more apparent than
 real inconsistency,  "the justness of the general conclusion, that
 the most perfect cure that can take place in  phthisis, is  merely
 temporary, we are still  entitled to  hope for a cure, or, at least,
 for such a suspension as may be deemed almost equivalent to it,
 since the  individuals may enjoy such a state of health as may 
TUBERCULAR PHTHISIS.
309
 enable them to fulfil all the duties of civil life for many years,
 or until such time as a fresh development of tubercles, at present
 immature, produces a fresh and final seizure."
   Besides this, there are  certain  conditions, out of which may
 grow exceptions to the  rule  above  laid down.   In  different
 subjects, the tubercular diathesis affects the lungs  in  different
 degrees, some presenting masses of  this  morbid deposit, others
 but slight traces of it.   Morton tells us, that in  examining  the
 body of a man who had died of fever, he noticed, on the apex
 of the  left lung, a single small  grey tubercle.   Still  more in
 point here, we have a case from Laennec, in which a similarly
 solitary  tubercle,  loosened by the suppuration  around it, was
 coughed up entire.  In such a case,  it is evident, that the lungs
 being relieved of the foreign irritant, are  somewhat in the state
 which constitutes  mere apostematous phthisis, and may heal,
 provided the general health  be not too much  impaired.   Still
 farther, we know that the tenacity of life—the  elasticity of its
 functions,  vary widely in different subjects.  Some fink readily
 under slight disease—others resist obstinately.   In these latter,
 we  may find such organic vigor as shall  not  only sustain the
 irritation  of one  tubercle,  but of several,  perhaps, and when
 these are  softened and dissolved and expectorated, shall  still
 preserve their hold upon  life.
   All these circumstances being duly taken into consideration, I
 hold myself bound to urge  upon  you the duty of attending
 assiduously even to the most desperate-seeming cases of phthisis.
 It is possible, that you may have mistaken the more manageable
 forms of pulmonary disease for tubercular  consumption ;  it is
 possible, that the case before you may be  one of the  rare  in-
 stances in  which even this latter destructive malady assumes a
 something less than fatal character, or in which the constitution
 is sufficiently vigorous to struggle  both  with its  original vice
 and the local lesion; it is not only possible, but certain,  that you
 have the  ability to retard, if not to arrest its progress, and to
 prolong indefinitely a life valuable, it may be, not  only to  the
 possessor, but to society and. to the world.
  And where is the physician bold enough  to  assign a limit to
the future  powers of the  Divine  Art of Healing?  If  there be
any such, I will not hesitate to pronounce him ignorant of  the 
310
TUBERCULAR PHTHISIS.
 steady advancement of the profession in the knowledge of dis-
 eases, and of the means of prevention and cure;  he is ignorant,
 too, or wilfully blind to the improvements  in  every branch  of
 our science,  which, within the present century, have been made,
 and are now making, under the auspices of the illustrious pa-
 thologists of France, England, Germany, Italy, and though last,
 not least, of America.
   Analytical chemistry has done so much of late  years to define
 and concentrate the  energy of drugs long  familiar to us, and
 experimentalists have been so successful in introducing new and
 valuable remedies, and in discovering new and preferable modes
 of  exhibiting the  old, that it  is not an unreasonable or  un-
 founded expectation, that much more will yet be  done in dimi-
 nishing the extent of the influence of disease, and in controlling
 its  malignant energies.
   And what  malady deserves more the attention  of every prac-
 titioner than consumption !—whose annual catalogue  of victims
 is  every  where so large,  and whose  ravages  appear, almost
 every  where, to be increasing.   It  selects,  too, as  if to wound
 more deeply and  permanently, the fairest forms, the most enga-
 ging dispositions and the brightest intellects  ; its fatal shafts are
 directed, with the most mortal aim, at the young, the beautiful,
 the highly gifted.   I will not be deterred by the cold and cal-
 lous sneer of the philosophic doubter, nor by the risk of being
 pitied  as an  enthusiast, from  pressing  you  forward in an  en-
 deavor so honorable even in failure—so ennobling and delight-
 ful in success. To strike from the list of opprobria medicorum—
 already reduced to less than half its original  limits by the labors
 of our  immortal predecessors—this, one  of its foulest specifica-
 tions, will afford you a triumph more   gratifying than  all  the
 glories of war or of literature.
  I  shall proceed to speak  of the Treatment  of tubercular
 phthisis under the heads of the palliative and the radical—the
 first comprising those measures calculated to diminish the vio-
 lence of the symptoms and retard the progress of the disease;
the latter referring to the various remedies by which it  is pro-
posed to procure the absorption of tubercles,  and prevent further
deposition of tuberculous matter in the lungs.
  And, first,  of the Palliative.   It  may be made  a question, 
TUBERCULAR PHTHISIS.
311
 whether a tubercle  is ever, of itself, and in the first instance,
 the means of exciting  that  inflammation of the pulmonary tis-
 sues  which constitutes the essential history of phthisis.   Be
 this as it may, it is certain, that it is  only when these  tissues
 are inflamed, that the malignant influences of such  morbid de-
 posites are developed, and  hence arise our first indications—the
 reduction of vascular action, and the diminution of local excite-
 ment and irritation.  These are best and most promptly  accom-
 plished by the lancet, which must be resorted to and used freely,
 if no contra-indication be present, such as is found  in a feeble
 state of the circulation or a specially debilitated condition of the
 general health of  the patient.   If there be pain  in the chest, or
 dyspnoea, it should, for the  most part, be tried, with such cau-
 tions as circumstances may require, but it would  be  an extreme
 case, indeed, of so chronic a disease, which could be seriously
 injured by the experimental loss of a few ounces of blood.
   Cups, too, may  be applied to different parts of the thorax near
 the seat of pain, and will usually give notable relief with  little
 or no risk.   The  patient, during the  progress of a  protracted
 consumption, will, from time  to  time,  be assailed  by  attacks
 truly  pleuritic, in  which the  acute  suffering and difficulty of
 breathing require  peremptorily to be  relieved by  this moderate
 abstraction of blood generally and topically, and by the applica-
 tion of warm  poultices  and  fomentations with or without mus-
 tard.  There are other modes of revulsion and counter-irritation,
 which are productive of similar advantage, of which the  blister
 is the chief;  dry cupping is  also useful, if employed with perse-
 verance.  The pustular eruption brought on by tartar emetic, is
 well-suited to some very chronic cases.   I have not  seen  the
 benefits writers  describe, from  the  various  issues  and  setons
 recommended, made by nitric acid, vegetable and mineral caus-
 tics, etc.
   Great stress has  been laid by some practitioners on the effects
 of nauseants in this form of phthisis—by none however so much
as by Dr. Jenner,  who says—"If ever I saw a case  or cases in
which tubereles have apparently been formed and afterwards ab-
sorbed, it  has been when the  individual  either  by accident or
design was kept for a while under the constant influence of sick-
ness, either from being tossed about on the ocean,  or by the use 
312
TUBERCULAR PHTHISIS.
of medicines which nauseated."  The good  effect of nauseants
so much exaggerated here, is nothing more than the reduction of
inflammatory excitement which may and does sometimes result
from their sedative influence on the circulation.   There is some
risk however in their protracted use, as  likely to bring on great
debility and impair the powers of digestion.
  Frequent emetics have  been generally and I think justly pre-
ferred.  Ipecacuanha and the  sulphate of copper are exhibited
as in pulmonary abscess—either separate or combined, and with
undoubted utility.
  The tartarized  antimony has also  been largely  administered,
and if the reports may be trusted, with singular success.  Laen-
nec and the Italians, aiming at its contra-stimulant effect,  pre-
scribe in  as free doses  as'the stomach will  tolerate.  Louis
recommends it highly.  Balfour and Lenthois  advise  a very
different method,  which I have seen serviceable.   They make a
very diffuse solution of it, which is taken in as  great quantity
as may be, without  nauseating.   It is thus a  good sedative
diaphoretic.
   Other diaphoretics  are  also  employed, as in  bronchitis and
chronic pneumonia, in modes and formulae which it is not neces-
sary to repeat here.   Digitalis,  too, is  almost  universally pre-
scribed, on the principle of directly  lessening the force and  ve-
locity of the circulation; and although it will not accomplish
more than a small part of what its eulogists  have promised us,
it is among our most  useful medicines.  The advantage of di-
minishing the velocity of the circulation is twofold.  1st. Its
mechanical influence  on the momentum with which the blood
is driven into the  inflamed vessels  and disorganized tissues, (the
momentum being compounded of  mass  and velocity,)—and,
2nd.  The lessening the irritation  and exhaustion of the heart
itself, which must be proportioned to its muscular exertions.
   I  have  acknowledged the want of a clear understanding of
the  best  adaptation of this medicine; it is  more easy to point
out  the  circumstances in which  it will do little or  no good.
We shall hardly  derive any advantage from it while the pulse is
hard and strong,  or the febrile excitement runs high ; and it will
surely do harm if given  so largely, or so long persisted in, as to
affect the appetite and digestion. 
TUBERCULAR PHTHISIS.
313
  Mercury is decried very generally as unsuited to the manage-
ment of tubercular phthisis, and, indeed, Cullen  and  others
affirm  that it hurries forward  the disease.   Its effect will  de-
pend on its mode of administration.   Much  injury will  accrue
from its hasty use, and  from the excitement  of an irritating
ptyalism, when the case is advanced.   But, in  the early stages
of pulmonary inflammation, whether  complicated with the pre-
sence of tubercle, or not, it  may be so prescribed as to do good
service.  I give calomel in small doses, at first with nitrate of
potass: and digitalis, or tartarized antimony, or  Dover's powder,
as circumstances may indicate.  Afterwards I use it in the valu-
able combination already spoken of—the deutiodide of mercury
and potassium.
  Concerning opiates, I have nothing to add to what has been
said on former occasions.  They are absolutely indispensable,
constituting our principal means of relief from  sufferings which
we cannot remove, and of lessening  evils which have no termi-
nation but in death. I do not hesitate to offer them as freely as
may be requisite for these purposes, and in such modes of pre-
paration as are best adapted  to the comfort of  the patient.   They
form the efficient ingredients in the numerous demulcent drinks
taken to abate the tickling and incessant cough which harrasses
the  sufferer by day and by  night, and which,  were  it not for
opium, would deprive him  altogether of his chief solace, "na-
ture's sweet restorer, balmy  sleep."
  Prussic acid, which, like digitalis, was at first held  up by its
encomiasts as possessed of specific properties which adapted  it
to the  radical  cure of phthisis, has already fallen into compara-
tive neglect, or is employed merely as a palliative.  In this
regard  its value is not to be doubted,  and we have the respecta-
ble names of Magendie, Granville, and  Brera, in its favor.   Dr.
Oliver, of Salem, claims the merit of having originally applied
it here, having prescribed both  the distilled water and the satu-
rated tincture of lauro-cerasus in phthisis as early as the year
1S10.   It seems to me to act on the nervous system chiefly as a
sedative and narcotic, diminishing the  irritation of the affected
tissue probably by subduing  its sensibility or super-sensitiveness.
It is thus calculated to assuage both the violence and frequency
of the habitual cough, dry and urgent, partaking of a convulsive
       vol. ii.—27 
314
TUBERCULAR PHTHISIS.
or spasmodic character.  Generally  those  formulae  are  to be
preferred in which this powerful agent is diffusely mingled, such
as I have  already  mentioned, and the water of bitter almonds;
but sometimes it  is  necessary  to  have recourse, with  proper
caution, to the concentrated acid of the chenijsts.  It is, perhaps,
though  not uniform, and not very definitely manageable in its
influence, the purest example of a  sedative in our hands.  Dr.
Thomson observes, "that he has never  seen its  sedative effect
preceded  by any increase of the action  of the  heart  and arte-
ries ; nor  does it appear to be  capable of producing  inflamma-
tion in parts to which it is applied."
  Local sedatives also have been applied directly to the diseased
lungs.   When the stores of  pneumatic chemistry were first laid
open to physicians, the discovery excited unbounded hopes of
finding here  medicinal agents  of importance, and especially in
affections of the respiratory organs, to which they seemed imme-
diately applicable.
   Dr. Beddoes, with laudable zeal, instituted a course of experi-
ments, which were,  at first, alleged to' have  been  strikingly
successful.  The gases have, however, fallen into almost entire
disuse, though Murray has lately endeavored to renew our lost
confidence in the  nitrous gas,  which he  eulogizes highly as a
specific and very promising remedy.
   Of chlorine and iodine inhalations, I have  nothing to add to
what was formerly said.  My  trials with them have produced
no good results whatever.
   We would anticipate some soothing influence from the inspi-
ration of air made to contain a less quantity of oxygen, which
is generally regarded as a stimulant, such  as  atmospheric mix-
tures with nitrogen and hydrogen and with carbonous oxyde or
carbonic  acid.   In a similar way, we  may account  for  the ad-
vantage said to have been derived by some consumptives from
residing in stables with cattle,  so much in vogue in England in
the time  of Darwin and Beddoes.  Dr. Priestly's  daughter, and
 another English lady of distinction, are said to have been thus
 cured.
   I have already spoken  of the  inhalation of finely powdered
 alum and acetate of  lead, etc.   Whatever may be the effect of
 these in the latter stages of phthisis, when the lungs are exca- 
TUBERCULAR PHTHISIS.
315
  vated by abscesses, and the vessels  are  relaxed  with copious
  expectoration, they must be injurious in the earlier periods of
  irritation and inflammation.  It is scarcely necessary to remind
  you of the caution with which, in the meanwhile, all exposures
  to cold and  moisture  must be avoided.  During the summer
  your patient may be allowed to enjoy the  delights  of a clear sky
  and a genial atmosphere ;  but when the seasons become change-
  able, he must either confine himself to  his apartment, or  adapt
  his clothing, with the utmost care,  to the  vicissitudes of the
  weather.
    Much stress has recently been laid on the injury done by the
  admission of cold air  into  the lungs, and methods of evading
  the evil have been invented and pressed upon* our notice.   Some
  urge, that the patient be compelled to breathe through a metallic
  tube, which,  soon  becoming warm by the air  expired, will,  in
  time, give warmth to the inspired column.   The  same effect is
  said to be produced by a metallic net of fine wire  gauze, like
  that of Davy's safety lamp, worn before the mouth and nostrils.
  Experience teaches invalids to imitate these modes by breathing
  through a handkerchief, or, which is still better, a loosely woven
  woollen comforter.  Flannel or fleecy hosiery must be worn at
 all times next the skin.
    The diet of the consumptive is a matter of considerable im-
 portance.  It is a common error to lay down  universal rules on
 this subject, and prejudices  have  run  strongly in  favor of this
 or that particular article as adapted for  the exclusive use of all
 patients.   Milk, Iceland and  Irish moss, the  several mucilagi-
 nous solutions, as of arrow root, gum Arabic, and the like,  have
 all their encomiasts.  I am  not friendly to any exclusive  diet.
 I have repeatedly tried the  experiment of confining my patients
 to a milk diet, but they have usually "become  disgusted with it,
 and so lost strength with  appetite.   Asses'  and  goats'  milk,
 which, in Europe,  are  preferred to that of  the cow,  are not
 readily to  be  obtained among us. Whey is  less cloying, and
 should be chosen in the  early stages.   Indeed, while there re-
 mains much  local or constitutional excitement, I would forbid
all animal food and sustain  life on gruels  and thin mucilages.
This stage having  past, I would allow milk and  eggs, light 
316
TUBERCULAR PHTHISIS.
vegetables, fruit,  and bread  in  its common forms.  It is  not
unusual  to  see  the appetite  and  digestion unimpaired, even
when the debility and emaciation are very great.  Under such
circumstances, a free and nourishing diet  should be accorded of
whatever may be agreeable.  Salvadori  and  May, who look
upon phthisis as  originating  in  and  depending  upon debility,
prescribe copious meals of soup, meat, eggs, oysters, porter, and
wine, alternately with the use of emetics, bark, and laudanum.
  In  regard to exercise,  the same discrimination is  required
which I have just  advised as to  diet; yet we find Sydenham
directing promiscuously horse-back riding, and Salvadori making
his patients run up hills and  climb mountains.  I well remem-
ber a case which  exhibited all the evidences of a most gratifying
convalescence, when the patient being induced to walk quickly
up a steep hill, was seized with haemorrhage, and sunk at once
into a premature  grave.
   That  by a judicious employment of exercise, we give vigor
to  the invalid, and impart  to his constitution  such tone and
energy as often to enable  him to bear without exhaustion a long
protracted pulmonary affection, and sometimes, as we hope and
believe, to wear  out the  consumptive diathesis,  is not to be de-
nied.  Yet we must carefully adapt the mode and amount to
the circumstances of the  individual.   The passive exercises—
those of gestation,  are  the first  which  can be  borne and  are
scarcely ever unsafe.   Rocking  in a cradle is known  to have
been serviceable—swinging, sailing—riding in a carriage, espe-
cially if he is able to drive himself.  If his strength will permit,
set him, however, on horse-back, in preference to all other modes
of exercise.  The obvious objections to it, are, that it fatigues a
weak patient, and sometimes occasions pain in the chest, brings
on difficulty of breathing or  panting, and increases the inclina-
tion to cough.  When it produces either of these consequences,
it is positively prohibited, and we must choose some other mode
of  exercise.  But when  it is well-borne, I do not hesitate to
affirm, with Sydenham, that "it will  do more  good than  any
other remedy, or than all other remedies put together."
   To obtain the full benefit from these exercises, they must be
persisted in with constancy, steadiness and regularity ; and hence 
TUBERCULAR PHTHISIS.
317
 we should  advise a sea voyage, or a long journey on land—
 which will combine also the peculiar advantages of a change of
 climate.
    By those who are fond of laying down uniform and exclusive
 rules for the government of invalids, the question has  been
 warmly discussed,—whither shall we send our consumptive pa-
 tients ?  and the best proof of the  vagueness of the reasonings
 on the subject, may be found in  the fact, that sufferers under
 pulmonary diseases are often advised to  remove  to districts of
 country particularly subject to such affections.  This is said to be
 strikingly true of Bristol in England, and of Montpelier, Nice,
 Lisbon  and Naples, on the European continent; which have,
 therefore, fallen of late  into comparative disrepute.
    My own  opinions on this point are briefly these.   That a
 change of climate is always desirable, according to the max-
 im of Celsus, that "the air in which a  man grows sick is the
 very worst air for him ;" that a preference is generally due to such
 regions as enjoy greatest equability of temperature; that a north-
 ern winter should be avoided by migrating to a southern latitude
 and that  a southern summer is almost equally dangerous, in its
 ultimate effect, though  perhaps less promptly fatal.
   Rush  advises American  patients to pass the winter and a part
 of the spring in South-Carolina and Georgia ;  in summer, to go
 northwardly into Canada, as  far as  Quebec; and to return in
 autumn to Pennsylvania and New Jersey.  He inculcates strong-
 ly the necessity  of keeping far from the  sea  coast, believing a
 mixture of land and sea air highly prejudicial.   I  think it is so
 in bronchitis, and the discrimination should be made ;  for it is
 rather beneficial  in most cases of apostematous  and tubercular
 phthisis.  The atmosphere of islands and of many points on
 the coast, Madeira, the West Indies,  St. Augustine and Savannah,
 is found  to be generally salubrious to pulmonary patients.
   Lamentable  disappointments are annually experienced by in-
 valids, who have sacrificed the comforts of home for unimpressive
changes of climate in vague hope of  recovery.   An East Indian
voyage or a circumnavigation of the globe, will  afford the best
chance of advantage ; beyond this, facts scarcely warrant us in
speaking confidently in  favor of any change, except that which
we may enjoy in a winter's visit to Cuba, Santa Cruz or Madeira
       27* 
318
TUBERCULAR PHTHISIS.
  Much was said a few years since, of benefit to be derived from
living in a low  malaria district, and the opinion was seriously
entertained, that the malaria of miasmatic districts which gave
rise to intermittent and remittent fevers, was antidotal or curative
in phthisis.   No error can be more unfounded.  It is not proved
that the  proportion of consumptive patients, is at all less than
the average in such districts;  and every physician must have
seen phthisis developed and hurried  on by attacks of malaria
fever.  I have personally witnessed several melancholy instances
of this kind.
   We shall not  be detained long by the discussion of our second
head.  The radical remedies by which it has been proposed and
expected to procure the removal of the tubercles already formed,
and prevent the farther progress of such  morbid deposition, are
few in number,  and, it must be confessed, all  of them of doubt-
ful efficacy.
   We  have already had occasion to  arrange, among the mere
palliatives, several medicines which had received high commen-
dation for their  specific adaptation here, as the nauseants, extra-
vagantly extolled  by Jenner ; foxglove so exultingly lauded by
Beddoes ; the gases, so confidently regarded by Darwin and Mur-
ray ; and the prussic acid, on which  so much recent encomium
has been heaped by Magendie and Granville.
   Whether we shall ever be able to procure the absorption of an
immature  tubercle, or  of tuberculous  matter deposited in any
form, is  very doubtful;  Laennec  decidedly thinks we shall not,
but the effort must be assiduously made and indefatigably persis-
ted in.   In the present  state of our  knowledge of the subject,
iodine doubtless offers us the best hopes  of success.  Of  all the
agents in our therapeutical armory, it exhibits the most obvious
efficacy in promoting the dispersion of tumors—probably by ex-
citing  the action  of the absorbents.   Under its  administration,
bronchocele and  mammary tumors very  generally disappear,
and the diminution of scrofulous swellings of various kinds has
been unhesitatingly attributed  to it  by the  best authorities.  I
will not indulge any enthusiastic anticipations of benefit from it
 in the present case ; but 1 must  not fail to urge it upon your at-
tention, as the fairest  subject of frequent, cautious  and minute
experiment.  I employ in preference, the valuable compound 
TUBERCULAR PHTHISIS.
319
 more than once mentioned to you—the deutiodide of mercury
 and potassium.   I have never found any of my patients injured
 by it.  I have heard only of one instance of ptyalism occurring
 under its use.  I have not been able to extend the dose so far as
 Channing and some others speak of, from twenty to twenty-five
 drops ; the greatest  quantity that I have known any stomach
 bear withont derangement or uneasiness, has been from ten to
 twelve drops thrice a day.   This should be continued for two or
 three weeks at least.  If this formula be irreconcileably offensive
 you may substitute Lugol's  dilute aqueous  solution.  I have
 abandoned  the  alcoholic tincture,  as  so frequently  irritating,
 that its use implies some unnecessary risk ; and the hydriodates,
 as having proved in my hands entirely inefficient.
   The scrofulous character of tubercular phthisis, has led to the
 trial of every remedy or  mode of treatment which has from time
 to time been found useful in strumous affections.  The result of
 these proceedings has been so little flattering,  that most physi-
 cians have come to the same conclusion  with Cullen, that "the
 analogy of scrofula gives us no assistance in this matter."  Dr.
 Roberts, of  St. Bartholomew's Hospital,  with a praiseworthy
 zeal and perseverance, ran through the whole range of such me-
 tallic salts as have been  commended in cases of scrofula—the
 muriate of barytes, the nitrate of silver, the preparations of cop-
 per, arsenic, zinc and lead—and has had the singular  candor to
 acknowledge the failure of them all.
   Dr.  Trotter, however, affirms, in  his  Medicina Nautica, that
 salt and a salt diet have proved of eminent service ; and that the
 most effectual remedy for this modification  of phthisis,  which
 he regards as essentially  scrofulous, is the combination  of cin-
 chona with sulphur.   From the latter, I have never derived any
 benefit; but after the maturation of tubercle, the  diminution of
 pulmonary inflammation, and the establishment of free expecto-
 ration, I have found great advantage from cinchona, administered
 in cold infusion.  Others tonics also, as  iron and bismuth, are
 admissible, but I do not imagine them to exert any specific pow-
 ers in the case; they are  useful simply as tonics.
  It is well known that the symptoms  of phthisis pulmonalis
are checked and controlled, and at any rate, the disease is made
to progress more slowly, by the occurrence of pregnancy in our 
320
TUBERCULAR PHTHISIS.
female patients.   The most delicate and feeble woman will pass
through this period, without any apparent increase of the affec-
tion of the lungs, and generally, with  alleviation  of her suffer-
ings.   She lives long enough to give birth to the  infant, which
has not only derived from her  its formation and  development,
but by a striking reciprocal influence,  has prolonged  her life—
and soon after dies exhausted.  Or it may be, when the case is
less advanced, that  successive pregnancies shall  put off the fatal
termination, until the consumptive diathesis has,  so  to speak,
worn itself out, or the constitution has, in some manner accu-
mulated sufficient vigor to resist successfully the destructive pre-
disposition.
  During lactation, however,  this truce, as it has  been well
termed, does not seem to be continued, and the  dreaded symp-
toms recur.   Indeed,  the emaciation and debility  progress, for
the most part, with greater rapidity, under the abstraction of so
much from the mass of fluids,  in the secretion of milk for the
support of the infant.  For this reason, we should advise women
of scrofulous habit, or such as  seem liable to pulmonary affec-
tions, to abstain from suckling  their children.  We thus dimin-
ish the chances of transmission of the scrofulous  or  tubercular
diathesis, by causing  the child to be  nourished from a healthy
breast; and besides this, we know that the woman is much more
likely to become  again  pregnant, than if the infant  were per-
mitted to keep up the determination to the breast by nursing.
  A similar suspension of the progress  of phthisis,  to be ex-
plained, no doubt, upon the same  principle of revulsion, is ob-
served to occur, if the patient is  attacked by fistula in ano, a
circumstance by no means uncommon.  The fistula being cured
by  the knife or otherwise, the symptoms generally return, though
not always.  Good records an instance of recovery, by the forma-
tion of a fistulous abscess, which was itself cured by an opera-
tion.   It is also stated, that those who have been  afflicted with
fistula in ano, are specially liable  to fall subsequently  into con-
sumption.   The  truth of  these remarks I do not doubt, having
repeatedly verified  them; but I am disposed to regard both the
fistula and the phthisis, as being derived from the same morbid
condition of constitution, and  by no means as  standing in the
relation of cause and effect to each other. 
                    TUBERCULAR PHTHISIS.                321

    I should also notice the alternation of consumption with  ma-
  nia, gout  and rheumatism,  as  affirmed by  Mead, Rush,  and
  others, and the suggestion, that as it has been found  to be in-
  fluenced, and at least, in a temporary way restrained  by other
  affections, it may be supplanted by some other less fatal malady,
  which "shall exert  over it a control, like that of cow pox over
  small pox."  The whole inquiry, however, is as yet hypothetical,
  and barren of all  practical consideration.
    The importance of the Prophylaxis—the preventive manage-
  ment of subjects predisposed to the invasion of so uncontrollable
  and mortal a form of disease, is evidently peculiar, and entitled
  to our most particular attention.   Two plans are proposed.  The
  first, which is almost universally received and acted on, consists
  in the strictest endeavor to evade exposure to what are regarded
  as exciting causes of pulmonar}?-  inflammation.  Upon this prin-
 ciple, parents arrange the education of their children, and allot
 to them their future pursuits in life.  If a boy seem weakly, or
 exhibit any defect of constitution, or his chest  be narrow or ill
 formed, he is destined to the desk, the bar, or the pulpit, because
 he will not be able to bear the fatigue of physical labor  in the
 open air.  More and more indulgence and shelter are  provided
 for him, if, as he  grows up, he shows more muscular feebleness
 or more obvious consumptive predisposition.   Such a course as
 this, merits the most unqualified censure, and ought to be utterly
 abandoned.  And, both from reasoning and  the observation of
 facts well authenticated, we are led to prefer the second method
 of prophylaxis, which contemplates the effectual confirmation or
 strengthening, if it be possible, of such defective constitution,
 by such modes of life as, disregarding all ordinary exposure to
 the causes of disease,  shall confer strength to resist them, or
 elasticity to throw them  off.
   Phthisis, though perhaps not exclusively limited  to civilized
 and refined conditions of society,  is found to  occur in a  pretty
 regular ratio to the progress of sedentary  and effeminate  habits
 of living, every where.   The Indian hunter, and the pioneer of
 our western forest, are comparatively free from it, and even the
 agriculturist, when his toils are extreme, as in clearing new coun-
tries.   It prevails most in cities, in the library of the student,
behind the desk of the merchant,  and in the close, ill ventilated 
322
TUBERCULAR PHTHISIS.
apartment of the tradesman and the  manufacturer.   Exercise,
constant and rough exercise in the free, open air, or what is still
better, hard labor, is the true preventive of consumption.  The
original curse, which doomed man to till the earth and  to  pro-
cure his bread by the  sweat of his brow, is a blessing of the
highest order, when compared with the artificial evils of indo-
lence and effeminacy.
   The unfortunate youth, who, by his  descent from consump-
tive parents, by original defect of constitution,  or by some  mal-
formation of his thorax, is apparently destined to a life of debility
or a premature death, has one chance for escape.  Let him be-
come a ploughman,  a sailor,  a mechanic—let  him choose for
himself some mode of active and hardy life, which shall  tend
to invigorate his frame.  If it be replied, that  he  is unable to
bear the toils of such occupations, 1 answer, that he can be made,
by proper exertion and reasonable exposure, able  to bear any
thing.  Speaking of exercise in the saddle, with this view, Dr.
Fuller says, "He  must, like a Tartar, learn to live on horseback,
by which means he will acquire, in time, the  constitution  of a
Tartar."  "Weakly children," says Rush, "should be trained to
the laborious, and the robust to sedentary occupations;" and his
advice should be  followed in  this matter, as if uttered by  the
voice of  an  oracle.
   I must not, however, be understood to recommend this harsh
course of management, when  phthisis has already begun its
organic ravages—when pulmonary inflammation obviously ex-
ists—or the  fever of irritation has assailed the system.  I would
confine my remarks to the  modes of  prevention  calculated to
eradicate or  control the hereditary  or constitutional predisposi-
tion, before any circumstances have excited it into action.  When
the symptoms of  phthisis  have  actually  presented themselves,
the case is widely different  in  its aspect,  and  demands much
delicacy in its treatment, as well as skill and nice judgment.
Yet even now, in certain instances, the patient may be saved by
the measures above recommended—and hence it  becomes an
important question, though not "the  first," as it is esteemed by
an excellent writer, "Whether he is able to ride on horseback?"
   If he cannot bear exercise, he must  avoid exposure.  Regu-
late with assiduous care, all  his habits, his diet, his dress.   Do 
ASTHMA.
323
not "suffer the winds of heaven to visit his face too roughly."
Hopeless as we may be of his ultimate restoration to health, we
may both protract his life, and alleviate his sufferings;  and by
our anxious, faithful and persevering attention to these duties,
we shall at least be certain, whatever the success or failure of
our professional efforts,  to obtain the applause of our own con-
sciences, and the esteem of all the good and intelligent.
                     CHAPTER XLIV.

                          ASTHMA.

   This formidable and distressing disease,  which in the course
 of your practice, you will but too often have occasion to encoun-
 ter, may justly be ranked among the most obstinate and indom-
 itable that affect  the  human frame.  Whether  it be from a
 peculiar inherent tenacity in  the nature of the morbid action
 which constitutes its proximate cause, or from our not having
 yet obtained possession of the proper means adapted  to control
 its movements, or arrest the influences which excite it. 1 cannot
 take  upon  me to  determine;  but I am,  in candor, obliged to
 acknowledge, that it is seldom allotted to the physician, to enjoy
 the gratification of relieving permanently, an asthmatic patient.
 We are able, however, to effect something in his behalf.  By pur-
 suing judiciously, the measures about to  be pointed out to  you,
 we may  always  procure a very considerable alleviation of his
 sufferings ;  and by assiduous attention, we shall often succeed in
 evading, or at least, diminishing the ill consequences  ready to
 accrue from the wearisome malady under which he labors.
   The term Asthma, is applied correctly to designate a species
of dyspnoea, which may be described as paroxysmal—spontane-
ously remitting-, or  subsiding altogether after a certain duration—
and recurrent, disposed, that is, to return of its  own accord,  as
well as upon the re-application of the same exciting causes which
originally gave rise to it. 
324
ASTHMA.
  Laennec, in one of his paragraphs, seems partially inclined to
deny it a  distinct  existence as a separate form of disease,  and
speaks of it as a mere symptom of certain organic lesions which
he points out.  A little farther  on,  however, he confesses une-
quivocally, that it may exist, unattended by, and  independent
of any such organic lesions, though he affirms this to be a very
rare case.   Admitting the fact to be as he asserts, the question
would still be entirely undecided, whether these  lesions are or
are not connected essentially, either as causes or effects, with
the disease under  discussion.   He treats of it as  complicated,
chiefly with "chronic catarrh;" and Mcintosh implicitly follows
him, confounding  it with "chronic bronchitis."  I am at a loss
to imagine how any one can be misled, by  views so obviously
erroneous.  Catarrh  and bronchitis exist in thousands  of in-
stances, without the supervention  of asthma.   The  dyspnoea
which may be present in these, is perfectly distinguishable from
the peculiar and characteristic dyspnoea of the asthmatic.
   Asthma is often described as of two species or varieties, the
dry or nervous,  or spasmodic ; and  the humid or humoral.  In
the first, the difficulty of breathing is convulsive, attended with
a hissing  or creaking noise;  the paroxysm,  though severe, is
usually short, and terminates with little or no expectoration.  In
the second, the respiration is labored and vehement, apparently
impeded by  the effusion of an  inordinate quantity of mucus
within the lungs ; the mucous  rale is loudly audible ; the pa-
roxysm is of tedious length, and terminates at last with free ex-
pectoration of a frothy or tenacious mucus.
   The differences thus dwelt on, are sufficiently notable, and indi-
cate corresponding variations in the actual condition of the parts
affected ;  but there are points enough  in common, and of such
characteristic nature, as to justify  us in considering the  two
modes of asthma under one head and denomination.
   It is frequently asserted, that asthma exhibits itself as a symp-
tom of other diseases of the lungs, and of affections of the heart
and large blood vessels.  This I do not  believe; I  have  met
with no such instances,—nor am I satisfied with  the alleged
proofs.  Dyspnoea is a common symptom of all  these;  but
dyspnoea is not asthma.  Asthma may, perhaps, by the vascular
obstructions and  congestions which arise  during its progress, 
ASTHMA.
325
after long continuance and frequent recurrence, originate any or
all  of them.  Or, it may  be transiently connected with some
among them, as produced  by the  same  excitement  in  systems
predisposed or habituated to it, as when an asthmatic is attacked,
after getting wet,  with pleurisy  or  pneumonia or bronchitis.
This is only admitting the two states of disease to be compatible
with each other, but by no means placing them in the relation
of cause and effect.
  The paroxysms  of asthma have their access almost uniformly
in the night, and are generally preceded or accompanied by evi-
dent tokens of gastric disturbance or  indigestion, oppression at
the scrobiculus cordis, heartburn, flatulence,  vomiting, and a
loose, griping stool.  The patient is attacked  soon  after going
to bed, or awaked from his first light sleep, with a sense of un-
easiness and constriction of the chest, difficulty of respiration,
and cough.   He is obliged to sit up, and cannot bear the weight
of the bed-clothes, nor the confinement of any fastenings about
the upper part of his body;  he seeks for fresh and cool air with
the most intense eagerness and avidity.   There is wheezing and
panting; the shoulders are elevated, the nostrils expanded widely,
the eyes staring and bloodshot, the lips  bluish, and the whole
countenance expressive of the deepest anxiety and distress.  The
cough is, in most,  loud, sonorous, often repeated, and  at  first
dry; in some bad  cases,  it  is  husky and  feeble, gasping and
whispering;  after  a little while, some frothy mucus is brought
up, which in the humid  variety,  increases in quantity as the
paroxysm declines, and often becomes abundant.  The  violent
efforts made in coughing, sometimes occasion  the rupture of one
or more small blood vessels,  the effusion from which,  scarcely
ever fails to bring a degree  of  relief.  In very severe attacks,
and when the patient is much debilitated, he  may  be entirely
unable to cough or expectorate;  his sufferings from  dyspnoea
being of course proportionally greater and more protracted.
  The symptoms thus briefly enumerated, being those connected
immediately with the morbid condition of the respiratory organs,
are not liable to any very striking variation, but occur with nota-
ble  similarity in all the several orders of cases.  The impres-
sion made by the  attack,  however,  upon the functions of the
general  system,  sympathetically, is  diversified, as we would
      vol n.—28 
326
ASTHMA.
anticipate, by all the differences of constitution,  habit, age and
temperament.   In the plethoric  and robust,  the pulse will be
found hard and frequent, and of large volume ;  the visage will
be flushed and  turgid,  the eyes  prominent and reddened, the
tension across the thorax severely painful  and  urgent.  In the
feeble and aged, on the other hand, and when  the disease has
become habitual, we meet  with a set of very opposite circum-
stances.  The features are shrunk and contracted; the face pale
or livid; the skin relaxed, moist  and cool; the ears,  nose and
extremities, cold;  the pulse low, small and weak; the tokens of
gastric and intestinal disorder are prominent;  there are cholicky
pains, sometimes with  tenesmus and  diarrhoea; eructations of
wind and acrid fluid, and perhaps nausea, with retching and
vomiting of foul  pancreous matters, and occasionally gastric
spasm or cramp of the stomach,  violent  and painful, with or
without  hiccup.
   Blood drawn during  a paroxysm of asthma,  is always  dark.
The urine is, for the most part, discharged frequently and co-
piously,  being of light hue or limpid.   Bree mentions a case, in
which it was always deep red or coffee colored, for a  short time
previous to a paroxysm.  I have had for  many years under my
care, a female patient, in  whom  a troublesome  incontinence of
urine attends every attack.
   The duration of the paroxysm is very  uncertain.   A remis-
sion of the more violent symptoms usually takes place with the
return of morning, when  our  patient,  languid and  exhausted,
falls into a slumber, from which he wakes unrefreshed,  to pass
a restless and uncomfortable day, teased  with  some  remaining
oppression  of breathing,  accompanied by slight but  frequent
cough:  At night, he is again attacked in the manner above de-
scribed,  and this alternate remission and  exacerbation continue
for a few days, four perhaps, or five on the average, and then
gradually subside and disappear.  An  instance  is recorded, in
which this state of things lasted through  seven  miserable weeks.
   The general Prognosis, in regard to the result of a given par-
 oxysm,  is favorable.  In treatises of the physiological function
 of respiration, it is stated, as you will recollect, that a small pro-
 portion  only, of the air in the thorax, is forced out at each ex-
 piration, and hence, that a very limited part of the actual capacity 
ASTHMA.
327
of the lungs, is employed in the successive movements of breath-
ing.  The reason is then, obvious, why this disease, so terribly
distressing to the patient, and so alarming in its appearances to
those who surround him, should so seldom offer a  termination
promptly fatal.   Suffocation, indeed, would  seem  to follow
nothing less than a total closure  of the air tubes, and an  abso-
lute deprivation of oxygen, or its non-admission into the cells
of the pulmonary tissue.   A few instances, however,  of imme-
diate death in  the paroxysm,  are related.   EUiotson says, in his
Lectures, "I have seen people die from pure spasmodic asthma"—
and goes on to give an example.
   Yet we must not imagine, that attacks of such violence should
be repeated, without the  most serious injury.   The  asthmatic
may live  to old age, but his life  is  languid  and joyless;  his
muscles are weak and flabby;  his digestive organs  lose their
tone, and his whole frame, bent  and emaciated,  gives evidence
of premature decay and oppressive debility.   He falls a victim,
frequently, to hydrothorax or universal dropsy; or his lungs be-
come organically affected, and he dies of chronic bronchitis  or
phthisis pulmonalis.  One of the consequences or attendants of
asthma, is the  production of emphysema of the lungs.  Its fre-
quency is exaggerated somewhat by Laennec,  who  errs also, I
think, in ascribing to it as a cause, the phenomena  of the par-
oxysm of asthma.
  Autopsy. Dr. Baillie had,  before Laennec, correctly described
this  state of the organs.   "The bronchial cells are found, after
death, largely  dilated, and do  not collapse on opening the cavity
of the thorax,  the cells being  enlarged, not only by  this disten-
sion, but also by the breaking down of two or  three  into one;
and  there is also extravasation of air under the pleura, forming
vesicles attached to the edge of  the lungs."  It  is unnecessary
to dwell upon  such appearances  presented after death, in  com-
plicated cases,  when there have been bronchitis, and other pul-
monary disorders and cardiac affections combined.   Of course,
the lesions will vary with the history of these.   But in simple,
or what EUiotson calls "pure spasmodic  asthma,"  there  is no
change of structure traceable.  In the case already  referred to
he says, "no signs of disease  were found; but  the  lungs  were
all distended, had lost their contractile power, so as to be unable 
328
ASTHMA.
to collapse, and were as light as a feather."   Ferrus,  quoted by
Copeland, "after extensive experience states, that he has been
unable to detect any lesions which can be attributable to uncom-
plicated asthma.  Willis records a case of protracted asthma,  in
which no morbid appearances could be  detected; and  similar
cases have occurred to Andral, Cruveilhier and Bouillaud."
  The Pathology of asthma is in the highest degree obscure and
uncertain.   Cullen ascribes the disease to "accumulation in the
lungs,  or some fulness in their vessels."   He  observes,  that it
depends upon a particular constitution of the lungs; that the
proximate cause is a preternatural, and in some measure, spas-
modic constriction of the muscular fibres of the bronchi, which
not only prevents the  dilatation of the  bronchi necessary to a
free and full inspiration, but gives also, a rigidity that prevents
free and full  expiration.  This preternatural  constriction, he
adds, like many other spasmodic  and convulsive affections, is
readily excited by a turgescence of the blood, and other causes
of any unusual fulness and distension of the vessels of the lungs.
Parr maintains, that  "the  proximate cause of the convulsive
asthma, when complicated with the humoral, is a spasmodic con-
striction of the air vessels of the lungs, occasioned by an increased
secretion of mucus, from a relaxation of the  mucous glands."
Bree, a late writer of  no little reputation, whose portraiture of
this cruel malady is made more accurate and valuable, from his
personal sufferings under it, takes a similar view of the  matter,
attributing the train of symptoms "to inordinate effusion from
the pulmonary exhalents."   Indeed, it has  been common for a
long time past, to assign this supposed relaxation of the mucous
exhalents of the lungs, as the sufficient cause of humoral asthma,
which is the form chiefly taken, when  the disease has  become
habitual by repetition.
   Professor  Cooke of Kentucky, ascribes asthma simply to ve-
 nous congestion—a condition admitted partially, both by Cullen
 and Mcintosh—to "an accumulation of blood  in  the  cava and
 its branches;" which he  thinks may produce and explain all the
 phenomena present.   I have already alluded to the opinions of
 Laennec, who regards "the cases denominated humid or humoral
 asthma, as simply examples of chronic catarrh," and "spasmodic
 asthmas, as differing  in  nothing  from cases of emphysema of 
ASTHMA.
329
 the lungs."  He goes on to say, however, with more than usual
 caution,  "I do not mean to deny that there may be asthmas, or
 to speak more exactly, dyspnoeas purely nervous, or unattended
 by organic pulmonary lesion.  Under this head of purely nerv-
 ous, he would range the spasmodic asthma, when  this is well
 characterized by an  evening paroxysm  and morning remission,
 after a slight expectoration."  Mcintosh, who follows him closely,
 after mentioning "chronic bronchitis, emphysema and conges-
 tion, as the true conditions of the lungs which most frequently
 produce  asthma," says farther, "and I believe it is also occa-
 sioned by some kind of nervous irritation, the nature of which
 is yet unknown.  There  is almost always something  more in
 this disease than the original organic lesion"—"and I imagine no
 one can deny, that asthma may be produced either in consequence
 of some diseased action in  the brain, or in the nerves themselves
 which supply the lungs."   EUiotson says, "the disease is literally
 pure spasm,  and does  not depend upon any  organic cause."
 Watson, after arguing the question ably, and at length,  comes to
 the same conclusion.
   Both  Reississen and Laennec have shown  that the bronchi
 possess a muscular structure, through  the agency of which these
 air vessels contract,  when  under the influence of spasm at least,
 if not in  ordinary respiration.  The former traced  these  fibres
 in tubes of a very small diameter;  the latter in bronchial rami-
 fications less than one line across.  Watson has demonstrated
 them "exaggerated by hypertrophy" in the large bronchi.  Wil-
 liams has proved that these fibres are contractile to a very consi-
 derable degree, under chemical, electrical and mechanical stimuli;
 and  Valentin  declares that "the rings  of the  trachea  can be
 made to contract visibly and distinctly, by irritating the par va-
 gum.  From all this Watson is led to infer that "asthma is one
 of the spasmodic disorders of the excito-motory system of nerves.
 The  spasm may be either of  centric or excentric origin; in the
 latter form the par vagum is  doubtless the afferent nerve, and
 the impression  it conveys to the medulla oblongata is reflected
through  the associated motor nerves  to the bronchial muscles
The centric variety results from a similar impression originating
in  the nervous  centres, which respond mysteriously to certain
feelings of the mind."
       28* 
330
ASTHMA.
  These recent views of the pathology of asthma  were in good
degree anticipated by the sagacious Cullen.  My own opinions
of the subject are built upon a similar basis.  I do not doubt that
asthma is often connected with pulmonary congestion  and in-
flammation ;  but I regard it as essentially dependent upon a spas-
modic affection  of the muscular fibres  of the bronchial tubes—
and this spasm indeed, as its true proximate cause.   I do not see
that it is necessary to imagine these fibres to have become rigid
uniformly in the state of complete contraction.   Their rigidity
in the intermediate condition accounts for the sense of constric-
tion so much complained of, even when the passage of air does
not seem to be greatly impeded, the blood  being  of florid color
in the cheeks and lips.  And as Cullen has remarked, the patient
complains quite as much, if not more,  of difficulty in expiration
as in  inspiration.  Some of the severest attacks of  asthma pre-
sent little indication  of effusion  within the lungs ;  the resonance
upon  percussion is loud, occasionally too great; the rale is sibi-
lant and crepitant rather than  mucous, and the solution of the
paroxysm is effected with little or no expectoration.
   The remote Causes  of  asthma are  various.  They may be
naturally enough divided into—1. Such as affect locally the res-
piratory organs ; and 2. Such  as act  upon them through the
medium of the general system.
   Of the first class,  the most important perhaps is the proclivity
derived from original peculiarities of structure, vicious  confor-
mation of the thorax and its contents, the lungs, heart and large
vessels.  This predisposition  is of hereditary transmission, and
in such cases the disease is very readily brought on,  and special-
ly unmanageable both as regards violence and duration.   When
an attack has once occurred, it generates promptly a remarkable
tendency to its own repetition.   Habit has hence  almost irresis-
tible force in giving it  permanency or rendering it obstinately
tenacious.
   The second class  of causes, those namely which act indirectly
on the respiratory system,  may  generally be  considered exciting
or occasional.  Among the most impressive are cold and mois-
ture ;  exposures to  sudden variations of temperature;  inappro-
priate changes of dress ;  and briefly,  all such circumstances as
give  rise to catarrhal affections, with which, in this respect, hu- 
ASTHMA.
331
  mid asthma seems closely allied.  Repelled eruptions are by se-
  veral writers  enumerated among the efficient exciting causes of
  asthma.  The air of crowded  rooms  and  other  ill-ventilated
1  places will bring  it on.  Laennec ascribes it in one case to the
I  exhalation—so offensive often in smell—of a newly extinguished
\ lamp.  Many other  exhalations and  odors are accused of the
  same ill  effect.   It is recorded of several  persons that they are
  seized  with  dyspnoea—quasi asthmatic—upon breathing  the
  effluvium of ipecacuanha.  Of hay-asthma, as the English call it,
  I have spoken when treating of catarrhal fever.
     Full meals, especially if of unaccustomed or indigestible food,
  are dangerous to the asthmatic.  Late suppers are hurtful.  So
  are violent exertions in speaking and singing, walking, running,
  leaping, and lifting weights. I have  noticed, in two patients at
  least, a connection between  electrical disturbances in the atmos-
  phere,  as in thunder storms, with the repetition of their attacks.
  But when the predisposition is very strong, either originally, as
  when the tendency has been hereditarily transmitted, or has be-
  come so by habitual recurrence, the paroxysms frequently come
  on spontaneously, as the phrase is, or without the intervention of
  any apparent exciting or occasional cause.
     Asthma is not often met with in childhood or early youth.  I
  have seen it well marked  and habitual in one subject under ten
  years of age, whose mother was nearlyall  her life a martyr to it.
  Its access is usually about the middle term, or between thirty and
  forty, unless when hereditary ; in which cases it appears I think
  at or soon after puberty.  Cullen affirms it to be of more com-
  mon occurrence in the male sex, but  it has happened that fully
  two-thirds of the  patients  under my care and observation have
  been females.
     Of the Treatment.  Like all other chronic affections which
  have their periods of spontaneous  remission  and occasional re-
  currence, asthma  is a fruitful  theme of discussion with nurses
  and empirics; each  of whom is possessed of some  specific or
  peculiar nostrum, by means of which infalible relief is promised,
  if not absolute and lasting cure.  Relief indeed, in some degree,
  greater or less according to the contingencies present, may in the
  majority of instances be hoped for, and some palliation of  suf-
  fering  expected from our resources if  directed with skilful judg- 
332
ASTHMA.
ment;  but a permanent removal of the malady and of the pre-
disposition to its occurrence, is seldom—perhaps it would not be
too much to say, never—accomplished by art.  It is affirmed to
have disappeared in a few examples abruptly, permanently and
spontaneously__or under influences too obscure to be detected or
pointed out.
   The treatment of asthma is obviously divided into,  1st. The
measures  required  to be pursued for  the  relief of the  patient
during  the paroxysm; and,  2nd. The remedial  management
best calculated to prevent its return, if possible—at any rate, to
lengthen the  intervals of freedom from dyspnoea.  Our indica-
tions under the first head will demand to be modified to suit the
circumstances  of each particular case.   In a first attack, the
subject being of full habit and good constitution, and especially
if there be evidence of bronchial inflammation or pulmonary
engorgement, with febrile excitement  and a pulse full and hard,
and a visage  flushed and turgid, venaesection  is plainly called
for, and the loss of a proper quantity of blood will take off the
tension across the chest, and  remove  or palliate proportionally
the  oppression  and difficulty of breathing.  But we  must not
allow ourselves to be tempted to the  too  frequent  repetition of
this operation in any case, nor resort to it at all in instances of a
character contrasted with such  as I  have just described, as in
old habitual attacks in persons  debilitated or  far  advanced  in
a°e.  There is a degree of temporary alleviation which  seldom
fails to follow the use of the lancet, which will be  apt to induce
us to over-step the proper and prudent limit, and pay less atten-
tion than we ought, to its probable ultimate effects. I have  no
doubt of the correctness of the old notion expressed by Dr. Parr,
"that repeated bleedings in repeated fits, tend to hasten the com-
mon termination in dropsy."  Where the remedy is insisted on,
or earnestly requested by our patient,  we may  avail ourselves of
the knowledge of the fact, that in  such habitual cases, small
bleedings bring about all the  good results that can be  derived
from large losses of blood—nay, we  are  told by Dr. Whytt, of
 an  instance in which the  paroxysm was put  an end  to by a
 mere puncture of the arm, the patient having  been accustomed
 to expect ease from bleeding.  There is  rarely, if ever, at least
 in ordinary constitutions, any objection to the application  of 
ASTHMA.
333
 cups to the chest, either with or without scarification, their in-
 fluence being, as I suppose, rather revulsive  than  depletory.
 Similar relief may usually be procured from hot mustard poulti-
 ces applied assiduously, upon the same principle of derivation or
 counter-irritation.
   Emetics are very generally serviceable in asthma, and will be
 found applicable to a great diversity of the forms and conditions
 of the disease.  I fully agree with Akenside, who is one of the
 warmest advocates for the use of the  emetic, that  it should  be
 exhibited  as  early as may be.   At this  period of invasion, the
 dyspnoea  is almost always associated with  evident  tokens of
 gastric disorder, such  as  nausea,  flatulence, eructations of air
 and acid, straining to vomit, and the actual  ejection from  the
 stomach of foul and acrid matters.  Nor  is it merely beneficial
 by the removal of these irritating crudities;  it appears to me to
 produce a  directly relaxing effect upon the rigid and constricted
 bronchial fibres, and is  farther the very best and most influential
 of our expectorants.  Ipecacuanha is often preferred, but must
 not  be  offered until we have  ascertained, by enquiry, that  no
 idiosyncrasy exists  to  make it hurtful.   The tartarized anti-
 mony—the sulphates of zinc and copper—the  squill, and  the
 seneka, separately, and in varied combinations, have their advo-
 cates.   I see little reason for  any exclusive selection from among
 them, but  regard the  two latter as, perhaps, the best adapted to
 our  purpose, when a repetition of the emesis seems required.
 This may  be  advised, if, after waiting an hour or two, the diffi-
 culty of respiration does not diminish.
   These medicines will often act, too, upon  the alvine canal, a
 few loose stools being procured, and  usually with decided  ad-
 vantage.   To insure  this beneficial action, it is my custom to
 order a large  warm laxative enema.  After the  bowels have
 been thus emptied, a glyster of assafoetida may be administered.
 Indeed, under  the  general  impression of the spasmodic nature
 of the morbid affection here, the whole class of anti-spasmodics,
 as they are called, has been perseveringly experimented with,
but so far as I am to  speak from  my own  knowledge, with no
flattering success.  Musk, valerian, aether, castor oil, etc. have had
their advocates, but are now little, if at all employed.  Assafoetida 
334
ASTHMA.
alone retains any share of the confidence of the profession, and
seems, in some degree, to deserve it.
   In the class of narcotics, we find several valuable remedies
for asthma.   Of these, I  do not hesitate to give the first place to
opium, although its employment has been subject of severe ani-
madversion.   When  properly managed and well-timed, it  is
always useful.   The earlier symptoms of circulatory excitement
being reduced, the gastric oppression removed, and expectora-
tion promoted by the emetic,  I know nothing so well-calculated
to relieve the sufferings of the patient as a full dose of anodyne.
I combine the opiate prescribed with ipecacuanha or camphor
or nitrous aether, all of which formulae  determine  pleasantly  to
the  surface, occasioning  a free, warm perspiration, during the
continuance of which the cough becomes less harrassing;  there
is an easier  expuition of the bronchial mucus, and a kindly
relaxation  of the  pulmonary constriction;  the  difficulty  of
breathing subsides, and a  quiet, refreshing  slumber comes on.
I am not certain, whether I should rank here, or under the head
of emetics, the lobelia  inflata, which has, of late years, received
so  much commendation in   the treatment of  asthma.  It  is
highly prized, and has long since been favorably reported  of in
the Eastern States.  Elliottson has prescribed it with advantage
in England.   I  have often  found  it  serviceable, but use  it
chiefly in the early stage, to procure easy vomiting and expecto-
ration.  It is, however, asserted to give complete relief, notjun-
frequently, before occasioning any sensible evacuation.  The
datura stramonium is considered by some asthmatics an invalu-
able remedy.  It is commonly  smoked like  tobacco, the dry
leaves, stems and root being cut up and  burnt in  an  ordinary
pipe. To many, it is an unfailing means of relief, and resorted
to, as a matter of course, to avert a menacing, or arrest an  inva-
ding paroxysm.   It may not  be irrelevant  to  remark, that in
Williams' experiments upon  the  lungs of animals, those killed
by stramonium exhibited a striking defect of contractility in the
air-tubes, scarcely any contraction being producible in them by
the application of galvanism.  The smoking of tobacco is found
available by some asthmatics—others place confidence in a simi-
lar  use  of the leaves  of the black sumach.   Coffee, in very 
ASTHMA.
335
 strong infusion, is in common domestic use, and I have known
 it, in many instances, signally beneficial.
    The spider's web is mentioned  by Dr. Robert Jackson, and
 by Dr. Webster, of Boston, as having, in their hands, been pro-
 ductive of striking advantage.   The former having given to a
 patient who had long suffered the most distressing symptoms of
 the disease, a dose of twenty grains of this  article, it procured
 him a long, sound and uninterrupted sleep, "a blessing to which
 he had been an entire stranger above six years."
    The employment of the factitious airs  or gases so  strongly
 recommended  by Thornton, Beddoes and Darwin, has been
 almost altogether abandoned—more, I am persuaded, from their
 not being in general  procurable with facility or convenience,
 than from any want of efficacy or adaptation in the case before
 us. In habitual asthmas, I should confidently hope for much
 benefit from the  inhalation of oxygen, or rather of those Com-
 pounds in which it exists in large proportion, such, for example,
 as the nitrous oxyde or exhilarating gas.   I do not know whe-
 ther there is anything analogous in  the relief experienced by so
 many, from  breathing  the fumes  of paper  which has been
 steeped in a strong solution of the nitrate of potass: and burnt
 in the chamber.
   Dr.  Wilson Philip, whose  contributions to modern pathology
 and therapeutics are often  highly valuable, has been led by his
 observations on  the influence  of galvanism upon  the  secretory
 and exhalent vessels, to the application of  this impressive agent
 in many varieties of disease.  Among others,  he has experimen-
 ted with  it  in  asthma, and, as  he  affirms,  successfully.  He
 found it best adapted and most effectual in old habitual humoral
 attacks, in which, indeed, he declares, it will  scarcely ever fail
 to  produce immediate results, most prominently palliative or
 remedial.
   His  mode of operation is  as follows:—Two  thin plates of
 metal,  of  two or three inches  diameter, dipped  in water, are
applied, one to the nape of  the neck, the other to the lower part
of the  epigastric region.  Wires from the different poles of the
apparatus  are brought  into contact with these plates, and the
amount and intensity of the power increased, of course, or dimi-
nished  according to circumstances.  Though the trough is most 
336
ASTHMA.
efficacious, you will find the voltaic pile to answer every purpose,
and on account of its facility of transportation, far more conve-
nient to those of you who shall practice in  the  country.  The
sensibility of different  individuals  to  the  galvanic influence,
you should be aware, varies very notably, although, as a general
rule, it is in correspondence with their age.   Some are not able
to bear the impression of more than from 6 to 8 four inch plates,
while others require, to  affect them, from 25 to 30.  The nega-
tive wire excites the strongest sensation, and has, indeed, been
known  to occasion  the  sphacelation of a blistered surface.  I
feel myself bound to recommend this remedial agent, galvanism,
as worthy a fair and impartial  and persevering experiment in
your hands.  I have seen it more than once, though imperfectly
applied, give unequivocal  and immediate relief to the habitual
asthmatic.   Watson tells us, he once saw it bring on an attack.
This, to a homoiopathist, would be only an additional fact or
argument in its favor.   An eclectic would  not  regard it as a
serious objection to  its use.
  I would suggest, too, the propriety of making an experiment
with  the  newly  contrived electro-magnetic  apparatus.  It is
portable, convenient and impressive.  Its influence, analogous to,
though  not  identical with, that  of galvanism, seems to promise
some useful results.
  In the management of a  patient during the paroxysm, there
are some minor points which you will do well to attend to. His
apartment must be freely ventilated but kept at a regulated tempe-
rature, nor should his bed be placed in a draught or current of air
at any season.  This will be more particularly forbidden, if you
find him, as is often the case, covered with a relaxing sweat and
fatigued with the violent efforts of his unrelenting cough and
dyspnoea.    His  feet should be kept immersed  in  hot  water,
and  warm poultices made irritating with mustard or pepper put
to the arms, wrists, thighs, legs,  abdomen, and thorax; and
every effort  made to obtain relief from the so frequently  coinci-
dent thoracic determination and congestion,  and an equable dis-
tribution of  the circulating fluids.
  Under the second of the  general heads into which we divided
the  treatment of asthma, that, namely, having  for  its  object to
oppose and  diminish and eradicate, if possible, the tendency to 
ASTHMA.
337
recurrence of this periodical dyspnoea, we must first mention as
the  most important of our  measures, a careful  and constant
avoidance, as far as may be practicable, of all the ascertainable
causes, predisposing and occasional, which bring on an  attack.
Exposure to sudden alternations of temperature must be guarded
against, for  catarrh and bronchitis are very apt  to usher in a
paroxysm, which they also tend to aggravate and prolong.  An
asthmatic should, of course, wear  flannel next his skin, with
woollen  stockings, and boots ; cold and moisture  applied to the
feet, seem to make a surer and more promptly deleterious  im-
pression than upon  any other portion of the surface.
   The very familiar connection between gastric disturbance and
the respiratory disorder of which we are treating, has been more
than once referred to.   An undigested meal of food, improper in
quality, inordinate  in quantity, or  taken at an unaccustomed
hour,  will, in many  persons, excite  a  fit  of their tormenting
persecutor.  They soon become aware  of this, and learn, whe-
ther they practice  these virtues or not, the value of  prudence
and temperance.
   If, in the interval between  his paroxysms, the  patient seems
to labor under any permanent derangement of the respiratory
organs and functions, the nature  of such affection  must  be
attentively examined into, and when  ascertained, the  proper
course of treatment for its removal immediately instituted and
assiduously  carried into operation.  It  is in examples  of this
nature, obscurely developed, perhaps, that we find recorded  so
many  eulogiums  upon one  and  another  mode of  alterative
management.   Among these, a system of moderate purging
persevered in for some time, has  been found most frequently
beneficial—and it is  in such, that the  Cheltenham waters in
England, and other cathartic springs both in Europe and our own
country, have gained  so much reputation.  But the plan must
not be promiscuously resorted to.   I have seen it most servicea-
ble in  subjects in whom  there was a persistent determination
to the thoracic viscera, rather congestive than inflammatory; and
in such cases as  were obviously connected with  or dependent
upon indigestion or dyspepsia.
  In these latter—the dyspeptic class—and in some of the ane-
mic  subjects of habitual humid asthma, much  benefit may be
       vol. n.—29 
338
ASTHMA.
derived from the occasional use of tonics.  Of these, iron in its
several forms of preparation deserves the preference.  The Cha-
lybeate Springs are often highly beneficial, and a visit to them
should be advised.   Of the officinal formulae, I prefer the acetate.
  External revulsion by counter-irritants, is universally trusted
to, but I have not seen the decided advantages which the books
teach us to  expect from  their persevering application.  The
pustular inflammation from tartar emetic—that from Croton oil
or from ipecacuanha, may be tried, and will benefit such patients
as labor under the complication of chronic catarrh or bronchitis,
but I think  them little adapted to make any impression upon
"pure nervous or  spasmodic asthma."  The same remark will
apply to the establishment of perpetual blisters to the chest, and
the insertion of issues or setons over  the ribs or in the arms or
the back of the neck; and to the attempt to re-produce repelled
eruptions which the patient may have  got  rid of, and  the re-
opening of old ulcers that  may have healed or dried up.
   But, above all prophylactics in the  case  under  consideration,
change of air will be found, in the majority of instances, most
efficient.  Asthmatics differ much in  the  choice of situations,
but they are generally, I think, more at ease  in low, flat districts
of country upon the sea-shore, and on the banks of rivers, than
in higher and dry sandy or mountainous regions.  The atmos-
phere of cities, too, will   be  remarked, for the  most part, to
deserve  a  selection in preference  to  that of country places—I
scarcely know for  what reason.   With regard to this  matter,
however, each  patient should be encouraged to observe  and
judge for himself,  and to  choose for his  permanent residence
that spot in which  he breathes most comfortably.
• 
HOOPING-COUGH.
339
                      CHAPTER XLV.

                 PERTUSSIS--HOOPING-COUGH,

    Pertussis—Tussis  Convulsivus—Bex Convulsiva—Chin-
  cough—Kinck-cough and  Hooping-cough, are the  names by
  which this singular affection  is known, each of which appella-
  tions is significant of some circumstance in its history or cha-
  racter.  The  three first refer  exclusively to the violent and
  spasmodic cough, which is its most  prominent  and essential
  symptom.  The term Chin-cough  has been variously derived;
  by Good  it is written Kind^cough, and traced  to the  Saxon
  "kind"—a ehild,  as  being  chiefly met with  in early life; by
  others, it is regarded as an allusion to  the paroxysmal severity
  of the cough.   In Scotland the disease is called  Kinck-hoast;
  and the word kink is used in all  the Northern parts of Great
  Britain, and in some regions of our  own  country,  to  denote
  vulgarly a fit or paroxysm.  Its most common title among us__
  Hooping-cough—is affixed to it on  account  of the  sonorous or
  hooping inspiration which attends the  strong effort in  coughing.
   Pertussis is almost universally  ranked among  the specific
  contagions.  Cullen defines it  "morbus contagiosus, tussis con-
  vulsiva, strangulans, cum inspiratione  sonora, iterata, scepe vo-
 mitus."  The common consent as to its contagious character, is
 broken only by the doubts suggested on the subject by Laennec
 and Desruelles in  France, and  the decided opposition, in our
 country, of Caldwell.  It is  often traceable distinctly from sub-
 ject to subject.  In towns  and  cities  of dense population, it
 occasionally becomes epidemic, as the  phrase is.  It is affirmed
 to appear occasionally, even in remote  country places, without
 obvious source, as is equally true of measles, mumps, etc.
   Like most of its congeners, it affects its  subjects but  once,
 and hence is  looked upon  as a disease  of children  specially!
 Yet it  is supposed, that, besides this, the adult is less liable to
its influence, though  not  entirely exempt from it.   Dr. Heber-
den declares, in his Commentaries, that  he saw a woman  of 
340                   HOOPING-COUGH.
seventy, and a man  of eighty  years of age, afflicted  with it.
You will very rarely, however, meet with it in an adult.
  In its  incipient stage, hooping-cough can  scarcely, if at all,
be  distinguished from catarrh or common cold.   Hence, in
making up  our  opinion as to the nature of any particular in-
stance, we must take into consideration "the epidemic constitu-
tion of the air,"  or the prevalence of the contagion within the
neio-hborhood.   In  the mildest class of cases, indeed, it cannot
be positively determined by any diagnostic.  More usually, how-
ever,  after  commencing with  an ordinary cough, which con-
tinues  for a few days, a week or  a fortnight, harrassing princi-
pally by its frequency, we observe  the paroxysms to come on
less often—to be more violent, and to  become  protracted; the
expirations  are  quick, involuntary, convulsive, and repeated in
long succession ; the face flushing, and the eyes protruding and
being reddened  and watery—the  little  patient seeming almost
exhausted  and  suffocated, until it is  at  last able to effect an
inspiration,  which is rapid, deep, sonorous, and  attended with a
loud hooping noise.   After a time, a  large  quantity of thick,
tenacious mucus is expectorated, or vomiting ensues, with great
though temporary  relief.   These fits of  coughing return at
various intervals, shorter or longer, according to  the severity of
the attack ;  the  respiration, in the meanwhile, is seldom entirely
free from disturbance, though, in light cases,  the child will
return immediately to his play.  Examination of the thorax
detects a loud mucous rale, with crepitation or cooing  in most
instances, and the breathing is generally hurried and irregular.
A majority  of subjects present the complication, if it be one, of
bronchitis and  true pneumonia, when, of  course, we shall  dis-
cover  the   physical signs of these  conditions.  This  state of
things is said  to occur  uniformly  in attacks taking  place in
more advanced  life.   A child soon becomes aware of the ap-
proach of a paroxysm, and runs to some one  for  support, or
catches hold of  a chair or table.   The  cough, when more vehe-
ment than ordinary, may bring on epistaxis, or  terminate, as I
have seen,  in a  pulmonary haemorrhage; one little patient of
mine,  ae 4J years, brought up a considerable amount of blood,
apparently  from the  lungs, at every  fit  of coughing.  These 
HOOPING-COUGH,
341
 are more apt to be specially violent at night, the exacerbations of
 fever being then most  perceptible, and  the general suffering
 aggravated in a great variety of  modes.  After such severe pa-
 roxysms, the patient remains for some  time languid and weary.
 "Adults," says Heberden, "concidunt—fall at once, conquered in
 a moment by the  accession of the paroxysm, but recover imme-
 diately ; and this sign or mark is proper to, or  characteristic of,
 the affection in them."
   Pertussis  is  essentially pyrectic.  It  is true, that  in ordinary
 or mild attacks, the tokens of vascular  excitement may not run
 so high as to attract attention ; yet I fully agree with Watt, who
 declares, that "even in the lightest cases, as long as the kinks or
 paroxysms continue, there is always some part  of the day when
 the  presence of fever  can be detected.   It may hardly deserve
 notice, but still, to a careful observer, who has opportunities of
 seeing the patient day and night, it is abundantly obvious."  "I
 have  remarked it," he goes on to say,  "even in those favorable
 cases where  the appetite continued good throughout, and where
 the patients  seemed to suffer little or nothing  in their  general
 health."
   The febrile exacerbation, as I have hinted, usually takes place
 in the evening, and is protracted  through  a considerable portion
 of the night.  In the severer cases, where pulmonic inflamma-
 tion has distinctly supervened, this  symptomatic fever assumes
 an almost  continued type,  with  scarcely any notable remission
 for days together.   The stomach and bowels seldom fail to be-
 come more or less disordered.  Those seem to suffer least, how-
 ever, in whom the paroxysm is apt to end  in free evacuation of
 the stomach  by vomiting.  In hot climates, and in autumn, the
 diarrhoea  which  occasionally attends,  is  a very obstinate and
 troublesome  symptom.   Convulsions not unfrequently happen,
 especially where  the subjects of hooping cough are engaged in
 the process of dentition.
  The exciting Causes which tend to produce and aggravate the
paroxysms of coughing, are, a  full meal—violent muscular ex-
ertion—mental  emotion—a fit of  crying—exposure to a current
of cold or damp air, or to any irritation  of  the fauces or trachea
from dust and the like. The duration of pertussis is exceedingly
uncertain, varying from a fortnight to three or four months   It
       29* 
342
HOOPING-COUGH.
seems sometimes  to take on a habitual persistence, and is liable
to renewal after having subsided, being in this way susceptible
of almost indefinite prolongation.  Dr. Percival tells us that it
occasionally assumes  a periodical character, in which form it is
singularly unmanageable and tenacious.
   The general  Prognosis in this disease is favorable ; the pro-
portion  of mortality not being  great under  ordinary circum-
stances.   It varies with the age of the subject.  Between six
months and three years of age, die four-fifths of those carried off
by pertussis.  The season of the year is of some importance in
this climate.  Here we lose—as reference to our bills of mortal-
ity show—a very large majority in  the hot months;  contrary to
what might be  anticipated.  The  same documents exhibit, as
indeed  we should expect, a preponderance of colored subjects.
Children  of scrofulous or asthmatic  parents  are said to suffer
peculiarly under attacks of hooping  cough.   I have  observed
this to be strikingly true of such as have previously shown any
marks of strumous disease, in whatever form.
   The  individual prognosis must be drawn from the severity
and frequency of the paroxysms—from the condition of the res-
piratory organs, as exhibited during the intervals ; and from the
nature and  intensity  of the accidental complication with other
disorders.  Comparative freedom from fever,  easy respiration,
the occurrence of vomiting when  the cough  urges, and abun-
dant mucous expectoration, are among the most favorable symp-
toms.   It is a common belief that the danger diminishes as soon
as hooping or sonorous inspiration attends the cough—but this is
an error.
   In bad cases, on the other hand, we have panting, dyspnoea,
orthopnoea, stricture  across the chest; in  very young patients,
suffocation may take  place, from their inability to  bring up the
oppressive amount of mucus effused in the air passages.  Hence
in these the effort of vomiting is so useful and desireable.   We
meet occasionally with hemorrhage, as  the consequence of the
vehement paroxysm of coughing.  I have mentioned a little pa-
 tient in whom every fit during the  night brought on a discharge
 of blood from the lungs—yet she ultimately, though with great
 difficulty, recovered.   If the paroxysms are attended with strong
 determination  to the  head—as  happens  not unfrequently—the 
HOOPING-COUGH.
343
   face becomes flushed and turgid—nay, sometimes livid and pur-
   ple, and blood gushes from the nose.  Under such circumstances,
   we must dread the supervention of convulsions ; or if these be
   warded off by repeated epistaxis, a  dangerous debility ensues.
   The incidental complications of pertussis sometimes assume the
   prominent place, and  become of paramount importance.  Thus
   the gastric and intestinal irritation, which so commonly attend,
   run high in unfavorable seasons.  I have  seen diarrhoea twice
   fatal in subjects of hooping  cough—in a hot and moist August,
   in a malaria locality;  the patients (black males) having attained
   the ages of thirteen and sixteen years.
    The Pathology of hooping cough is obscure.  There exists in
   the mucous membrane of the whole respiratory apparatus, a very
   peculiar irritability, morbid in nature and intense often in degree,
   which gives rise to vehement  paroxysms of convulsive cough,
   and is attended by or productive of an inordinate determination
/  of blood to the organs affected ; this, in its turn, results either in
   oppressive  congestion, or a violent inflammation,  with its disas-
   trous consequences.
    Desruelles regards  the disease  as  in  itself and  originally a
   complex irritation of the brain and of the bronchial membrane,
   and proposes to term  it a broncho-cephalite.   He believes  the
   respiratory affection, however, to be the primitive, and the cere-
   bral to be  the consecutive element.
    Dr. Watt, of Glasgow, from whom we have  a  useful treatise
   upon this  subject, describes  the appearances, on examination of
   several  bodies dead of pertussis, among whom we learn with
  painful sympathy that  two were his  own children, as  distinctly
  showing an inflammatory affection of the  pulmonary mucous
  membrane; and goes on to conjecture, that "hooping cough con-
  sists in some eruptive disease of the  mucous membrane3 of the
  air cells and bronchi, so  minute as to escape ordinary observa-
  tion, yet so considerable as to excite inflammation."  This "con-
  jecture" has hitherto met with no confirmation ;  but if we admit
  it to be correct, and  receive on Horner's authority, the eruptive
  affection of the gastric membrane  as characteristic of cholera
  asphyxia, and  regard,  with  Chomel  and others, the rosaceous
  eruption in typhoid fevers as specific, we shall have established
  the  exanthematous character of the whole list of  febrile conta- 
344
HOOPING-COUGH.
gious disorders, very nearly ; the only exceptions now occurring
to my recollection being parotitis and yellow fever.
   It is also affirmed that hyperaemia, congestion, inflammation
of the brain and its membranes, are among the ordinary changes
found to have taken place in bodies dead of pertussis.  Yet
these views of the  inflammatory nature of the  disease, though
perhaps supported by a large  majority  of the profession,  have
not been admitted without dispute.  Among others, Dr. Gran-
ville maintains, in very positive terms, the opinion, that "hoop-
ing cough is never, in itself, an inflammatory disease.   No traces
of inflammation," he distinctly affirms, "have been found in the
respiratory organs of those who have fallen victims to it—and that,
even  when the complaint has  been violent and has lasted a  great
length of time."  "The only  tokens of inflammation," he  says,
"have been found in the brain, as the result  of strong and re-
peated spasms of the organs of respiration, producing a  great
determination of blood to the head."  You  will readily  infer
from what I have said above,  that I differ widely from Dr. Gran-
ville.  The condition of the spinal chord has not been exam-
ined  with proper care,  in cases  of pertussis.  There is much
reason for the conjecture of M. Hall, that all spasmodic or con-
vulsive affections have their seat in this  portion of the nervous
system.
   Of the Treatment.   The profession in  general, whatever may
be their theoretical  opinions on the subject, appear willing  prac-
tically to admit the futility of any direct endeavor to put an end
to, or get rid of the attack of this  strange malady.  Like certain
others of the specific contagions,  it seems beyond the power of
our art absolutely to arrest its progress, and we content ourselves
with the fulfilment of humbler indications.  We aim  to mode-
rate the  violence of its symptoms; to obviate its injurious ten-
dencies ;  to prevent all lesion of organs  assailed in its course;
and while on the one hand, we diminish  the vehemence of mor-
bid action, on the other, we sustain the vital energies in resisting
its ravages.   I have already  spoken of the modifications of our
therapeutical management  necessary in  the  various  classes of
 disease,  known as self-limiting and unlimited.  Pertussis holds,
as I stated to you, a sort of middle place between them.   Arising,
as it undoubtedly  does, from a specific  contagion, it  seizes an 
HOOPING-COUGH.
345
unprotected constitution with so forcible  and tenacious a grasp,
as not to be shaken off with  any  possible effort,  until it  has
wrought in the system certain changes entirely unappreciable,
but sufficiently impressive to destroy the liability of the subject
to any future attack.  Its duration,  however, is not like that of
measles and small pox, precise and  definable ; we know not its
periods of increase, maturity, decline and subsidence.  Hence it
is reasonable that we should keep in view, though we cannot
make it our principal purpose, the  abbreviation  of the attack,
and I do not doubt that we can  effect a good deal in favor of
our patients, by judicious  efforts of this kind.  I  believe, how-
ever, that our success will depend less upon our medicinal pre-
scriptions, than upon  the  institution of  a  proper  regimen  and
correct general conduct of the case,  so as by the  avoidance of
all occasional  excitement or superadded  irritation, and by the
prevention of  any undue complications, to  reduce  the disease to
its own minimum limit of spontaneous existence.
   A very large  proportion of the  severe  attacks  of pertussis,
commence very much as catarrhal fever—with pain or stricture
of the chest,  dyspnoea, and harrassing cough; attended with
febrile movements of greater or  less violence, full, hard pulse,
headache, pain in the back and limbs, flushed face, red eyes, etc.
Venaesection  is occasionally  necessary, under these  circum-
stances, as a prompt means of obviating the tendency to inflam-
mation and  consequent lesion, of organs  so rudely assailed.  It
is not often, however, an indispensable  measure,  and  in very
young subjects is sometimes so inconvenient, that  we  resort to
the substitute of topical depletion, as by leeches or cups, the ap-
plication of which may be repeated pro re nata.
   Purgatives are next to be resorted to, and serve here a double
purpose.  No one can  fail  to  observe the  derangement of the
primae viae,  which, if not one  of the earliest symptoms of the
hooping cough, seldom or never fails to supervene in the course
of the attack.   The tongue is furred, and the breath foetid;  the
bowels are constipated in some, and in others, there is an irregu-
lar looseness, with pain, and tenesmus, and discharges of ill con-
ditioned character and appearance.  Castor oil deserves the prefer-
ence, as effecting readily, every purpose for which a cathartic is
demanded, under the  present circumstances.  It operates with 
346
HOOPING-COUGH.
sufficient activity, when exhibited in proper doses and at proper
intervals, removing all morbid accumulations from the cavity of
the intestines, without exciting local irritation or arousing fever.
In some patients, however, it disturbs the stomach with nausea,
and we may substitute for it the solution of epsom salt, rhubarb
or senna.   The addition of calomel to the purgatives prescribed,
has been highly recommended by some respectable writers;  but
I have not found any particular benefit accrue from  it in ordi-
nary cases.
  The use of emetics in pertussis, is a point in practice,  almost
universally agreed on.   They are the promptest of our expecto-
rants, and unload at once the respiratory  organs, oppressed by
the viscid mucous secretion with which they are engorged.  At
the same time, they determine to the surface, and give rise to a
salutary diaphoresis.  The squill and ipecacuanha are best  en-
titled to our confidence, as fulfilling these purposes.   The anti-
monials I object to, because they  act irregularly, sometimes with
violence;  and the stomachs of young children do not well bear
their repeated exhibition.  Squill, besides the common action of
emetics, appears to me to affect directly the pulmonary exhalents,
and is thus specially useful in promoting expectoration.  Ipecac:
superadds an evident antispasmodic influence, and is a good su-
dorific.   A similar combination of powers has been ascribed to
the sulphate of zinc, which has been employed freely and largely,
and which is, without question, highly serviceable.   The effica-
cy of each of them is  assisted, and  their  advantageous  action
promoted by the use of the warm bath, which will be found an
admirable auxiliary, at every step of our  treatment of hooping
cough—determining to the surface, relaxing spasm, subduing pul-
monary constriction,  and promoting expectoration;  and in all
these modes, contributing largely to the relief of the little sufferer,
from the most  distressing of the  symptoms which assail him.
  The emetics above mentioned, are, by some practitioners, ex-
hibited as nauseants simply; their administration in smaller doses
than those required to bring on vomiting, being persisted in for
some time.   I only mention this  plan of prescription, to repro-
bate it decidedly.  The state of suffering and prostration thus
induced, has not seemed to me to be  followed by the salutary
changes which are spoken of, as  compensations to  the  patient. 
HOOPING-COUGH.
347
 On the contrary, it appears not only  to  depress, but  to detract
 from the energies of the system; not only to subdue, as we are
 promised, the inflammatory tendencies, but  to  result in actual
 exhaustion of the vital powers.
    As aiding us in the endeavor to diminish the force of thoracic
 determination, and preventing or removing the bronchial and
 pleuritic inflammation, which so often  show themselves in the
 early stages of pertussis, we must not forget the assiduous appli-
 cation of warm fomentations to the chest, and poultices  with or
 without mustard.  These form our  best modes of local relief,
 in the first instance, while fever is high, and the skin hot, and
 the pulse full.   When the general excitement  has  been some-
 what diminished, and these less impressive appliances have lost
 their effect from repetition, we may  derive much benefit  from
 epispastics.  They should be laid on different  parts of the  sur-
 face of the thorax successively, and although they  must  occa-
 sion some inconvenience and discomfort to the little patient, this
 is more than counterbalanced by their revulsive efficiency.
   Thus far, we have been speaking of the  incipient conditions
 of pertussis, while yet its influences have  been  diffused  over
 the universal system, and its invasion has presented  no features
 which may avail to separate it definitely from catarrhal fever, on
 the one hand, or acute bronchitis,  on the other.  We now come
 to consider its characteristic history, after the peculiar nature of
 the spasmodic or convulsive affection of the respiratory appa-
 ratus, in which  it specifically consists, has  become  prominent
 and fully developed.   The patient may seem perfectly well, in
 the intervals between  the attacks  of  cough—may eat heartily
 and sleep well;  may recover strength, and repair lost fulness of
 habit; yet, from time to time, he is reminded of his tenacious
 tormentor,  by  the recurrence of irresistible irritation  in the
 trachea and lungs, which brings on a most harrassing series  of
 involuntary and forcible expirations, so quickly repeated as to
 impede the long desired inspiration,  until at last, after many
 laborious efforts, a loud sonorous hoop attests his  success;  and
 this struggle may be renewed for many times, with such violence
of exertion that  the blood shall gush  from the nostrils, and  the
purple visage, the  blood-shot eye and swollen  eyelid, and  the 
348
HOOPING-COUGH.
hemorrhagic expectoration, all  bear  witness  to  the severity of
the attack.
  Under such circumstances as these, anodynes  and anti-spas-
modics  are obviously  indicated,  and universally resorted to.
The whole class of narcotics have been, in their turn, employed
here, extolled, abused, and neglected.  Hyosciamus, cicuta, and
stramonium, have had their day and their advocates, but.are now
little depended on.  Opium alone, retains  the confidence of  the
modern practitioner, and when judiciously prescribed,  will be
found of invaluable utility.   It is specially useful in two  of its
combinations—with ipecacuanha, as in the  admirable  Dover's
powder, and with stimulants and aromatics, the camphorated
tincture, the ancient familiar paregoric elixir, a domestic remedy
of almost unequalled power in calming irritation, relieving cough
and dyspnoea, and procuring rest.  I need  hardly remind you,
that the use of opiates  should  be preceded  always, by proper
anti-phlogistic and depletory treatment, in inflammatory attacks.
A neglect of this precaution has occasioned much  blame  to be
heaped on the remedy, which properly belonged to the physician,
who advised it under improper circumstances.
  Of the  anti-spasmodics, properly so called, castor and musk,
once extensively relied  on, are  fallen into almost entire disuse.
Assafoetida  is much employed  among the common people, and
highly recommended by some practitioners.  A watery solution
seems to be preferred.   The oil of amber  has enjoyed some re-
putation, but it is now  abandoned,  except as an  ingredient in
the preparation of the tinct: mosch:  fact.   This is, with  me, a
very favorite remedy; the artificial musk is obtained, you know,
by  the action of nitric acid upon the ol: succini. I seldom fail to
find it of  obvious service—and its efficacy extends widely to all
varieties of spasmodic cough, whether occurring in children or
adults.  It has lost  its value, in the hands of  many practitioners,
from beins: exhibited in too small amount.   You will obtain no
useful results from  it, unless given in full dose,  (ten to twenty
drops,) repeated as often as may be  required. I  am not aware
that any ill consequences  are ascribable to it, in  any quantity;
as far as I have observed,  the effect of an over dose to an infant
is, to bring on easy vomiting, which, in the case before us, is
rather a beneficial than  injurious operation. 
HOOPING-COUGH.
349
   In this connection, I may speak of the Prussic  acid, though
 it is hardly decided whether  we are to class  this  impressive
 agent  among anti-spasmodics  or  narcotics.  The testimonies
 which have been adduced to establish the success of its applica-
 tion in  pertussis, are numerous and of unequivocal character.
 Dr.  Oliver, of Salem, (Mass.,) who claims to have been the first
 to use it here, recommends it as the most prompt and effectual
 of all the remedies for hooping-cough.   Dr. Granville, an  En-
 glishman, who has written much and enthusiastically concern-
 ing  this acid, goes so far as to declare, that "no case of hooping-
 cough need be suffered to proceed longer than eight or ten days,
 if timely and judicious recourse be had  to it."   These encomi-
 ums seem to me not a little  extravagant.   Yet  they contain
 some truth, and I  do not hesitate, with a majority of the most
 respectable practitioners on both sides of the Atlantic, to rank
 the Prussic acid  among the most available of our  palliatives in
 pertussis.  You  must never forget the requisite precautions in
 exhibiting it.  In its concentrated form,  it is the most  immedi-
 ate and remediless of our poisons.  The dose  must, of course,
 be proportioned to the formula  you employ, and you should be
 assured of the accuracy of your preparation, which ought to be
 recent and well put up.   A single minim of the strong acid of
 the  shops, and  its  equivalent in the other  formulae, (among
 which, I am much in the habit of using the aq: amygd: amar:)
 is the dose for a  child aged one year, and onwards  in  the same
 ratio.
   We  must not omit to notice certain other remedies, much em-
 ployed in pertussis,  the  efficacy of which  is not  easily to be
 explained by their  ordinary influences,  or the  qualities which
 have given them their place in our books on the materia medica.
 Among these, the alkalies are first to  be mentioned, as constitu-
 ting the basis of a very large proportion of the  prescriptions in
 general use, either domestically, or in the hands of the regular
 practitioner.  An alkaline solution is made  the  vehicle for the
 assafoetida of one, the musk of another, and the  cochineal of
the third.  I  desired you to observe, that throughout  the whole
duration  of the malady, a greater or  less degree of gastric  and
intestinal derangement is evidenced by the morbid alvine evacu-
ations,  the sour and foetid breath, and by the swelling and hard-
       vol. n.—30 
350
HOOPING COUGH.
ness of the belly.   These  disorders are not  to  be controlled
without a persevering administration of some one or other of the
alkalies, which are fortunately well adapted for combination with
such other remedies as may be indicated.  We may mingle with
them neatly and  advantageously our purgatives, expectorants,
narcotics and anti-spasmodics.   I am in  the  habit of preferring
the carb: potass:  to a weak solution of which,  the tinct: mosch:
fact: and  the  tinct:  op:  camph: are added  in  proper  amount.
Castor oil or rhubarb should be  given pro re nata, if the bowels
are confined, and the tinct: kino, if too loose.  Under these latter
circumstances, we may resort to the acetate of lead, which is
not, indeed, limited to this contingency,  if we  may  believe the
favorable reports of writers who speak of it; Sauvages, Rush and
Barton, all regard it  as possessing some specific efficacy, in the
treatment of pertussis; but I confess, that 1 have failed to obtain
any striking advantage from it.
   The tinct: cantharides, anciently employed among the Eng-
lish, is a favorite prescription with  some physicians.   It is not
much used, as it  is harsh and severe in its  operation,  its good
effect seeming to  depend on the strangury produced by it;  this
revulsive and painful irritation of the neck of the bladder being
substituted for the morbid affection of the respiratory apparatus.
Certain of the tonics have been supposed to exert a beneficial
influence  in  hooping-cough.  They are obviously adapted to
the latter stages of the disease, when the sympathetic  derange-
ments  of  the general system which  have accompanied it have
subsided, and its  protraction appears to be  occasioned by the
mobility of feebleness, or to grow out of the tenacity  of habit.
Cinchona is placed by Cullen at the  head of the  list,  and  sel-
dom fails, indeed, to show a salutary power.  The infusion, I
think the best mode of exhibiting it, made aromatic and diapho-
retic with the serpentaria, which improves its efficacy.
   I do not deny the greater impressiveness of the sulph: quinine,
but from its intense  bitterness and  incapability of disguise,  it is
extremely difficult to administer it in sufficient quantity to young
children.   This observation will apply likewise to all the other
bitter tonics, such as Colombo, quassia, gentian, etc.,  whose good
effects are in a  great measure lost  or  counterbalanced by the
extreme  reluctance and disgust  with  which  they are taken. 
HOOPING-COUGH.
351
 The metallic tonics are free from these objections.  Zinc,  iron
 and arsenic are used.   The latter is  particularly convenient as
 being  tasteless and  inodorous, and  thus  \rery  easily adminis-
 tered to the most unmanageable patient.   It is the  subject of
 very strong eulogy from Dr. Ferriar, who, as you know, is high
 authority, and who declares his belief, that "the only remedy
 which promises to shorten the disorder effectually, after the pro-
 per preliminary steps have b&en taken, is the solution of arsenic."
 Some caution is necessary in administering an  article  of such
 known poisonous power, the dose being carefully proportioned to
 the age  of the patient.   I have  not  made many trials  with
 arsenic, but am disposed, from the analogy of its striking influ-
 ence over other affections of paroxysmal and recurrent character,
 to expect much good from it.
    Some years since, pertussis, like all  other respiratory  disord-
 ers, was  subjected to experiments with the various gases, newly
 discovered by chemists, with the reasonable hope that the direct
 application of impressive agents to the diseased  surfaces, would
 be productive of valuable results.  The reports  then made, led
 physicians to anticipate decided advantage from  the inhalation
 of nitrous acid gas, which was asserted to have  been followed,
 in certain cases, with pointed benefit; and the experiment seems
 worthy of a trial.   Sulphuric acid being poured upon the nitrate
 of potass, this gas escapes and  diffuses itself through the air of
 the patient's apartment.  If this aerial  impregnation should be
 found irritating, and likely to affect the lungs unpleasantly, the
 little subject may  readily be removed from the chamber.
   I have already spoken in terms of  scarcely sufficient force, of
 the pleasant  and useful influences of  the warm bath, in  the in-
 vasion and early stages of pertussis.  In this latter period of its
 protraction, the cold bath has been administered by some un-
 shrinking practitioners,  and as  they  affirm, with obvious and
 undoubted advantage.  It may possibly be ventured on without
 injury, in the summer season, and in robust, hardy patients, but I
 should think it very seldom safe.
   It will be your special duty to guide  with assiduous care, the
general management of the invalid, and direct the whole course
of conduct of those in attendance upon him.  A proper regimen
will, I believe, do more for him, rather by palliating the violence
of the attack, or shortening its duration—than can be  effected 
352
HOOPING-COUGH.
by the best selection of the most powerful medicines, if this be
neglected.
  The diet allowed, should be at first exceedingly light and tin-
stimulating ;  as the case progresses and the inflammatory symp-
toms decline, the restriction may be made less precise, and more
and more latitude  permitted.  Excesses  in  quantity, must  be
absolutely prohibited throughout, as  there is  no more  certain
excitant of violent coughing, than a full meal; yet a reasonable
desire  for food, should always be reasonably gratified.
  The apartment of the child should be well ventilated, but his
bed should not be placed in a draught or current of air, and all
ordinary prudence should be exerted to prevent his taking cold,
as the phrase is.  It is by the supervention of  catarrh that the
morbid irritation of pertussis is most apt to be renewed, and may
thus be,  with intervals,  almost  indefinitely  protracted. His
clothing should be warm and comfortable, and though suited to
the season, should be adapted to guard the surface  of the body
from the impression of  atmospheric dampness  and alternations
of temperature.
  There is a very strong popular prejudice, in favor of exposure
to the open air, in cases of hooping cough.   You will not yield
to this, farther than it is consonant to reason and common sense*
While catarrhal or pulmonic symptoms are in any degree promi-
nent, you will confine your patient to the house,  or even more
closely—to his chamber or his  bed; and  although when these
have entirely subsided, you will allow or enjoin suitable exercise
out of doors, in genial weather, yet you will still order the care-
ful avoidance of  cold and  moisture.  Easterly and north-east-
erly winds are, almost every where, found injurious in affections
of the respiratory organs ;  and during their  prevalence the con-
valescent should be housed.
  In tedious  and obstinately protracted cases,  it may be found
necessary to advise change of air, and a temporary removal from
an accustomed residence.   A locality should,  under these cir-
cumstances be  sought, as strongly contrasted  as possible—the
low-lander sent to the mountains, and the native  of our interior
country brought  down to the sea-shore.   These impressive alter-
nations are certainly more effectual than any less revolutionary
measure, in breaking the  chain of morbid action, now rivetted
firmly by habitual recurrence. 
         'OP THE DISEASES OF THE SENSORIAL SYSTEM.     353



                      CHAPTER XLVI.

         OF THE DISEASES OF THE SENSORIAL SYSTEM.

    The Sensorial  Functions are performed by three sets of or-
  gans—the brain, the spinal marrow and the  nerves.  The se-
  parate and distinct offices attributed to each of these, are discus-
  sed in detail by  physiologists.  We are now to regard them
  pathologically, as a connected whole;  exerting a ceaseless influ-
  ence upon the universal  frame, which exhibits  throughout its
  remotest parts a close and direct sympathy with  their morbid
  affections.
   It is almost unnecessary to remind you of  the  intimate and
  indissoluble connection of these  physical organs with the intel-
  lectual portion of our being.  With reference to this connection,
  it has long been the custom to arrange  under our present head
  the numerous and diversified alienations of the mind, the Vesa-
  niae of Cullen, the  most shocking and afflictive of all  "the ills
 that flesh is heir to."   Nor can there be a doubt of the propriety
 of this arrangement;  every individual among these (so called)
  mental diseases, being obviously dependent upon and implying
 some functional or  structural disorder of  the brain, either prima-
 ry or secondary. Nay, there  is scarcely  a single one of the dis-
 orders  of  the sensorial  system which  is  not, sooner  or later,
 complicated  with deprivation or derangement of intellect in
 greater or  less degree.
   Cullen, you will recollect, in  establishing as a separate class,
 the  diseases of  the nervous system, his Neuroses, has made a
 vague and inconclusive attempt to follow up the affections of
 this system, throughout its wide and universal distribution in all
 parts of the body.  .Our nosological rule of classification refer-
 ring to the various organs as connected in the immediate perfor-
 mance of special physiological  functions, is of much avail here
 by circumscribing the  otherwise almost unlimited extent of  the
series of maladies  now about to  engage our attention.   Thus
for example, we  exclude three out of the  four of Cullen's second
order Adynamia:   1.  Syncope;  2.  Dyspepsia; 3.  Hypochon-
      30* 
354
PHRENITIS.
driasis; 4. Chlorosis;  which belong to the vascular,  digestive
and genital systems ;  and from his third order, Spasmi, which in-
cludes sixteen genera,we remove nine : 1. Palpitatio;  2. Asthma;
3. Dyspnoea;  4. Pertussis ;  5. Pyrosis ; 6. Colica ; 7.  Cholera;
8. Diarrhoea;  9. Diabetes.  The first  is a symptom of cardiac
affection; the three next are properly merged in the history of
the disorders of the respiratory system; the fifth, sixth, seventh
and eighth belong to the gastric and intestinal derangements ;  and
the last is a disturbance of one of the most important excretions.
On the other hand, we would bring under this general head se-
veral of his  Locales, such for  example  as the affections of the
organs of sense, when idiopathic  and not  symptomatic of or
consequent upon inflammation of the  structures in which these
organs are distributed, (a  case by the way, exceedingly rare,) as
gutta  serena, or amaurosis; dysecoea, (deafness,) in  some in-
stances ; depravations of  smell, taste, etc.

   The first in order of the diseases affecting  the Sensorial  sys-
tem is Phrenitis, or inflammation  of the brain and its mem-
branes.  Phrenitis is divided (as is usual among inflammatory
diseases) into the acute and chronic.  This  distinction is sup-
posed to be analogous to that which has been offered between
other  parenchymatous affections and those of the investing mem-
brane, as in the example  of acute and chronic hepatitis.  Acute
phrenitis is affirmed chiefly to affect the membranes, and chronic
 phrenitis the substance, both cortical and medullary of the brain.
 The opinion is plausible and supported with some ingenuity, but
 is not clearly established.
   Acute  Phrenitis is  a disease  of rare occurrence, whether as
 idiopathic or symptomatic.  This may seem  a strange doctrine
 to those who, with  Clutterbuck, are disposed to regard all the
 painful and annoying disturbances of the cerebral organs and
 functions, so commonly  met with in fevers, as truly phrenitic.
  The  brain is deranged in  its actions, and becomes the seat of
  very  painful affections, under the  influence of a great diversity
  of causes.  Thus,  we have headaches, some of them of most
  intense severity, and yet without fever,  from mental emotion;
  from study; from  exposure to  light; from  particular kinds of
  motion,  as in a swing and at sea; from gastric disorder, and 
PHRENITIS.
355
 even from inanition ;  from known articles of food and drink ;
 from heat and cold; from hysteria and other sexual disorders.
 Are these all to be regarded as cases of cerebral inflammation ?
 Surely not. They are the products partly of irritation and partly
 of congestion in the vessels of the encephalon, conditions clearly
 cognizable and separable  from inflammation.  In a muscle we
 have painful sensation from fatigue, the precise nature of which
 we may not be able to define, but which nobody confounds with
 the conditions attendant on inflammation.  This particular mode
 of discomfort, I think very commonly produced by long protrac-
 ted or  vehement use of the  brain, in  patient study or intense
 thought.  In confounding them relatively to  the brain and mu-
 cous  membranes, Clutterbuck and Broussais  have fallen  into
 analogous and similar errors.
   I have said  that acute  phrenitis is of rare occurrence, even
 sympathetically.   In  examining  the heads of subjects dead of
 fever, we seldom  fail  to find hyperoemia, congestion of  the
 brain ;  but we  do not  often discover the unequivocal effects of
 inflammatory action.  Yet, that such morbid action is sometimes
 excited during  the  tumults of fever, and such effects occasion-
 ally produced, cannot be  denied.  Determination to the brain
 indeed  seems very readily to result,  as has been remarked by
 Wilson Philip,  from the very nature  of the vascular circulation
 in the head, under any influence which shall much increase the
 force or velocity of the action  of the  heart; whence we have
 headache, flushed face, suffused eye, etc.; but this determination
 is sometimes irritative, most generally  congestive,  seldom  in-
 flammatory.
   Causes.  A predisposition to phrenitis is sometimes heredita-
 rily derived.  It may be remarked more  commonly in  the san-
 guineous temperament; in men of intellectual activity and stu-
 dious habits; in those  addicted to excesses in eating and drink-
 ing, and accustomed to yield to gusts of passion.
  The ordinary exciting causes are found in accidental exposure
and mechanical violence, as  when a blow has  been received
upon  the head, or  a fall  not  sufficiently severe to fracture the
skull.   Exposure to the direct rays of a summer sun, in  hot
climates, may  bring it on.  I  have seen  it more  than once
supervene when a patient was  recovering from the immediate 
356
PHRENITIS.
effects of coup de soleil or insolation, such as apoplectic stupor,
coma, etc.  Here congestion was followed by acute  inflamma-
tion.  Violent fits of  any  passion, but  especially anger, have
given rise to it.  Intoxication, with inordinate draughts of ardent
spirits, has produced it promptly*  Popular prejudice has long
ascribed it to the direct influence of the  moon, at or near  the
full.
  Symptoms.   Acute phrenitis  commences with a sense of  ful-
ness and pain in the head, at first general, but afterwards referred
to some particular part, to which the hands are often raised;  the
eyes are red and suffused  and vehemently  intolerant of light;
the face is flushed and turgid.;  there is pain down  the spine,
and especially in the back of the neck ; a feeling of restlessness
and pain in the  limbs also attends, with an aching of the loins;
the stomach is often oppressed, sometimes  to the extent of re-
peated  retching and vomiting; the pulse is usually full, hard
and bounding, but not very  frequent.  The spirits of the patient
are much dejected, and his countenance is  expressive of great
anxiety ;  there is thirst with jactitation;  the  skin is hot, dry  and
harsh.  There  is more or  less derangement of the mind, from
the first, in a great many instances, and incoherence or furious
mania is developed in the progress of all cases, in greater or less
degree.  The pain  in the  head increases to the  most  intense
severity, the scalp itself being sometimes excessively sensible to
the  slightest  touch  ;  the  patient complains often of internal
burning and  throbbing; there  is unbroken perviligium;  the
eyes  are inflamed, and suffer great pain on the admission of the
least ray  of  light;  the countenance  is  fierce  and wild;  the
hearing often becomes exceedingly acute, and the softest  and
gentlest sound  is complained of as distressingly loud ;  in a few
instances, deafness more or less complete attends.  I  was called
up one night to a female patient, who stated, that having been
awaked by some uneasiness in her ear, she had inserted,  to
examine  it, an  ordinary pin, but that this had slipped from her
 fingers, and  now gave her  intolerable  pain deep within the
recesses of the  organ.  On examination, I  could find  nothing
 in the ear; but while I  remained with her,  acute phrenitis
developed itself with the most unequivocal clearness.   Among
the other symptoms, was wild incoherence and mental derange- 
PHRENITIS.
357
ment, of which the fancy concerning the pin, was only one of
the early tokens.  She recovered, but with great difficulty.
  As the attack progresses, the  tongue becomes furred with a
thick coat, and the breath offensive;  the respiration is  little
affected until  the very last stages.  Effusion of serum or pus
having taken  place, we have a new set  of symptoms.   The
patient sinks into a soporose condition ; the ear  is less sensible
to noise, and the eye to light; strabismus often ensues ; there is
sighing, grinding of the teeth, tremulous debility of the muscu-
lar system ; respiration and deglutition become more and  more
difficult, and absolute  coma or  convulsions are  the immediate
precursors of death.
  Prognosis.  The general Prognosis is unfavorable. If  the
symptoms of sensorial disturbance increase or  continue, while
the pulse sinks and general debility supervenes, the  danger is
imminent, and the prospects of  the patient gloomy.  Dyspnoea
and difficult deglutition, hiccup, stupor, and  coma, are unplea-
sant signs.  On the other hand, a gradual return of reason, the
occurrence of  tranquil and refreshing sleep, subsidence of the
suffusion of the eye, and  relief of the pains  in the  head and
back, conspire to gratify us with prospects of recovery.  Much
may, however, be hoped, provided the patient is seen early, and
the nature of the case at once detected, so as  to fall under  the
prompt and courageous application of the proper management.
I have had  but  three cafes terminate  fatally under my notice.
In  one, there  was extensive  sero-purulent effusion within  the
ventricles and upon the surface of the brain;  the second, was a
child of about twelve years old.  These I saw  in  consultation,
the nature of the  last not having been suspected for two or
three days after the invasion.   The third was an  adult negro,
who  recovered  very  imperfectly, became maniacal,  the  acute
running into the chronic condition, and ultimately died.   This
miserable termination, far worse than death, is to be anticipated
when  the case  is  but vaguely distinguished, or too cautiously
prescribed for.   Any delay in the application of a proper course,
for  a brief period after  the commencement of the attack, will
probably be fatal either to the life or  mental intelligence of the
subject.
  Autopsy.  The appearances,  on examination after death, vary 
358
PHRENITIS.
considerably according to  the  circumstances of the attack, and
in reference also to the period of death.  Morgagni says, that in
phrenitis he has most frequently observed  the  inflammation  to
affect the membranes and the substance of the brain at the same
time.  There is  always turgescence of the vessels distributed
and ramifying upon  the membranes; coagulable lymph is some-
times found adhering  to their surfaces; effusion of serum,  in
greater or less quantity, is  often found within the ventricles  or
upon the surface of  the brain ; purulent matter is formed some-
times within the  substance of the  brain, and  sometimes within
the ventricles.  I  saw it filling these  cavities in the case of a
man who died of exquisite phrenitis from  a  blow on the head
without fracture of  the skull.  Ramollissement—softening  of
portions of the cerebral substance to a  greater or  less extent,  is
said to be a consequence  of inflammation  by no means infre-
quent.  A degree of induration is also described  as occurring
occasionally.  Portions of  the brain  are said, by Baillie, to be-
come gangrenous, occasionally, when  the  inflammation is the
consequence of external violence, but very rarely, if it be  pro-
duced by other causes.
  Treatment.  The  first of our remedies, both in point of time
and importance, as  you will readily anticipate, is venaesection.
Universal experience has established it as the principal  depen-
dence of the practitioner, and  proved the degree of its efficacy
to be in direct proportion to  the promptness and  boldness and
freedom with which  it is employed.  The patient  being  placed
in an erect posture, a large orifice  must be made in a vein or
veins of sufficient volume  to afford a free and rapid abstraction
of blood.  It has been  objected to this method, that it is calcula-
ted to bring on  quick fainting, which Parr  and some  others
strangely regard as  an impediment to  the full remedial effect  of
the operation.  For my own part,  I cannot but look upon syn-
cope as an exceedingly beneficial condition, when I reflect on
the languor which must invade the dilated and inflamed vessels,
and the consequent check to the morbid determination and cir-
culation within the  diseased portion of the brain.  And when
the patient revives, there is no  difficulty in  re-opening the vein
and allowing the blood to flow  again as  long  as we  please.
The jugular vein  has been selected  by many physicians as the 
PHRENITIS.
359
preferable vessel from  which  to obtain a flow of blood,  and
there would seem to be good reason for the preference.  Yet,
we shall generally procure a sufficient discharge from  the veins
of the  arm, which  are in  every  way convenient and easily
manageable.  If they should be small in diameter, or  from the
corpulence of the patient, bleed slowly, I would not hesitate to
open a vein in the neck.   Some  have  recommended  very
strongly a resort to arteriotomy,  upon various grounds,  and
pointed out the temporal arteries to be operated  on,  as giving
opportunity for a more  direct abstraction of fluid from the  ves-
sels leading to the  inflamed part.   There is some uncertainty,
however, in the  effect of this division of the artery named.
Many  declare that  they  have found  it difficult  to procure a
sufficient flow from it, the blood merely trickling  forth or issu-
ing  by drops.   Such, I fear, will generally be the fact in cases
of recent cerebral disease.   I have however witnessed, in  two
instances, a state of things exactly opposite and contrasted, the
arteries being  dilated  and distended  far  beyond  the  ordinary
volume, by the general determination to  the head which  had
previously existed.  In one of these,  I  was obliged to tie the
vessel both above and below the  orifice, when it became neces-
sary to abandon farther blood-letting.
   Next to the lancet,  and  little, if at all  inferior to  it, in  ulti-
mate and permanent efficiency in reducing  morbid excitement
and counteracting inordinate determination to the encephalon,
we must rank the  active  cathartics.   By obtaining  frequent
and copious evacuations from the  bowels, we often procure a
remarkable degree of revulsion from  the  head.   Nay, syncope
may thus be brought on to the great advantage, generally, of
the patient. The neutral salts deserve to be first exhibited, and
will often serve our purpose admirably ; but where they are not
sufficiently effective, we must resort to the more drastic articles,
as antimon: tart:, jalap, gambog:, etc.   Whatever  formulae are
exhibited,  should be freely and  promptly used  and repeated
pretty frequently.  A spontaneous  diarrhoea supervening in the
course  of an  attack of phrenitis, of which  instances  are  now
and then recorded, is said  to be  a very favorable circumstance,
and  to  exert upon  the condition  of  the  unfortunate  patient a
most happy influence.  A judicious practitioner will, therefore, 
360
PHRENITIS.
be  careful not to put  a  stop  to, or interfere with it, unless it
threaten to reduce disproportionately the strength of the patient,
and even then he will not check it rashly or suddenly, for fear
of worse evils than loss of strength.
  Antimonial diaphoretics  are next recommended  as highly
advantageous.  The tartarized antimony is employed, and may
be relied on to produce  a certain degree of useful  effect in the
diminution of morbid excitement and the production of a centri-
fugal determination to the skin.  For these purposes, its exhibi-
tion has  been sometimes  carried to a great extent, and the
condition of the sensorial system and functions is such  as to
occasion a most extraordinary tolerance of it.  A member of
the class in  1837-38, while laboring under acute phrenitis, took
3i. in 13 hours without  any effect whatever, except a very slight
retching,  which  took  place in  the course of the 14th  hour.
The pulvis antimonialis has, however, been much lauded, and
especially by Professor  Elliottson, who  declares it to be admira-
bly adapted to the management of the cerebral affections gene-
rally.  He carried his exhibition of it to an enormous amount,
giving a drachm, or even more, at a dose, repeated thrice a day.
If it were not  for the  record  of similar facts from the Italian
contra-stimulant school, we might be led to think his prepara-
tion inert.  I have found the antimonials most serviceable in
moderate  doses, repeated  at fair intervals, and given  in combi-
nation with  other diaphoretics  and with  cathartics.   Thus, I
rely not a little upon a formula containing the pulv: antimon:
or antimon: tart: with jalap, nit: potass: and mere: dulc: in  such
proportions as to prove  actively cathartic, sudorific, and perhaps
nauseating.
  These, thus briefly detailed, are the principal remedies  to be
depended on  in the manageament of acute phrenitis; but our
treatment will be vain and  futile, unless instituted with the ut-
most promptitude and vigor, and pursued to the utmost extent of
which the strength of the patient's constitution will admit. The
organ to which injury is threatened is of the highest importance,
and will not brook the minutest lesion, without consequences pro-
foundly to be  deprecated.  On  the one  hand,  the intellectual
operations demand its perfect integrity for their exact  and uni-
form performance; and on the  other, none  of the vital functions 
PHRENITIS.
361
can be carried on without impediment, if this centre of life, mo-
tion and harmonious sympathies suffer any notable deterioration
of structure.  Palliation of troublesome symptoms, so often one
of the benevolent purposes of the cultivator of the divine art of
healing, has here no place.  We must aim,  by the  most ener-
getic  interference, at the immediate  arrest and total  resolution
of the inflammatory affection, which being allowed to fix itself, for
but a  short period, or to proceed to any of its ordinary results, not
only strikes a blow at the existence of our patient, but far worse
than  this, may, by depriving  him of his reason, reduce  him to
a level with the beasts that perish, and dispossess him of a privi-
lege not inferior in value to his boasted immortality.  For I am
persuaded, and the doctrine is now very generally received, and
is, indeed, capable of abundant proof, that the  greater number,
if not all, of the cases of  confirmed lunacy,  are instances of un-
detected, neglected, or badly  managed inflammation of the brain,
chronic supervening upon acute phrenitis—which from this im-
perfect treatment, have become permanent and incurable, con-
demning their unhappy subjects to  the dreary cell and the soli-
tary dungeon—to chains and darkness—to the varying delusions
of restless fancy, or the gloomy visions of unutterable despair.
   But to return.   The effect of the leading measures above
recited, should be aided by all other  means which may conduce
to the same end.   Cups  should be  extensively applied to the
scalp, which should be shaved completely, as soon as the nature
of the case is known.  Leeches should be put, in large numbers,
to the temples, and the mastoid or occipital regions, and as much
blood taken, in this way,  as  the strength permits.  The use of
cold should be  early resorted to.  I prefer to all other modes of
employing  it, the pouring of very cold water, from a height, in
a full stream, upon the head  and shoulders of the patient placed
in a sitting posture; and this should be repeated as often as the
face becomes flushed, or the  skin of  the head  and body is hot
and dry. The general cold bath is not often used, but I scarcely
know why.  Some have advised the  immersion of the  trunk
and limbs in the warm bath, while  cold is thus  applied to the
head,  in order to produce a sort of double derivation, "a  prac-
tice, of  which," as a modern writer has well-remarked,  "the
theory is ambiguous, and a sufficient  experience has  scarcely
      VOL. II.—31 
362
PHRENITIS.
been  obtained to warrant the recommendation."   Others  lay
pounded ice to the  scalp, enclosed  in a loose bag, and others
still follow the  ancient  mode  of putting  on a wet  clay cap.
Some  wash the  head  with alcohol or aether, which, by their
rapid evaporation, certainly abstract heat quickly and decidedly.
In  the meanwhile,  the freest dilution  may be permitted with
various cold drinks—iced water, lemonade, etc.  Additions may
be made to these, of the nitrate or super-tartrate of potass, as
laxative, diuretic and diaphoretic.
  There has been much discussion concerning the propriety of
the application of epispastics and other counter-irritants; and
their efficacy, as  early revulsives, has been highly extolled  by
some writers, who place them, with this view, upon the extremi-
ties chiefly or exclusively.  It is clear, that the same rules must
guide us in the present, as in all other instances, and that if, in
any manner, we  irritate the surface  painfully before we have
reduced the morbid vascular excitement, local  and general, by
V. S. and cathartics, we shall add to, rather than  diminish,  the
sufferings  and dangers  of the  patient.   But if we delay the
resort to these measures until the proper period has arrived,  we
shall find them of great utility.   Mustard poultices may be kept
upon the soles of the feet or the insteps, changing their position,
from time  to time, when they seem to give pain.   Blisters may
be applied to the  same points, or to the  thighs  and arms, or  to
the scrobiculus cordis.   It is common to vesicate the scalp in
the latter stages  of  these cerebral affections : but although I do
not doubt the beneficial effect of it in the  congestive  condition
of the brain, forming a part of the history of the low types of
fever, yet I have not seen it of any service, nor do I believe it
to be  adapted in exquisite  instances of  phrenitis or cerebral
inflammation.  We  shall derive, I am persuaded, infinitely more
advantage by persevering to the very last  in the application of
cold in the various modes above specified.   It is, farther, of very
great consequence, to direct  judiciously the details of  the atten-
dance upon, and  friendly management of the patient during the
attack.  His apartment should be airy and cool  and perfectly
ventilated.  It should be kept as much darkened as is consistent
with  the services of those about him ; nothing distresses or irri-
tates the sick man more than light.  For similar reasons, every 
PHRENITIS.
363
thing around should be kept as quiet and still as possible; noise
rouses the patient, vexes  him, increases his intolerable head-
ache, and diminishes the chance of procuring restorative sleep.
His posture in bed should be with his  head and  shoulders  ele-
vated as high, by pillows, as convenient, in order, by this posi-
tion approaching to the erect, to oppose some impediment to the
force of the cerebral circulation.  The fluids of the living body,
although  themselves, doubtless, endowed with vitality, are  not
independent of the laws of hydraulics, or exempt from the in-
fluence of gravitation.
   There is much difficulty sometimes  in controlling  the  ma-
niacal fury of the phrenitic.  If it be possible—and every effort
and gentle art of mild persuasion  should be  assiduously tried
before we abandon  the effort—if it be possible,  he  must be
coaxed and soothed, and governed by the voice of kindness and
affection.   But when he will not submit—when, by loud voci-
feration and violent muscular exertion, he adds  to the morbid
excitement and irritation which menace his life or threaten him
with  permanent degradation of intellect, we must restrain this
suicidal conduct by whatever means become necessary.  It may
even be requisite to bandage his arms, and bind his body to the
bed.  I mention these  unpleasant  measures,  however, chiefly
that I may express  the  ardent  and earnest  hope,  that  no  one
among you will regard a resort to them  necessary or admissible,
until  every other mode of reducing  the  patient to obedience,
shall have been tried most carefully and  perseveringly, and tried
in vain.
  During Convalescence, besides the ordinary regimen deman-
ded by the remarkable  debility under which the patient conti-
nues for some time to labor, and which is  so  readily accounted
for by reference to the intensity of his disease  and the prostra-
tion consequent upon the  depletory system instituted  as reme-
dial, we must direet our attention closely to the weakened con-
dition of the mind, left as the result of the disorder of the brain.
The  intellect will  be  found unfit for  the  performance of its
accustomed operations, as, indeed, sometimes happens  after se-
vere attacks of fever.   Everything must be done to amuse your
convalescent, and entice him to give  his  attention to trifles
exclusively, allowing him to engage in no process of reasoning; 
364
INSANITY.
suffering him to be provoked into no discussion, however slight
it may seem.  He will be found captious, whimsical and peevish-
His caprices must, for the present, be submitted to, and his will,
whenever expressed, be law to  his friends and associates, unless
he desire something absolutely prejudicial  to him.  This state
of things will not,  however, if he be  judiciously managed, con-
tinue long.  As his constitution recovers its  strength, his intel-
lect  will also regain its impaired energies.   As  his physical
powers improve, his temper and judgment will be restored, until
at last  you will enjoy the gratification—a noble reward for your
beneficent  exertions—of seeing in him a renewed exemplifica-
tion  of the true  perfection and dignity of our species—mens
sana in corpore sano.
                     CHAPTER XLVII.

              CHRONIC PHRENITIS--INSANITY.

   Chronic  Phrenitis.  It happens, occasionally, that with
all the care and skill of the most scientific and  conscientious
practitioner, the recovery of the patient from the attack of acute
phrenitis is imperfect.   A certain degree of organic lesion  has
been  incurred, which, while  it  does  not,  perhaps, impede or
prevent the performance of the vital  and  organic  functions,
impairs sadly the animal or relative functions, and  disturbs  the
operations of the intellect;  or, without actual lesion of structure,
the disturbance of function has been so great, and continued so
long,  that the organ does not readily, if at  all, resume its usual
trains of action.  And thus, we are led to a brief discussion of
the weighty subject of Insanity, a topic of which I have always
been somewhat reluctant to treat in this place, on account of its
extreme  difficulty, in part, but  chiefly because my own views
are not sufficiently matured and settled to justify me  to  myself
in communicating them to you with any great degree of confi-
dence.  Hence, I propose to offer you little  more than an  out- 
INSANITY.
365
line, which you are to fill up for yourselves hereafter by your
own diligent study.
  Although, as you perceive, I regard chronic phrenitis as prin-
cipally, if not exclusively exhibiting itself in the various forms
of insanity, yet you are by no means to understand  me as  in-
tending to assert or imply, that every case of mental  derange-
ment depends upon or proves the existence of organic lesion  of
the  brain from  inflammation of  some  part  of its  substance.
This, although perhaps probable,  and, as a hypothesis, consis-
tent with the great mass of observed facts, is by no  means  so
clearly made out, that it may be  proposed to you as an esta-
blished principle or doctrine.   We know not how long inflam-
mation of a part may subsist without permanent and notable
deterioration of structure; and the  delicacy of the  minute ar-
rangement of  the cerebral tissue is such, that permanent change
may take place without  our being aware of it, or able to mark
in what it consists.   Nor, on the other hand, is  it certain, that
every case of chronic  inflammation of the contents  of the cra-
nium,  the brain, its membranes, its vessels, shall be  attended of
necessity, by  mental  derangement or insanity.  This also is
highly probable;  but we are not  yet prepared to  affirm the
essential or invariable connection of intellectual disorder with
every  imaginable deterioration of every portion of these tissues.
   Every writer upon  this subject has endeavored to define In-
sanity.  I  need not inform you, that  all have failed.  If I am
correct in regarding the several varieties of mental derangement
as symptoms merely of cerebral disorder, functional and organic,
primary and sympathetic, it is easy to see why they have failed,
mistaking, as they did, a series of  signs or phenomena, for a de-
finite  form of disease.  The mental  operations of a healthy
intellect are infinitely multiform ; their aberrations or irregulari-
ties in disease must be also indefinitely diversified.  Even re-
garding  these aberrations as symptoms, we shall  find it a task of
extreme difficulty, to  propose any mode of classifying  them,
which shall not be liable to  fatal objections.  Let us reflect, for
a moment, on the nice  lines of distinction  which separate the
several conditions of the mind, and divide from each other the
varied mental operations, morbid  and regular—reverie, absence
of  mind, dreaming, somnambulism, exalted passion, enthusiasm,
       31* 
366
INSANITY.
intoxication, delirium, mania, melancholy, hallucination, mono-
mania,  fatuity,  incoherence, idiocy and senile  imbecility;—
who shall  offer  us a clear diagnosis of each  of these, and yet
how  little actual danger there is of confounding them.   How
shall  we draw even the single distinction, so well recognized, of
delirium, from mania or lunacy 1   How point out  the shades
which separate intoxication from  delirium tremens, its attendant
frequently, and this latter from febrile delirium?—the delirium of
typhus from that of synochus ?  Delirium has never been defined;
indeed, no  attempt worthy notice has ever yet been made to dis-
tinguish it, on the one hand, from hallucination, and on the
other, from true lunacy.  Typhomania  is  always, apparently,
wretched and gloomy, and attended with discontent  and  petu-
lent muttering ;  that of inflammatory fever is often highly cheer-
ful and pleasant.  One of our most eminent public speakers,
when in this condition, is always wildly exhilarated, shouting,
singing,  uttering witticisms, laughing and making rhymes, and
has often exclaimed to me, "you know not how delighful it is to
be excited by fever."
   A peculiar erethism or irritation of the brain, connected  with
and symptomatic of disorders of the functions of other organs,
may produce a transient derangement  of the mind, as in hyste-
ria, fevers,  etc., or may be  idiopathically excited by the impres-
sion of some efficient  cause, as the passions, alcohol, opium,
stramonium, etc., etc.  How complete, while it lasts, is often the
insanity of intoxication, whether from alcohol or nitrous oxide;
how perfect the  insanity of hysteria  and  of fever;  how  total
the amentia of epilepsy and apoplexy;  how free from visions
and hallucinations  the "dreamless  sleep" of those  terrible dis-
orders !  All men agree, with very few exceptions indeed, to  refer
all  these to the brain as their seat, either primarily or secondarily.
Not only do many of the irritations  and congestions of that or-
gan arise sympathetically, as we every day see, from affections
of the viscera, and indeed of all parts of the  body,  disturbing
the operations of the  intellect, but  chronic phrenitis  itself  may
be of  two  forms, the idiopathic  and symptomatic.  Hence the
opinion of Pinel and others, (Broussais among them,) that insan-
ity is, at least in  part, owing to visceral disorder.   If farther it
be objected to the doctrine of causation of insanity, which I am 
INSANITY.
367
now advocating, that sudden cures have been made under moral
means hereafter to be spoken of, I reply that  such cases (the au-
thenticity of which I will not dispute, but the frequency of whose
occurrence has been much overrated,) do not disprove the reality
of the physical functional  derangement and structural lesion, to
which I attribute insanities.  Let  it  be remembered  that the
brain is a double organ,  and that  one hemisphere may retain its
organic fitness for its functions, though its sympathetic harmony
of action may be unstrung, and that a resumption of those func-
tions may occasionally happen.   Indeed  it is to this duplex ar-
rangement that I attribute most of the recoveries which  have
happened in any manner.   It is also possible (though  upon this
hypothesis I will not lay any stress)  that an organ  which has
been somewhat altered by inflammation,  may be restored to its
natural condition, or very nearly so, and yet the habit of morbid
action which has been formed during protracted disease, may con-
tinue for a time ; until at some fortunate moment the application
of some well adapted mode of excitement, shall rouse it, at once,
into its usual train of operation.
  It is proper that I should endeavor to enumerate the several
modes of mental derangement which  point out the existence of
a chronic  phrenitis, constituting Insanity proper, and designate
the reason why I regard these as thus separable from the other
forms.   We begin this delicate  task by a negative mode of in-
quiry, and set aside as not pertaining to our present investigation:
  1st. Those disorders  of the mind which depend, sympatheti-
cally, upon some transient affection of the system, or some one
of its parts, appearing when it invades, and disappearing when
it subsides.  Here, we have intoxication, the delirium of fever,
the imbecility of hysteria, and here too I would  class what is
called puerperal mania.
  2d. Those which have followed such diseases as have inflicted
lesions of  the brain of cognizable character, but distinguishable
from inflammation, and usually exhibiting congestion of the ves-
sels, or extra-vascular  pressure, in some  way or other, upon the
organ or some part of  it.   Here  we shall arrange all the amen-
tiae of apoplectics, and paralytics,  and epileptics, and those which
follow blows on the head and depressions of the skull.  Amne-
sia, or a loss of the memory of words  or things, inability to con- 
36S
INSANITY.
 nect language with meaning, is a  common  effect of apoplectic
 seizure.  A variety of exhibitions  of fatuity and imbecility at-
 tend  hemiplegia, and often follow in the train of quickly recur-
 rent or long protracted epilepsies.
   3d.  Those which are attendant upon states of cognizable and
 temporary  excitement—irritation—erethism of the brain, or (as
 we phrase  it,) "determinations to" that organ of specific  morbid
 character.  Here,  I would place somnambulism, mania a. potti,
 and the brief but extraordinary aberrations which follow the vio-
 lent explosions of passion.
   4th. Those mental deficiences which attend upon general de-
 cay of the  body, and the loss of vital power in the system. Such
 we must obviously regard the varying degrees  of senile imbeci-
 lity, from the  first impairment of memory down to the drivel-
 ling dotage of that extreme term of life, when the shrunken and
 palsied limb, the  dim eye and the dull ear  show the welcome
 approach of the dark messenger, now no longer a king of terrors,
 but the harbinger of relief and joy.  Here, also, I would class the
cases  of  occasional fatuity,  amounting even to idiocy,  which
follow violent attaeks of acute  disease of whatever character,
allowing sometimes of ultimate and perfect recovery, but too of-
ten remaining in melancholy permanence.
   Causes.  We shall be farther assisted in our endeavors to dis-
tinguish and classify the modes  of  mental  derangement which
depend upon chronic phrenitis, by  an enquiry into the causes
 which are  efficient in producing them.  I shall divide these into
the moral and physical.   Of the latter, we have numerous ex-
 amples—1st.  A very strong  predisposition to insanity is derived
from a deranged  ancestry.  This hereditary  taint is matter  of
every day remark, and forms a  gloomy  example  of the trans-
 mission of  disease.  It is apter to attack children born after, than
 before the development of the disease  in a parent.  It  is  most
 likely to show itself about the same age in the children, at which
 it appeared in the  parents.  It is most  likely to put on the same
 character and history.  2d.  Particular temperaments give  (or I
 should perhaps better express it by  saying  constitute,) predispo-
 sition to insanity.   The  combination of the nervous with the
 sanguineous, if both are exquisitely developed, obviously tends
 to the production of furious mania; of the nervous with the 
INSANITY.
369
bilious, to melancholy.  3d. Exciting causes of physical  char-
acter comprise—a. All such as may bring on acute phrenitis, of
which, I have said, the chronic form is an occasional conse-
quence. They may, however, in the first  instance,  produce a
chronic inflammation, if they are applied successively in grades
of less intensity.  Thus, intemperance habitually indulged  in,
even though it may never be carried  to the extent  of absolute
intoxication, does, in some  instances  produce, instead of a  de-
lirium, a true  insanity, and indeed,  has come to be regarded
every where, as one of its most prominent  causes,  b. Many of
the forms of gastric and intestinal disease give rise, by sympa-
thetic radiation of morbid action, and the lighting up of a symp-
tomatic phrenitis, to a very obstinate form of insanity.  This is
much dwelt on by Pinel  and Broussais, in France, and Ferriar,
in England,  c.  Sexual irregularities produce  chronic phrenitis
and insanity.  Perhaps these cases occur most frequently among
women, who seem to be more under the dominion of the genital
system, than males.  Dysmenorrhoea, amenorhoea, and suppres-
sions of menstruation, and masturbation, are all enumerated  by
writers, under this head.   In the Report of the Worcester Asy-
lum, for 1839, the greatest  proportion of the cases is ascribed to
intemperance; the second largest number, to masturbation,  d.
Metastasis of other diseases to the  brain.  Numerous examples
of this kind are recorded.  Sauvages has made a separate  va-
riety of metastatic madness.  It is said to follow the disappear-
ance of cutaneous eruptions, of habitual discharges, hemorrhoidal,
or from ulcers, etc.,  and the sudden cessation of old gout and
rheumatism.
  The strongest among the predisposing causes, which act  by
moral  influence is, unequivocally—1st. Education.   I need  not
dwell upon  a subject so trite, farther  than to  remind  you, that
the word has an extensive meaning in this place, and comprises
not only the course of instruction by which the mind is inform-
ed, but the whole series of  measures by which it is directed and
controlled in  children, and taught  to  direct and control  itself
when childhood  is past.   Mrs. Hamilton is right in affirming,
that example is the principal part of education.  Slight excesses,
or occasional mere peculiarities or eccentricities, originalities, as
we call them, in the parent, are apt to be exaggerated or  en- 
370
INSANITY,
hanced into insanity, in the child,  unless counteracted by  acci-
dent or design.  I need not insist upon the predisposition  mor-
ally built up, by indulgence of passion, appetite, whim or caprice,
in early life.   It is matter of universal  notoriety.  2d. The fre-
quent or vehement excitement  of passion, especially  if that
passion or emotion of mind be specially excited, and long and
vehemently indulged, to which the subject  is prone, whether
hereditarily, or from original  formation  of character, or through
the influence of education and habit. It is thus that fanatical zeal
breaks down the intellect of its victims, by arousing terror, and
inflicting upon the conscientious or timid, the horrors of imme-
diate despair or impending doom.  It  is thus that anger and
malice are exasperated into murderous malignity, by political
and religious considerations too strongly colored, too closely and
gloomily brooded over.   It is here, perhaps, that we should find
the source of the long catalogue of the cases of monomania, and
most of those of deep melancholy which are to be found in our
mad-houses.  In the cells of the Poor-house here, was to be seen
for many years, a poor wretch, who having been a deserter from
the army, was  destined to be shot.   He was made to kneel,  with
his eyes  bandaged, upon his coffin, and the fatal word was about
to be given, when he was reprieved and pardoned, but too late.
He spent the remainder of his life in the condition of a maniac,
with but three connected trains of thought that could be noticed.
One of them was founded on his habits as a pugilist, a second
on those of a soldier, and a third referred to his fondness for tobacco.
3d. We may class separately, or arrange under the last head, ac-
cording to the circumstances of particular cases, the influence of
remarkable and  sudden, or unexpected change  of condition.
This is a fruitful cause of madness.  The loss of friends whom
our souls held  dear, and upon whom we depended for  all the
joys that give life its value ;  the transition from wealth to  pov-
erty, and strange to say, from poverty to wealth, especially
among the commercial  world, by whom the value of money is
habitually overrated, in a most incomprehensible degree; the
loss of honor or reputation ;  and  political reverses.  These all
unsettle  and derange the mind ; whether through  the influence
of violent and prolonged emotion, exciting the cerebral  actions
into a morbid state, or by directly  breaking up the  harmony of 
INSANITY.
371
  the intellectual operations, might  be made a  nice  metaphysical
  question.  There is no reason in  the  nature of the case,  why
  the functional should not, nay, it  probably often does,  precede
  the organic disorder.   It is,  however, and  perhaps must be,  a
  transient affection, unless the latter supervenes.   Perhaps all the
  cases of intermittent insanity, are properly of this  transient and
  purely functional character.   It would be out of place here, to
  discuss it;  it suffices to know, that whatever may be  the in-
  cipient steps of this moral ruin, its ultimate  progress is devel-
  oped by, and essentially  connected with cerebral  changes that
  can be detected and described.
    The Necroscopy of insanity, which we next investigate, also
  goes to prove the connection of the intellectual or functional de-
  rangement, with physical and organic change in the condition
  of the brain, often the obvious result  of chronic inflammation.
  Such changes are described by all pathological anatomists, from
  Morgagni down, who have examined  the brains  of insane  sub-
 jects ; and the later and  more minute the inspection, and the
 more scientific the detail, the more noteworthy  have been the
 observations made, as  to these changes.   You  will  be disap-
 pointed, however, generally,  by finding a want  of attention in
 these records, to the connection which  we might suppose to exist
 between the marks of disease, on dissection, and  the nature and
 history of the morbid phenomena.  Thus the want  of point, in
 the two principal inferences given  us by  Foville,  on whose re-
 ports great stress is laid, both  by the French and  English pa-
 thologists, is very striking.  He states  them  thus—1st. Morbid
 changes in the cortical  substance,  are  directly connected with
 intellectual  derangement.  2d. Morbid changes  in the white
 substance, are directly connected with  disorders in the  motive
 powers.   May we, then, venture to place motive  volition in the
 white, and the  other  modes of volition, with all  the rest of the
 intellectual  powers, in the grey or  cortical portions of the brain?
 If not, what other conclusion can be drawn ?
  There are two other general inferences described  by Foville
from his examinations, which are quite as well worthy your no-
tice as the above.  "The morbid changes,"  says he, "which we
have surveyed, present many of the  anatomical  characters of
inflammation;" "we are forced to allow that there exists  in  the 
372
INSANITY.
brains of lunatics, a state of true inflammation."  In opposition
to Bayle, who refers insanity to disease  of the  membranes, he
states, that  "as the different traces of inflammation  are  more
constant in the brain than  in the membranes,  we  must regard
the former as essential, the latter as the incidental condition."
   Sonumerous and varied have been the morbid phenomena noted,
and as I have stated, so little definite remark has been made, as
to their connection with the previous histories, that it is scarcely
of any  advantage to  offer you a  mere enumeration of them.
The cranial  bones are frequently affected; they are irregularly
thickened sometimes, and sometimes attenuated; sometimes the
diploe disappears, and they resemble ivory ; sometimes they are
spongy; "the form of the cranial  cavity is irregular  and une-
qual," says Georget.  The membranes are thickened, injected,
adherent,  both on their opposite sufaces, and to the cerebral sub-
stance which they invest.  This substance is injected, thickened,
"occasionally," says Foville, "in acute cases intensely red."  The
surface or superficial  stratum  of the  cortical  substance, is in-
creased in firmness and density.  Gall and  Desmoulins  have
observed in some, what they call "atrophy of the convolutions,
more frequent in their frontal regions; sometimes an  actual ab-
sorption, leaving chasms filled by serosity."   Haslam  noticed in
several cases, a peculiar looseness of the  scalp.  In a majority
of his cases, the  consistence of the brain  was not perceptibly
altered; in  some, it was firmer, and in others,  softer than  natu-
ral.  Esquirol notices, that the crania were "irregular in respect
to the different diameters, and to the cavities of the two sides."
Ossification of the arteries of the brain, has been seen.  Georget
has remarked "the color and consistence of the grey  and white
substances almost confounded."  Changes  are far less frequently
observed  in the cerebellum, than in the cerebrum.  The  infer-
ence  does not seem unfair, that the  cerebellum  is not the seat of
the amative propensity. Masturbation is one of the most ordi-
nary incidents of insanity ; in the female  sex, at least, the fact
is so.  A majority of the female insane under  my  notice, have
exhibited, either permanently or occasionally, erotic furor.  Es-
quirol has described, as a rare phenomenon, the presence in the
brain, of a  multitude of small cavities, from the size of a millet
 seed, to that of  a nut, containing fluid.  He  supposes these to 
INSANITY.
373
 be  the sequelae of extravasations.  It  is  remarkable,  that the
 medulla oblongata and medulla spinalis, rarely display any mor-
 bid changes of structure.
   From what has been said above, as to the causes of insanity,
 and the appearances of  alteration in the condition of the organ,
 with whose operations the intellectual functions  are  so closely
 connected, and upon whose integrity they  are thus proved to be
 absolutely dependent for their regularity, we are abundantly en-
 titled to infer the very general, if not constant and essential coin-
 cidence of chronic phrenitis with Insanity, properly so called.
   Having acknowledged the impossibility of offering any compre-
 hensive and accurate definition of this  morbid condition of the
 intellect, I now proceed to describe its prominent manifestations,
 and to endeavor to classify in some sort of general arrangement,
 its  several varieties.  One of the greatest difficulties with which
 we have to contend, in the  discussion of our subject, is the  dis-
 position to generalize too hastily, met with in the writings of
 almost all who treat of  it.   I have already referred to the infi-
 nite diversity of intellectual operations; let us suppose a calcu-
 lation made upon the variety of changes of relation which these
 will admit of, and we will then arrive  at  some  idea how  im-
 mensely multiform and complex the morbid appearances may
 become.  If we observe the play of the numerous muscles which
 perform the diversified motions necessary to the various  actions
 upon  which life depends, and through which, (if I may so speak,)
 it delights to expend itself, we shall find, that however  compli-
 cated the movements  of these several muscles, they  proceed
 fibre after fibre, and fasciculus after fasciculus, in a series of per-
 fect, exact and unchanging  regularity of succession,  as in  the
 nice execution of a proficient in music—Paganini, for example;
 the perfect consentaneousness of operation, and the  exact pro-
portion in degree, being both absolutely  essential to the  produc-
tion of the proper and expected result.  Suppose some muscle, or
some fasciculus, or even some single fibre of a muscle, to have be-
come  rigid or relaxed, or incapable of its  function, either per-
manently or for a single instant, provided that instant  be  the
point of its required action, discord must result, and the note or
notes, the production of which required the correct  movement
of that fibre, must be lost or misplaced.  It is the power of pre-
      vol n.—32 
374
INSANITY,
cise association, whatever it may consist in,  and wherever it
may reside, that renders all the physical actions, natural, proper
and healthy.  Now, the analogy seems to me to be  complete.
Insanity does not necessarily consist in the loss of any definite
power of the mind, the impairment of any one of the intellec-
tual operations; it consists in, and depends upon the incapacity
to effect that association of action, through which  these opera-
tions are conducted to  a definite result.  I do  not deny, you
must remark, that the loss or impairment of power may occur;
I only contend that this is not essential, and  that the loss of as-
sociation, the disassociation or breach of relation and succession
between  the operations of the intellect, is  the only uniform, uni-
versal, invariable and  essential symptom of insanity.  "The
sweet bells," to use the expressive figure of the poet, may each
ring forth its own silver sound, but  they  "jingle out  of tune."
   Hence, I cannot agree with Locke,  who defines madness the
reasoning rightly upon false premises—nor with  Esquirol,  in
considering moral alienation as  its proper characteristic—nor
with Cullen, who regards it as essentially hallucination, or false
judgment or perception of external objects.
   In looking over the recorded facts,  the  authentic histories  of
insanity, we shall meet every where, in the best authorities, with
statements entirely incompatible with either of these  views  or
definitions.  Pinel tells us, that he "found many, many maniacs
give evidence at no period, of any lesion of the understanding."
Some maniacs exhibit a high degree  of conscientiousness, and
are miserable under the depressing consciousness of inability  to
perform their social and moral duties.  This  fact,  I  think not
uncommon among religious lunatics.  Every one has  seen ma-
niacs who were perfectly free from hallucination.
   I will  venture, then, to subdivide insanity under  five heads,
according to the prominent symptoms which go to constitute the
history of each, without pretending for a  moment to affirm, that
these lines thus drawn, will be in all  instances,  or  even in the
greater number, obviously capable of separating, in an exclusive
manner,  one class from another.   It  must be  apparent to you,
that the various traits,  so far as they  are  compatible, may  run
together  and be intermingled, so that many cases may be classed
under more than one head,  without any striking impropriety. 
INSANITY.                     375
 My purpose is only to distinguish the prominent characteristics
 of each, as follows:  1. Incoherence; 2. Mania;  3. Melancholy;
 4. Hallucination; 5.  Monomania.
   1st. Incoherence.   It may seem singular, that after declaring
 incoherence, or more properly disassociation, to be an universal
 attendant upon all cases of insanity, I should designate one class
 specially, by a title drawn from this symptom.   It is true, how-
 ever, that certain instances, and these in very considerable num-
 ber, are distinguished by this particular trait; and that in such,
 all the powers of association, or nearly all, seem lost;  all  the
 affinities of connection, which bind together ideas, sentiments,
 feelings, thoughts, habits, words, and actions,  are impaired or
 rendered vascillating and uncertain in their influence.   It will
 be perceived readily,  then, that I employ the  term incoherence,
 as designating a form of insanity, and applicable  to a  class of
 lunatics, characterized in an eminent  and emphatic degree, by
 this impairment  of the  "power of association."  I spoke of a
 soldier, in  whom it was exceedingly prominent.   He was rest-
 less and impatient, and was almost always engaged in  uttering
 words and  phrases, with  unexampled volubility and  perse-
 verance.   No sense  or meaning could  be  extracted from what
 he thus said, on any occasion.   Give him the word of military
 command, however, and he would assume  the attitude of a re-
 cruit,  and  go through  the  motions  of the manual  exercise.
 Throw yourself into the position of a boxer, and he would take
 a  posture of defence.   Offer him tobacco, and his countenance
 would express a gleam of satisfaction, while he seized it and thrust
 it  into  his mouth.  Cases of this character are curious to study.
 While we wonder at the  ceaseless activity of the mind,  we  are
 struck with the absence of all the principles and powers of regu-
 lation.  Even the natural instincts and propensities  seem sub-
 verted, and some patients seem forgetful or  ignorant that  thirst
 is  to be quenched by  drinking,  or hunger allayed by food.
   2d.  Mania.  By this term, I  would be understood  to mean,
 what has been often spoken of as "moral  insanity," in  which
the restraints of education and habit, of law and order, are lost,
and man becomes a savage or wild animal.  This is also termed
by some, "furious or acute madness."   These are the  unhappy
cases, from which the fear of lunacy and the institutions  of  so- 
 376                     INSANITY.

 ciety regarding it, have  been drawn.   Here the  propensity to
 injure others—the propensity to do  mischief and destroy, is
 prominently developed.  Anger is readily excited, and  scarcely
 admits of being soothed.  Malice and violence possess the mind,
 and in the tumult of passion a wretched life passes away.  For-
 mer friends are regarded with especial dislike,  and efforts of in-
 credible  force and  perseverance are made, to wreak  revenge
 upon them.  It is astonishing with what cunning  and ingenuity
 these efforts are directed; how the patient will feign, flatter, and
 play the most deceitful part, in order to effect his most desperate
 purpose  of assault and  murder.  With admirable promptness
 and presence of mind, too, he seizes such  opportunities  as  acci-
 dent may present to him.   In many of these subjects, there does
 not appear to be  any defect of understanding, in the ordinary
 sense of the word; these were probably among those whom the
 ancients regarded  as under  demoniac  possession. Every wo-
 man whom I have seen laboring under  this variety, gave evi-
 dence of erotomania, and almost every one was addicted to mas-
 turbation.  The most  delicate, refined and  modest, previously,
 seem most likely to become obscene.  Religious subjects of mania,
 are almost always profane and blasphemous.
  3d. Melancholy.  It is  difficult to point  out any erroneous
 views, or  incorrect  trains of thought or reasoning, in some of
 this class of patients.  A gloomy apathy, a total indifference to
 all things around them, a state of prolonged reverie; this appears
 to be, in  some instances, the whole history of the disease.  I
 have seen an individual sit in the same posture, from day to day,
 from month to month,  and from year to year,  during  summer
 and winter, with his arms folded and his eyes  bent on the floor,
 maintaining a sullen and profound silence.   He  could,  by  per-
 severing efforts to  make him  speak, be roused into vehement
 anger, but this would  subside promptly,  if his persecutor  de-
 sisted.  At first, it was difficult to make him lie down,  or  rise)
 or eat, or dress himself; but by patient and quiet attendance, he
was brought into a sort of regular habit, eat and drank at given
times, mechanically, but did not notice what was brought him,
or the neglect of bringing it; rose in the morning and  permit-
ted  himself to be clothed, without saying a word, or undergoing
the  least  change of countenance. 
INSANITY.
377
    4th. Hallucination.  This is the form of insanity which bor-
 ders most closely on delirium.  Some have doubted whether the
 false impressions, under which the patient  labors,  originate in
 morbid sensation, and commence in the organs of sense, or arise
 from the diseased state of the brain.  You will readily infer my
 adhesion to the latter of these opinions, although I acknowledge
 the force of some of the cases on record.  A wretched creature
 under my notice, was harrassed night and day, with the annoy-
 ance of innumerable serpents, which perpetually inflicted upon
 him the agonies of Laocoon, without affording him  the relief of
 death.   These are they whom the furies torment with the stings
 of a lacerated conscience, and the recollections  of undetected
 crimes,   Alas ! that it were only the guilty who should suffer
 thus.   But cases of this sort are infinitely numerous and varied.
 It is strange, too, with what  ridicule, contempt and  resentment,
 they regard the hallucinations of others.  In this class we  may
 arrange, I think, many of the instances of religious mania; and
 here, find the key to most of the extraordinary delusions, which,
 from time to time, have led men to the solitude of the monastery
 and the desert, and mingled  so much deep and sincere devotion
 with such desperate imposture.
   Many of these, it  is true, belong to our  fifth  and last order,
 Monomania, with the history of which almost every man  of
 reading is at the present day familiar.   Monomania consists in
 insanity upon one subject, or  one set  of subjects only.  It is
 usually a quiet and harmless  form of derangement, but some-
 times assumes a dangerous direction.  Phrenology exults to bring
 forward  as illustrations  of her principles, examples from  this
 class.  Monomania  is often complicated with hallucinations,
 which are then also,  exclusively  directed to one  point.  This
 condition often arises from the protracted influence of  some one
 of the gloomier  passions, especially grief.   See the picture so
 exquisitely drawn by Shakspeare's Constance.
            "Grief fills the room up of my absent child;
            Lies in his bed; walks up and down with me,
            Puts on his pretty looks, repeats his words-
            Remembers me of all his gracious part—
            Stuffs out his vacant garment with his form."

The senses would not seem to be perverted here, but the impres-
      32* 
37S
INSANITY.
sions they receive,  however correct, are  less  vivid  than those
originating  in  the diseased brain, and often mingle with them
inseparably.  In those who are haunted by spectres, for example,
the imagination resists every effort to disabuse it.  A physician
placed himself exactly in the position pointed out as occupied by
a skeleton.   "Now,  it is looking over your shoulder!" cried
the patient.   An insane woman was persuaded that her husband
was dead.   When he was brought and set before her, she knew
his person, but insisted that it was  the devil who had  assumed
his form.   A girl had lost her lover, and saw his image  standing
perpetually at the  foot of her bed ;  a strong resemblance being
made and dressed in his clothes was made to stand in the same
place.   "II y en a deux!" she exclaimed, and expired.
  The relations which exist betwen insanity and other  diseased
conditions of the body, are interesting to be observed and known.
For my own part, I  have never seen a case of insanity in  which
the general health was not notably disordered.  How can it be
otherwise 1  If, indeed, as I have taught you, the brain,  the cen-
tral organ of sympathy and excitability, be thus deranged in its
functions and structure—how is it possible that  the physiological
actions of the several systems of parts should be carried on with
precision and regularity ? We shall notice here—
   1st. Coincident disease  of the sensorial system.  Besides the
impairment of the intellectual functions,  there is proof  of gene-
ral nervous disturbance.   In  almost all cases  we have morbid
vigilance, headache, jactitation, and a feeling of great discomfort.
The senses are morbidly acute, and receive none but unpleasant
impressions.  Many insane are perpetually annoyed with dirt and
filth ; others with bad smells.   In almost all there is morbid irri-
tability as well of the body as of the mind.  Convulsions,  par-
alysis, apoplexy, not unfrequently supervene in cases of  insanity,
   2d.  The digestive system is always apt to be more or less de-
ranged, as  is shown  by foul tongue, foetid breath, anorexia or
morbid appetite,  and obstinate costiven^ss.  The patient often
spits, carelessly and in every direction, a viscid saliva.
   3d.  The respiratory system is less liable to disturbance, but is
sometimes affected with dyspnoea, quasi asthmatic.
   4th.  The vascular system is often thrown into violent disturb-
ance.   Fever sometimes runs high.  The pulse is generally quick 
INSANITY.                     379
and frequent and hard.  Exceptions are said to occur in melan-
cholia.   The face is often flushed and the veins of the head and
neck swollen; the eyes red and suffused, and starting from their
sockets.
   Prognosis.  It is with  great regret I find myself constrained
to differ with almost all recent writers on insanity,as to the pros-
pect of cure for the insane, and to declare my belief that the gen-
eral prognosis  is highly unfavorable.   Esquirol  states that the
greatest number of cures is made in France; that the proportion
restored is one in  three, in that country ; less in England, and
still less in Germany and Italy.  Burrows, as might be expected,
gives a more favorable account of the  success of treatment in
England.  The results of the numerous tables offered by writers
who  have procured statistical information and  embodied it in
this form, are indeed highly gratifying, if we admit them without
deduction; but we  are  too much interested in ascertaining the
truth, to pass this question slightly.  I am inclined to attribute the
error, for such  I conscientiously  believe it to be, principally to
the want of a  correct diagnosis.   If cases are included under
the head of insanity, which depend on some  transient condition
of the body or its organs ; such as hysteric folly and derangement,
transient febrile delirium, and the protracted delirium  or fatuity
from attacks of fever,  or other acute disease which has passed
away, leaving behind it a gradually diminishing train of effects ;
or attacks of delirium tremens; or of somnambulism; or  puerpe-
ral mania, it is  not to be wondered at that the proportion of re-
coveries shall come to be rated high.  For these are very cura-
ble forms of  disease ; but, as I have already contended, they do
not come under the head of insanity from chronic phrenitis, the
topic of present consideration.
  Insanity is, of course, much  more curable  when recent, than
when it has existed any length of time ; but not so the cases just
enumerated,  which often spontaneously subside with time. The
cause and history determine also the prognosis in great measure.
Metastatic insanity, of whatever  kind or degree, may often be
relieved, by reproducing the  original disease.  With this excep-
tion, those which arise from physical causes are most difficult of
restoration.   Hereditary lunacy is hopeless or nearly so.  That
which arises  suddenly is more  manageable, speaking generally, 
380
INSANITY.
than that which is gradually built  up.   I  cannot help also ad-
hering to  the received opinion, that insanity always leaves be-
hind a strong disposition to recurrence.   I am aware that Pinel,
Prichard and others declare that  this liability is overrated; but
you will, I think,  have sad  opportunity to come to a different
conclusion.
  Treatment.  On this part of my  subject, I do not propose to
enter into minute detail, but merely to furnish you with a gene-
ral outline of the received principles and practice.  It is allowed
on all hands that  nothing can be done  unless a proper govern-
ment be  instituted over  the  unhappy lunatic ; his habits must
be regulated, his passions subdued or controlled, and his whole
conduct subjected  to a regular and strict, though mild and con-
solatory discipline.  For the attainment of these views, asylums,
public or private, are now acknowledged by every one to be ab-
solutely necessary.  In such establishments alone, can we hope
to attain and preserve a salutary influence over the insane. There
are, indeed, few whom it is either safe or proper to keep at home.
For the most part, and with rare exceptions, they either hate or
scorn,  fear or terrify their  ancient friends ; they often refuse to
know them or admit their identity.
   A judicious and proper control must,  however, be regarded as
remedial also, and not merely expedient.  I surely need not say
a  word  in reprobation  of  all severe  modes of management.
Experience has proved them to be unnecessary and injurious;
but where the  safety of the  patient—whose propensities  are
savage or suicidal—and those about  him,  or where  decency
demands, as  toward those who will not bear the restraint  of
proper clothing, or who yield to the impulses of nympho-mania
and satyriasis, we must apply efficient means of confinement
and restraint.  In some institutions, the muff for  the hands, and
a  chair  for  the feet and  body,  and in others, the method  of
straight-jacketing, is preferred.  I select the  former, but either
will answer our intention, and may be  so  arranged as, without
any just imputation of harshness or cruelty,  to effect  our pur-
pose.  I have been able, however, in almost every case, to bring
my patient into complete subjection, by  the use of the cold dash,
vigorously applied and  persisted in, until they submit uncondi-
tionally and yield me  an implicit obedience.   The most violent, 
INSANITY.                     381
 it is said, can be brought down by the sickening and depressing
 influence of the circular swing, but this I never apply, fearing a
 morbid determination to the' head from it.
   In the employment of remedies, the state of the general sys-
 tem must always be considered ;  this is either entonic or atonic,
 a distinction, for the most part, readily drawn,  and one which 1
 make the directing rule of the treatment of insanity.  Venaesec-
 tion is highly extolled by one  set of writers, while others declare
 it to be useless  or worse.  I do  not  consider  it adapted to the
 ordinary history of chronic phrenitis, but where a suddenly
 aggravated determination takes place to the head, as shown by
 flushed face, red eyes, head-ache, etc., and the patient becomes
 wild, talkative,  or fierce, I  should not hesitate to bleed freely.
 It  is only under the same circumstances, that  leeches or  cold
 applications are of any definite utility;  at other times, they only
 annoy and  irritate  the  patient.   A very  efficient means  of re-
 ducing the  patient  to tranquillity,  and  relieving the  cerebral
 determination, is found in  the antimon: tart.  It  is one of my
 most important  formulae in the domestic management of these
 sad cases characterized as "maniacal."  I instruct the attendants,
 as  soon as they perceive  any aggravation of  their violence or
 obstinacy,  to add this nauseant  to  the fluids  taken, and thus
 bring on a certain degree of sickness and depression.
   In recent cases, I have derived some  benefit  from mercurials
 urged to ptyalism, but  cannot lay much  stress on this course.
 Opium I use freely ; I can  scarcely point out where  it is best
 adapted, but I have never yet seen it do any harm, and employ
 it  extensively.   If  the  subject of your treatment  is morbidly
 wakeful, and gives himself, and  those about  him, any distur-
 bance  by nocturnal riot and noise, you may administer  it with-
 out hesitation.   It will probably do much good by soothing  and
 tranquilizing him, and cannot  surely be in any mode productive
 of so much irritation and general  evil as must result from want
 of sleep, and its immediate train of consequent excitement.
  Purgatives are of universal  application from the most ancient
 times, and it is impossible to doubt their  efficacy in numerous
cases.   But the distinction  above  referred  to, must be carefully
made, and their exhibition strictly confined to the entonic condi-
tions of constitution.  In the  opposite  class, nothing more  ra- 
382
MANIA A POTU.
pidly or irrecoverably prostrates the lunatic, than the ill-timed
or undue operation of a  cathartic.  Indeed, they sink readily
under accidental diarrhoea, from whatever cause.
  I can hardly advocate the use of diffusible stimulants in  any
instance of insanity ; but I would always  be willing to accord
to the feeble  and atonic, a generous and  nourishing diet  and
warm clothing.  It is  an error to suppose  that  madmen are
indifferent to changes of weather or insensible to cold.  Some
are so, indeed, who labor under  a perpetual  excitement of the
vascular circulation ; but, in  general, though they  may  not
complain,as being melancholy, abstracted and absorbed in their
peculiar  contemplations, they are very susceptible of suffering
and injury from this cause.
                    CHAPTER  XLVIII.

                       MANIA A  POTU.

  I have had but too frequent occasion, in  the  prosecution of
our enquiries into the causes and history of diseases, to refer to
the deleterious influences of the various forms in which ardent
spirits are employed.   Long, and gloomy, and disgusting, has
been the catalogue of maladies introduced  and aggravated by
this  species of poison.  With the immediate consequences of
indulgence in the use of alcoholic  liquors, we are all so familiar,
that the lesson of horror early imprinted on the  mind of the
young Spartan by the exhibition of a drunken Helot, is entirely
lost upon us.  The tottering, uncertain walk—the  broken, con-
fused speech—the red eye, and the distorted countenance of the
drunkard, shock us no longer ; and even the total, though  tem-
porary deprivation of reason—the connecting link,

             "Which makes man kindred with the Deity,"
serves rather as a matter of jest and ridicule, than of pity and
dismay.  We sport with this destroyer as the Indian plays with 
MANIA A POTU,
3S3
 his venomous serpents—but, unlike him, we possess no talisman
 to protect us in our thoughtless rashness.  Man dies by famine,
 by pestilence, and by  the  edge of the  sword.  His joys—his
 hopes, fall before the withering blast of many and diversified
 agents of evil; but to intemperance must be conceded the first
 place in the  list of these  malignant  influences, whether "we
 regard the number and value of its victims, or the extent and
 amount of ruin which  follow in its train.
    The evil habits comprehended under this  familiar term, con-
 stitute peculiarly the blot upon our national character.  It is
 affirmed, that as great a quantity of ardent spirits is consumed
 among us as by the inhabitants  of all the rest  of the world.
 The miseries  occasioned by their use, are, in the same ratio,
 common in our land.  That disease, in particular, which is now
 to be the subject of discussion, is  comparatively little known
 elsewhere, and the few trans-atlantic writers who  notice it, are
 found to make, in their treatises, an unwonted reference to Ame-
 rican  authorities  as  specially familiar with it.  It has been
 known by various names, each of them  expressive and signifi-
 cant.  Drunkards themselves call  it "the horrors," and well does
 it  deserve the appellation.  In every other  disease of which
 mental alienation forms a part, the reveries are sometimes agree-
 able, the illusions occasionally pleasant; but,  in this, the excited
 imagination presents a cup of unmingled bitterness.   The hal-
 lucinations of the sot are full of gloom—of dismay—of despair;
 and hence some are disposed to regard it as the "demono-mania"
 of the ancients.  Armstrong entitles it the "brain fever of drun-
 kards ;" Broussais calls it "oino-mania;" Craigie, with learned
 affectation, gives it the double name of "meningitis phantasmo-
 tophora,"  and  "methystic brain fever;" Pearson  designates  it
 "delirium tremens,"  a phrase which points  out the  two most
 striking  incidents of  its history—the disturbance of mind and
 the nervo-muscular derangement always attendant  on it.  It is
 most commonly  spoken of, in  this country, as mania a potu,
 which appellation I  prefer to  retain, partly on account of this
familiarity, and partly because of the useful and pithy reference
made to  the cause.  I must not omit, however, to acknowledge
that the intellectual disorder is by no means properly designated
as maniacal;  it resembles rather the pathological description of 
384
MANIA A POTU.
delirium.   Yet  Craigie contends, that it  belongs, correctly, to
neither of these heads, but comes under the definition of hallu-
cination—that is,  error in sensation and  perception.   It  is a
matter of  great  nicety to  draw the precise line between these
several affections of the sensorial system  speculatively, but in
practice they are less liable to be  confounded.  Prichard asserts,
that lunatics very often "bear an infinitely greater resemblance
to persons in perfect health, than to  patients laboring under
delirium,"  and  the same is true of hallucination, so called.
The very obvious  disturbance of the general health here, which
so frequently and  so closely resembles fever, seems to  ally the
mental disorder to delirium,  rather than to the other modes of
insanity.
  The Cause which produces it is obvious and distinctly known.
It arises from the  habitual employment of the several  forms of
distilled spirit, and alcoholic  mixtures in inordinate  amount.
The point of such excess  as  shall give rise to  it, will of course
vary  somewhat in different constitutions, and may  undergo
some modifications by changes  of circumstance in the same
constitution.   The habitual  use of opium  is said also to occa-
sion it. Of this, you will see few or no examples.  I have met
with nothing of the kind, and  am disposed  to doubt the fact.
That opium is capable of exciting much and serious disease, I
do not question; but, on the  whole, I regard alcohol as the sole
and exclusive cause of mania a potu.
  The  direct effect of the  use  of this stimulant is too  well
known to need description.   Some have suggested a difficulty
in deciding whether the  patient, in certain contingencies, still
labors under mere  intoxication, or has  sunk into delirium  tre-
mens.   Coates and others maintain, that the latter is "the result
not of the application, but of the sudden  intermission of the
employment of such stimulants."  If this were true,  we should
be  in  possession of an  easy  diagnostic, for, as intoxication  is a
transient condition, we should, by allowing  time for it to sub-
side, set apart the case under the  contrasted  head of permanent
disease, a distinction which the practice of Courts of Justice has
rendered important.
  But this opinion is entirely erroneous.  I will not deny what
is affirmed on respectable  authority, that attacks of this sort may 
MANIA A POTU.                    385
 happen where drunkards have been abruptly debarred access to
 ardent spirits, as in prisons, hospitals,  etc.;  but such  examples
 must be rare.  The keepers of our jails and penitentiaries make
 very little of the  danger of such occurrences, of which  they
 have every opportunity to notice both the number and severity.
 On  the other hand, I have very frequently seen mania a potu
 supervene abruptly, surprising the sot  in the midst of a "frolic,"
 as it is called, and while surrounded by his reeling and  exhila-
 rated companions.
   I  am aware, that  to  this enforced abstinence, some writers
 have ascribed that form of the disease  spoken of by Dupuytren,
 and  known to most  surgeons—delirium traumaticum, which
 attacks the subjects  of severe  accidents, fractures, etc., if of
 intemperate habits.  The assumed explanation is by no means
 so clear as the fact  is  certain.   That the habitual  sot is in a
 state of definite predisposition, will not be denied ;  the true
 question,  then, is, whether  the irritation from the  injury  re-
 ceived, or  the abstraction of his accustomed drink, is the exci-
 ting cause of  the attack.  A case very much to the purpose of
 illustration here, happened in my own  practice,  and was brought
 to the College Hospital in 1835-36.  A mulatto fellow fractured
 his  thigh  while intoxicated.  For five days he seemed to  be
 doing very well, but, on  the sixth, his wife being permitted to
 visit him, contrived to bring him privately some ardent spirits—
 gin ; of this  he  drank very  freely, and  became quite  drunk,
 upon which condition mania a. potu supervening, he soon sunk
 exhausted  by the sleepless irritation.
   Let me add here, a strong fact on the authority of Dr. Carter,
 an English physician, who declares that delirium  tremens is
 very common among  the landlords of inns in Great  Britain,
 "and that these are, as a class, among the steadiest drinkers  in
 the world."
   With regard to  the  question of causation, it  is often  asked,
 Wherein consists excess 1—what is it to be intemperate ? The
 answer is  easy.   We  over-step the limits  of  temperance, and
 commit excess, either as to the degree  or  nature of indulgence,
when we diminish our capacity for the ordinary duties of life—
when we shorten life—when we  disorder and disturb any of our
physical functions—when, most  of all,  we derange our intellec-
      vol. n.—33 
386
MANIA A POTU.
tual faculties.   The drunkard notoriously does all this ; he will
probably neither defend himself, nor find a  defender among
reasonable  men.   But there  are many who  do all this, and
much more, and yet  are not drunkards ; these are obviously
intemperate, as well in a pathological as in a moral sense.   It is
undoubtedly possible, and instances of the kind may be readily
pointed out, in which an individual has, during a long life, made
use of ardent spirits in small quantity occasionally, and without
any ill-consequences.   The use of them, indeed, is in this way
always begun—nemo  repente fit turpissimus—but after a time,
and gradually, an  artificial necessity  is thus  built up in the
system of a very large proportion of these moderate drinkers,
which calls for a regular and regularly increasing quantity to
be taken at the accustomed periods, in order that the stomach
and the brain may be enabled to perforin their offices.  Without
it, the whole system flags and falls below the  average state of
tone or excitement.  If, by any chance, deprived of his draught,
the habitual consumer of any notable amount of distilled liquor
will be found  more or less disturbed and disordered.  He soon
becomes languid  and  feeble, or restless and agitated, possessing
the full  control neither of his mind nor  his  body,  unable to
forget the pressing want, or substitute  any other means of ex-
citement or enjoyment.  He who has arrived at this stage, is no
longer a temperate man; although, as  yet, no  trembling of the
hands  nor  faltering of the tongue  may give warning of his
danger—although, as  yet, no  eye within the domestic or social
circle  may be opened to see his true condition—although, as yet,
no anxious looks  keep  watch at his own door  for  his dreaded
coming—no broken hearted wife tremble  at  the sound of his
distant foot-step, nor his children shrink from the glare of his
savage and unsteady eye.  All this impends, and will be deve-
loped, in his onward career, as surely as  the alternation of day
and night, or the unchecked progress of the seasons.
  The stomach, under these circumstances, has lost its ordinary
sensibilities.   The common appetite for healthy and nourishing
food—the thirst  for cool, bland  fluids, are gone.   The  organ
cannot be roused to action by the influence of the specific sti-
muli  to which it is  adapted  physiologically to respond.  Its
excitability is  not only blunted or exhausted, but has undergone 
MANIA A POTU.
387
  an absolute alteration  in  its tendencies, and refuses to be im-
  pressed, except by one class of agents.   The presence of these
  agents is always desired  ; their absence is productive of an
  intolerable craving, which all unite in  describing as the most
  oppressive of possible sensations.  Beyond this point, the farther
  development  of disease is  determined by the original constitu-
  tion  of each  patient.   In some,  the sensorial  system suffers
  directly;  while, in others, the digestive organs are subjected to a
  long series of derangements, before the brain and nerves are in
  any manner prominently assailed.
    In the first class of cases, the earliest symptoms attracting
  attention  may be those which indicate mental  disorder.  The
  patient seems dull, melancholy, abstracted, affects  solitude per-
  haps—perhaps shows a fear of  being left  alone, and more  espe-
  cially avoids being left alone in the dark.  He often mutters to
  himself, gives replies when not spoken to, and seems surprised
  and annoyed when this is noticed. He takes no food ; his hands
  tremble, as  also his tongue when  protruded.  The skin is hot
  and dry—the  eye suffused, and glaring, and  unsteady.   At
  night he  is wakeful  and restless ; when  he falls into a doze, it
  is heavy and soporose, but  evidently perturbed with bad dreams
  and distressing fancies—or he sleeps with  his eyes open, mur-
  muring and moaning, and waking with a groan or loud cry, and
 in alarm.   From one of these brief slumbers he starts abruptly
 into wild insanity.  His countenance is flushed and distorted—
 his  respiration hurried—his pulse  tense and rapid.  He labors
 under an undefined, but excessive terror; all who approach  him
 are regarded as enemies who seek to injure him, and he  resists
 furiously every effort to  soothe or control him.
   In the second order of attacks above alluded to, the repeated
 excesses in the use of ardent spirits  produce their prominent
 effects upon the organs to which they are more immediately
 applied.  The stomach loses its functional  capacity and its tone.
 There is anorexia, with  retching and vomiting in the morning.
 The mucous membrane of the  mouth and cheeks and throat,
and  the  surface of the tongue  and lips, are  of  a  fiery red, or
ulcerated, with aphthae.  The breath is foetid.  Digestion is de-
praved.  The bowels, for a while costive and inactive, are  apt
to be relaxed into diarrhoea, or irritated into  dysentery.  The 
388
MANIA A POTU.
skin and eyes are tinged with the sallow hue of jaundice.  The
lower extremities become oedematous, and while the limbs ema-
ciate, the  belly grows tumid.  The  man  is  indolent, drowsy,
stupid, imbecile.  His hand—his tongue—his whole frame trem-
bles.  He is unfit and unwilling to think, and reflection, when
he cannot avoid  or suppress  it, fills him with  gloom.  He is
overwhelmed at the sight  and feeling of the  calamities which
he  has brought  upon  himself.  He sheds tears  readily  and
profusely, and vows future abstinence.  But the  seducer offers
again the temptation ; he accepts again the cup of Circe, and is
again transformed into the likeness of a brute.   He  is  at last
roused from some beastly fit of intoxication by a violent convul-
sion, which is succeeded by another and another.  They go off,
leaving him with  a body debilitated to the  lowest muscular
weakness, and  a mind disordered and  unstrung.  He mutters
low and feebly his incoherent  ramblings.  When loudly spoken
to, his attention can, for  a moment,  be fixed, but only for  a
moment.   His  pulse is small and quick and rapid—his respira-
tion  uneasy and  irregular—his  skin cold, perhaps,  and from
time to time covered with a clammy sweat.  The stomach will
scarcely retain  anything ; his tongue is foul, coated thick with
a foetid, yellowish fur, swollen and indented against  the teeth,
and trembling  violently when  protruded.
  The delirium of this  disease is  peculiar and characteristic.
It is always gloomy ; the reverie or hallucination is always full
of fear and distress.  The patient sees apparitions whose aspect
is fierce and hostile.  He is condemned to die—executed, and in
imagination goes through all  "the pangs of mortal sufferance;"
or he is engaged  in deadly combat with numerous foes.  In the
terror of his flight, he will leap  a precipice  to  escape—in the
desperate  struggle of supposed self-defence, he will  inflict on
those around him  the severest injury.  I was sometime since
called to a sot who had  cut his own throat with  a  razor; he
was vehement  in his complaints against the ruffian who had as-
sailed and murdered him.  In many cases, there  is incessant
and irrepressible activity of the muscular system.  The patient
is constantly in  motion, starting, springing up, tossing, turning
from side to side.  The  pulse can scarcely be  felt for the cease-
less subsultus.   The pervigilium  is unbroken; the stream of 
MANIA A POTU.
389
  thought, and of words—sometimes entirely unconnected by any
  meaning—flows on without any intermission.
    I have mentioned convulsion as a frequent symptom.   Some
  writers—among them Coates—have met with it, as they tell us,
  but rarely.  In my practice, this complication occurs in a very
  considerable proportion of the cases.  Indeed, all the patients
  whom I have seen die, five in number, died convulsed.
    The nature of this singular malady is not,  as yet, well under-
  stood.  It is the property of the poison to which it owes its ex-
  istence, to affect with derangement, both functional and structu-
  ral, every organ and tissue of the body; and hence, as few die of
  it in its early stages, the confusion acknowledged by those who
  hoped to  detect its seat and  character,  by  investigations into
  "the Anatomy of Drunkenness."   "The liver," says JWcNish,
  « never escapes, in confirmed topers ; it is sometimes  enlarged to
  double its usual size, and totally disorganized.   There is jaun-
  dia and dropsy.   The stomach is affected with chronic inflam-
  mation ; is  thickened to  half an inch, or even an inch, and its
 tunics matted together.  The brain, losing its delicate and elas-
 tic texture, either becomes unnaturally hard, or of a morbid soft-
 ness.  The  membranes are thickened and rough, and lose their
 transparency; there is effusion on their surfaces or in  the ventri-
 cles."
   Leveille  regards  the disease as consisting  in  "an  exaltation
 of the vital properties of the brain,  by the influence of alcoholic
 particles absorbed and received into the circulation."   This I be.
 lieve to be a correct explanation of mere ebrietyor drunkenness"
 No one, I suppose, will deny the  absorption of alcohol, and its
 diffusion throughout the whole body of the sot.  There is a pe-
 culiar saccharine odor eliminated from the surface of all habitual
 drunkards,  exceedingly distinctive;  and such  seem to  have
 been without exception, the subjects of spontaneous combustion
 as it is called, which I suppose to be the accidental burning of a
 body, soaked and imbued with alcohol.  Craigie, following out
 this view, ascribes the congestions  found in the viscera of the
drunkard, and the results attendant on them, to the qualities of
the spirit-charged blood which circulates in his vessels.  Alco-
hol, he maintains, retards the motion of such  blood, by render
ing it viscid; this is a chemico-vital effect, easily noticed both in
      33* 
390
MANIA A POTU.
and out  of the body.   From this  spissitude come lentor and
obstructions  in  the  capillary vessels, abdominal,  thoracic, ce-
rebral  and cuticular;  this last  showing itself in  the  visage,
features and eyes of the sot.   The arachnoid, he tells us, is "al-
ways found opaque, thickened and elevated by serous effusion
into the  subjacent filamentous tissue."  From all  this, I think
we may conclude that mania a potu is a form of phrenitis or me-
ningitis  essentially modified—1st.  By the cause producing it;
and 2nd. By the complications universally attendant upon it.   It
maybe in the invading stage merely irritative or functional; but
it is always ready to run  into phrenitis both acute  and chronic,
and  to give rise to all the symptoms and  results which  accrue
from these well known affections.
   Your«Prognosis  in mania a potu is usually favorable; most
so, of  course, in  first  attacks, when your patient is young, and
has but recently fallen into the pernicious habits of  excess. Few
diseases are more readily curable under proper treatment.  There
are,' however, instances of frightful violence, which  terminate
rapidly  with coma  or convulsions;  and others,  in  which,
 whether from the condition of the  subject at the time of the  at-
tack, or from its being imperfectly understood and improperly
 managed, he will sink  irrecoverably into  a low typhous state of
febrile irritation, or will  enjoy a merely  transient  return of ap-
 parent health, to fall into  the more melancholy state of imbecility
 or lunacy.   Among the  most  unfavorable indications  are the
 restlessness,  muscular agitation, and  subsultus,  formerly de-
 scribed ; dyspnoea  and difficulty of swallowing, dryness of the
 tongue and mouth ;  protracted  pervigilium, frequently repeated
 convulsions; coma.   On the other hand, repose,  silence, sleep,
 are  favorable tokens.   A slumber long continued and profound,
 is almost always followed by a rational and calm awakening.
   The Diagnosis chiefly regards phrenitis proper  and  typhous
 fever.  The first is distinguished by the positive signs of active
 inflammation, full pulse, hot dry skin, etc.;  the  latter  by  the
 slowness of  invasion of  the delirium ; the patient  being less in-
 clined to motion, but instinctively assuming the recumbent pos-
 ture,  which, in delirium  tremens, is always distasteful, and only
 borne on  account  of exhaustion.  A correct knowledge of the
  patient's habits will, however, generally be our safest guide. 
MANIA A POTU.
391
  The Treatment of mania a. potu has been, and still  is the
theme of much debate.  Too little notice seems  to  have been
taken by the majority of writers, of the numerous and impor-
tant varieties of appearance and character impressed on the dis-
ease, by the circumstances and condition of the subject attacked.
On one  point, however, there is a pretty  general agreement
among practitioners; a consent of opinion, which deserves the
more regard from you, as the result altogether of observation and
experience, without being in any way based upon  a reference to
the opposing speculations offered in any quarter.   I allude to the
rule almost universally received, that notwithstanding the appa-
rent vascular  and  cerebral excitement so generally prominent,
and often so seemingly intense, the customary measures of deple-
tion are to be  resorted to with much caution, if  not absolutely
refrained from.
   Venaesection, which  an inexperienced physician might at once
infer to be indicated in a majority, at least of ordinary cases, is
very seldom necessary or admissible.  Even where it seems most
imperatively called for, the lancet must be  employed very mo-
derately and carefully;  a sudden and serious prostration often fol-
lows  its  use.  You will occasionally, in the young and recently
intemperate, find the pulse firm and hard, and the case approach-
ing in symptoms to acute phrenitis,  bearing the loss of blood
well ;  and in violent  or protracted convulsions, with a tense
pulse, you may by this means obtain a truce.   In such  cases,
cold affusions are also  serviceable, either  from the commence-
ment, or after premising proper bloodletting, general and topical,
from the temples and scalp.
   The use of purgatives is more frequently admissible, yet with
proper restrictions.   Where the circulation goes  on with aver-
age force, and the tongue is foul,  and the  bowels  costive, some
cathartic should be prescribed at once.  Generally speaking, the
mercurial  deserves  a  decided preference.  In  the subjects of
mania a potu, much visceral disorder  and derangement  have
been gradually built up by their  habits.   The  stomach  is in a
state of sub-acute inflammation;  the liver is engorged, obstruct-
ed, indurated; its secretions are deficient or depraved.  Calomel
in free doses,  is best adapted here.   It is  well  retained  on the
irritable stomach, which it soothes;  while it exerts upon the 
392
MANIA A POTU.
hepatic vessels a specific and salutary influence, exciting them
when torpid; and relieving them when oppressed, by soliciting
a free secretory discharge.   If it do not move the  bowels alone,
in the quantity of from ten to  twenty  grains, a  little  rhubarb
may be combined with it.
   The emetic practice, proposed originally  by Dr.  Klapp,  of
Philadelphia, has had many warm advocates.   There may hap-
pen instances in which an inactive  and oppressed stomach may
require thus to be unloaded of its foul and crude  contents, and
of the thick tenacious  mucus secreted by  its diseased  surface.
Besides this  local benefit, the emetic may  also  exert upon the
abdominal organs, generally, a serviceable  influence,  partly me
chanical and partly specific, exciting the circulation  in  their
vessels, thus disgorging them, relieving them from congestions,
and promoting their secretory operations.   For the  most  part,
however, emetics are harrassing and  injurious in  mania a potu,
as experience has proved, and as we  would,  indeed,  infer  from
the inflammatory irritation so commonly present in the stomach.
This is readily increased by the efforts of retching, and an un-
controllable nausea and  vomiting  thus brought  on, which ex-
haust the strength  of  the patient  irremediably.   On the other
hand, when the attack has affected directly, and in the  first in-
stance, the sensorial stylem alone or  prominently, the  stomach
is often so torpid and insensible, so  insusceptible  of the action
of medicines, that  the largest  doses of antimonials, and  other
most active emetics, are found  necessary to bring on vomiting;
nay, in some cases, the ordinary officinal  preparations  will not
act in any dose.  If, in  such  instances,  we persevere in the
mode advised to  carry out this plan,  we run the risk of giving
occasion for the poisonous operation of our drugs, before we can
obtain their emetic action on the stomach; and the journals con-
tain, indeed, several examples  of this fatal result  of their ad-
ministration.
   In cases complicated, or attended by convulsions, we are often
embarrassed by the coincidence of indications seemingly incom-
patible.   They put on much of the appearance of epilepsy, and
are liable to be repeated in a long  succession, unless something
 impressive be done to interrupt them.   The patient should be
 laid recumbent,  in  an easy posture, well supported, his head 
MANIA A POTU.
393
somewhat raised, and all  ligatures  about  the  neck and body
promptly loosened.  A wedge of soft wood, or a compress  of
some thickness must be held between his teeth,  to prevent the
laceration of his tongue.   Cold water should be poured upon his
head, from some  elevation, in a stream, and his  hair cut close  or
shaved away.
   The lancet may be of service, if the habit of intemperance be
but newly formed, the subject  young and vigorous, the  pulse
full and hard, the face flushed and turgid.  In the opposite con-
ditions, you will  need no warning to avoid its employment, not-
withstanding the strong popular prejudice in favor of bloodletting,
as a general remedy for every form of convulsion.
   The emetic is  urgently advised under these circumstances, by
some physicians.  I consider it, however,  as of very  doubtful
adaptation.   I would, perhaps,  administer it, if the stomach was
evidently loaded and oppressed, with unsuccessful efforts to dis-
gorge itself, during the fit.  Sinapisms should be put to the ex-
tremities and the epigastrium,  and  an  irritating enema  given
without delay, to be repeated, at no long  intervals,  until the
bowels are freely moved.
   I come now to speak of the remedy which deserves your spe-
cial confidence, in the treatment of this distressing malady—by
some regarded, as of itself sufficient for all our desired purposes,
and by almost unanimous consent, admitted to be of  paramount
importance and utility.  A wretched delirium; anxiety and hor-
ror unspeakable ;  with trembling and agitation of every muscle ;
singular prostration and debility,  combined  with the power  of
making transient efforts  of unaccountable and  morbid energy ;
a pulse quick and very frequent, and usually small  and  weak ;
a cold and clammy skin ; these are the symptoms you will most
generally meet with,  when called to a patient  whose  habits  of
intemperance have at last overpowered his  long abused  consti-
tution.   A set of symptoms, approaching in degree, and identical
in nature, with those which  now oppress  him, have  probably
often assailed him. in the miserable mornings succeeding nights
of riot and debauchery.   He has been accustomed to find relief
from them, in a resort to the  poison which has  produced them,
and has long exulted  in this familiar and proverbial success.
But the potent restorative has at last lost its boasted powers, and 
394
MANIA A POTU.
now fails to restore or recruit, even for a moment,  the  energies
of which it has gradually drained the system.  In this compli-
cated condition of indirect debility—excitability exhausted by
excess, functional disorder and structural derangement,  we must
have recourse to some substituted stimulus, different in kind, but
in force equal to that which has from habit lost its effect;  or na-
ture will sink hopelessly, undermined and  worn out.  You will
anticipate me in the mention of opium, of  which I will not af-
firm, as some have done, that it is  exclusively  indicated, and
alone adequate to the management of these  deplorable cases; nor
can I boast, as Pearson and Coates do, of uniform and uninterrupted
success with it.  But I  will not  hesitate to  declare  my  belief,
that it is singly worth all our other remedies  put together, and
that without it, the mass of suffering and proportional mortality
in this disease, would be indefinitely multiplied.
  I would not depend upon the frequent repetition of small doses,
as has been proposed.  Our object is to obtain tranquillity, mental
and  physical,  to quiet  irritation, to  procure  sleep.  Whatever
amounts are necessary to effect these purposes, I would exhibit
without, fear, without hesitation, without delay.  I have no dread
of any ill consequences from any  reasonable  quantity.   The
loss  of  susceptibility—sensorial  power—normal  excitability,
which we have no means of restoring, except the  indirect one
of inducing a state of sleep,  during which it seems to  be re-
cruited and reaccumulated, requires a relative increase of dose
of our narcotic.   "The patient," says Coates,  "must  sleep or
die."   "Sleep," says Chapman, "is the sine qua non in the cure
of this species of mania, and when this  is  effected, all difficulty
is at an end."   A great many  physicians use the solid drug, and
prescribe from five to twenty  grains, repeating  at  intervals, as
may be  required.  I prefer to employ the tincture, common
"laudanum," prescribing one, two, or three hundred drops every
hour, until the patient becomes quiet or sleeps.   I have not been
sensible of any injurious consequences from following this course,
and have given fourteen hundred drops in  a few hours, with the
best effect.
  I have said I prefer the liquid—the tincture.  It is more prompt
in its action, and besides, I have thought it possible  that solid
opium, in masses, especially in pills made up some time  pre- 
MANIA A POTU.
395
 viously, and thus hardened by drying, may lie in the stomach dis-
 solving slowly, and the latter portions coming into  operation
 when ill timed or  superfluous.   I  am  not fond of any  of the
 suggested forms of combination, but had rather, in the first  in-
 stance, depend on opium alone.  Nor do I place full confidence
 in any of the salts of  morphine,  or other extracts from the juice
 of the poppy,  but  put my trust in the crude opium, which con-
 tains them all, narcotine, morphine, codeine, and the meconic acid.
    According to my own experience, we may, in the greater num-
 ber of cases, commence the treatment at once,  with  the  exhibi-
 tion of the opiate;  I have endeavored to indicate those in which
 it would be advisable  to premise the lancet,  the cathartic, or the
 emetic.  When the cathartic is required, calomel may be com-
 bined, in proper doses, with opium, so that no time shall be lost.
 Digitalis has been  proposed, as a substitute for opium, when any
 circumstance contra-indicates its use, and is highly recommend-
 ed by some practitioners.  Large and full  doses are necessary.
 Pearson gave sixty drops of the saturated tincture, every three
 hours.   Prof. Hooker, of Yale College,  gives much larger quan-
 tities,  and assures me that he has met with  very gratifying suc-
 cess.  I have more than  once been pleased with its effect, in
 doses of 3ii of the  sat: tinct: every  six hours.
   The patient having  slept, will awake at least in an improved
 condition, and probably in his right mind, but weak and languid.
 It is scarcely requisite to urge upon you the importance of keeping
 him as tranquil as possible, and as free from  the disturbance of
 noise, light, company and conversation.   The camphorated julep
 will refresh him and stimulate his stomach  agreeably.  After a
 proper interval, if he does not sleep spontaneously, his anodyne
 must be repeated.  If he is conscious of appetite, and expresses
 a desire for nourishment, agreeable  and even stimulating food
 should be offered him.   In recent cases, you will often  be sur-
 prised  at the very rapid restoration of the digestive powers.
  While pursuing the  course above pointed out, it may be abso-
 lutely necessary, for his own sake, and for the safety of his friends
 and attendants, to coerce, restrain, and confine the unhappy sub-
ject of mania a potu.   It is consoling to reflect, that  restraint
 and confinement, so far from producing  the irritating effects as-
 cribed to them by some writers unfamiliar with this disease, are 
396
MANIA A POTU.
very generally, on the other hand, directly beneficial, and show
a useful tendency to the subduction of the disease, by  calming
the agitation both of mind and body.  I do not hesitate  to resort
to the most efficient measures of control, whenever they become
necessary.   An entire separation of the patient from his  friends
and relations may be called for, when he persists, as sometimes
happens, to regard them as hostile or dangerous to him, whether
he recognizes them or not.
  Convalescence is, in some  of the cases, slow  and  lingering,
and will require from you not a little attention.   There is deep,
nay, almost suicidal depression of spirits;—the  mind  is weak
and irritable ; the temper  capricious.  The appetite is uncertain,
and the digestion of food taken is rendered difficult and imper-
fect by the presence of  gastric  and hepatic  disorder  and  ob-
struction, forming  so common a  complication in all the varied
maladies which afflict the intemperate.   These will call for the
alterative  influences of mercury, which must be administered
slowly, in such forms, and so combined as to act in the least irrita-
ting manner ; while you continue the judicious employment of
stimulants, tonics and anodynes.   Among the stimulants, cam-
phor, the vol: alkali, and capsicum, deserve the preference.  Of
tonics,  it  is  difficult to decide the  choice before trial.  Iron
may be used ; the infus: cinchon; sulph: quinine ;  the  vitriolic
elixir.  If unwilling to  persevere in the use of opiates, you may
offer lactucarium, hyosicamus, or the preparations  of hop; but
they are all uncertain as anodynes.
  As your patient  improves,  he should be permitted or encour-
aged to resume slowly his ordinary avocations, and  to  mingle in
cheerful society.  Exercise proportioned  to his strength should
be taken in the open air; but fatigue and mental excitement care-
fully shunned.
  Of the importance of a Prophylactic or preventive  system of
management, which  shall evade  a repetition  of  the attacks of
which  we have been speaking, it is surely unnecessary to say a
single  word.  To effect  the  cure of the drunkard would  be
worth  the labor of a life; and he will be a second  Jenner, who
is so happy as to discover  the  means of protection or restoration
from such misery and debasement.
  In entering upon the  consideration of this part of my subject, 
MANIA A POTU.
397
 while I am desirous not to underrate the value and force of the
 moral means which have been applied, I  must express strongly
 my belief of their general inadequacy, and of the very  great
 importance of addressing  our remedies rather to  the  physical
 man.  We must either find some mode of satisfying the  facti-
 tious and morbid desires which so importunately urge him, or
 we must do away the state of the organs upon which these cra-
 vings are engrafted.   No one can have failed  to perceive how
 infinitely impotent,  in  opposition  to  this appetency, are the
 strongest resolutions of which the intemperate is,  in his better
 moments, capable; how vain the promises of reformation then
 offered to those around  him, and reiterated with  prayers and
 tears. The moral and intellectual faculties are totally benumbed;
 even the love of life is extinguished in him, and but one thought,
 one desire pervades the whole man.  This new and artificial
 instinct is no less strong, it would  seem,  than  those  originally
 interwoven by nature in our organization ; nay, it would not be
 difficult to show that it exerts over its victims a sway as  pow-
 erful as that of hunger, of thirst, or of the venereal impulse.
   This topic has engaged the  anxious, attention of many re-
 spectable and scientific physicians, as well as of numerous em-
 pirics, hitherto I fear we must acknowledge, without any flatter-
 ing degree of success.  The prophylactic measures which they
 have suggested, have it generally for their object,  to connect in-
 separably with the idea of the desired  stimulant,  some  associa-
 tion of extreme disgust and nausea. Plausible in the  abstract,
 these plans have been largely experimented with, by philanthro-
 pists all over our country, and although the majority have  con-
 fessed a  mortifying  disappointment, yet  we  have some  very
 gratifying instances of complete success recorded on  good au-
 thority.   An emetic, for  example, is mingled in the ordinary
 liquor used by the sot, and such a dose exhibited,  as shall  pro-
 duce much and  prolonged sickness of stomach or violent vomit-
 ing.  This operation being repeated several  times, a loathing  is
 expected to attend the sight or smell of the ardent spirit in which
 the drug has been mixed.   Thus a recent  habit is generated, to
counteract one not so new—a natural propensity, prompting the
avoidance of whatever has  annoyed and  disgusted us, set in
opposition to the artificial propensity which has been morbidly
       vol. n.—34 
398
MANIA A POTU,
acquired or built up.  In  many points of view,  this plan of
management seems well adapted to do good.
   If any infatuate be brought to feel deeply his debasement, so
as to desire strongly some effectual means of relief, a great point
is surely gained.  When such an one can be farther persuaded
to make any effort for his own extrication, a ray of hope has once
more dawned upon him.   That he should  voluntarily subject
himself to the persevering administration of the nauseants above
alluded to, seems to prove that he is thus  conscious of his con-
dition, and resolute to shun his fate,  if possible, and some aid
may be given him by the means proposed.
   Another method of treatment, first promulgated in Germany, by
Cramer, has been strongly eulogized by Dr. Brinkell, an Ameri-
can practitioner.  These gentlemen suppose, that the peculiar
morbid state of the stomach, upon which depends  specifically,
the insatiable  craving of   the intemperate, is susceptible  of
change and removal, by the action of remedies specifically cura-
tive.   The agent which they believe to  exert the most forcible
and beneficial influence, on this principle, is the  sulphuric acid.
Dr. Brinkell adds 3i  to ^ii of this acid to a pint of ardent spirit,
which the patient is then allowed to drink, in his usual quanti-
ties ; and though with proper  candor,  he acknowledges some
failures, yet he  declares that his perseverence has,  in several
instances, been rewarded by most gratifying success.   The ex-
periment is one very easily made; and upon the authority cited,
I recommend it to you, for  a fair and impartial trial.
   In  behalf of the unhappy  drunkard  still unreclaimed, one
farther effort remains to be  made.  He must have stimulants, he
will tell you.  Well! if it must be so, let us yield  to his suici-
dal wishes.  But I would not so far  comply with his insane
and perverted inclinations, as to grant him one  drop of ardent
spirit  in any form.  Upon them, with the benevolent  Rush, I
would lay  the  absolute prohibition—"Touch not! taste not!
handle not!"  Opium, one  of the most valuable gifts of a benign
Providence—opium, which  avails to  soothe the  most acute
bodily sufferings inflicted upon our race, and with  which we
can even  "minister to the mind diseased"—opium may be cho-
sen as a  sufficient mode  of substituted  excitement.  So  far as
my observation has extended, it  will never fail to satisfy the 
APOPLEXY.
399
 most  unmanageable sot,  if given  in  proper  quantity;  and I
 would accord it freely: better, far better an opium eater, than a
 drunkard!
   And yet, even yet, 1 would not have  you totally abandon
 him.  I would endeavor to wean him from  the  use of opium,
 by the occasional substitution of other narcotics, as lactucarium,
 the hop, hyosyciamus, etc., and by a gradual diminution of dose.
 These attempts failing, and the habit proving tenacious, I would
 not hesitate to withhold it  altogether, and at once.  If I am told
 of the danger of thus suddenly abstracting  the whole amount
 of accustomed stimuli, I reply, that this  risk has been beyond
 measure exaggerated.   The records  of our prisons and peniten-
 tiaries, establish beyond a reasonable doubt, the fact, that in the
 vast majority of cases, this deprivation has been  not only safe,
 but salutary.  If attacks of delirium tremens occur under such
 circumstances, they are affirmed to be as mild as they  are un-
 frequent.  I have already stated deliberately, and I am prepared
 to maintain, that convulsions, mania and death, are much more
 likely  to supervene during an  uninterrupted course of ebriety,
 than upon its abrupt intermission.   Nothing  can, then, be lost
 by the restraints proposed, while on the other hand, if fairly
 carried into effect, they  offer us the only conceivable  chance of
a cure  for our miserable patient.
                     CHAPTER XLIX.

                         APOPLEXY.

   Among the various morbid affections of the sensorial system,
Apoplexy claims a very prominent place.   It is by no means an
unfrequent disease, and its statistics show a very large propor-
tional mortality.  Its suddenness, and  the necessity of prompt
and efficient aid,  to those assailed by it, call upon us for a minute
investigation into its nature and causes, and the treatment best
adapted to cure and prevent it.   The obscurity, too, which con- 
400
APOPLEXY.
tinues to envelope some portions of its history, must serve to
stimulate our curiosity, and excite us to more ardent and perse-
vering enquiry.
  Apoplexy may be briefly defined to  consist in a  loss of the
powers  of sense and voluntary motion.   The organic move-
ments continue; the  circulation not usually much disturbed,
respiration somewhat embarrassed and impeded.  It is most often
met with in persons of middle age, or advanced in  life,  of full
plethoric habits; among those addicted to excess  of all kinds
whether moral or physical, those who  yield themselves to in-
tense study, those subject to vehement impulses, overpowering
emotions,  or violent gusts of passion, those abandoned to intem-
perance and debauchery.  A predisposition is found, in both per-
sonal and hereditary constitution, which may give rise to it in
the young and temperate.   The external configuration of body
is recognized here, and the "apoplectic  form," described by  wri-
ters, "a large head, florid  complexion,  a thick and short neck,
broad shoulders,  ample chest, globular abdomen, low  stature,
strong limbs, and general corpulence."   When we speak of ple-
thora, as among the predisposing conditions, let it  be  remem-
bered, that we allude to the morbid state formerly  considered in
detail, and that this is the result of extremes at both ends of the
scale of living, being engendered, as well by insufficient nutrition
from want or defect of food, as from too  high feeding, with de-
fective assimilation. We shall not,  then, feel  any  surprise at
the fact discovered and announced by Sir Gilbert Blane, that in
Great Britain, as many die from apoplexy among  the starving
poor, as among the luxurious rich.
  The exciting causes which tend to develope and which are of
themselves, when intense, quite  adequate to produce an attack,
are numerous and  diversified.   In the predisposed, such a list
would include almost every departure from regularity of ordina-
ry habits  or strict correctness of regimen.  Thus  a full meal,
especially just before going to bed, or indulgence in  stimulating
food or drinks in any quantity ;  muscular exertion of more than
usual force or protracted to unaccustomed fatigue ;  exposure to
a hot sun ; a tight cravat or other ligature about  the neck; a bad
position, as in lying with the  head low, or stooping  downwards
to pick  up anything from  the ground, to  tie a shoe  or the like; 
APOPLEXY.
401
a fit of anger or other  violent passion;  the suppression of an
accustomed evacuation, as the removal or drying up of an issue
or seton, the healing of an old ulcer, the stoppage of epistaxisor
hemorrhoids ;  the metastasis .of inflammations, as gout and ery-
sipelas.  Active aneurism, hypertrophy, enlargement of the left
ventricle of the heart, is alleged to be not unfrequently connec-
ted with apoplexy, either as cause or coincidence.  It is obvious
that such a condition of the organs must exert an evil influence
upon the cerebral circulation.   Indeed, all diseases of the heart,
whether of active or passive character, must produce some such
disturbance; either driving the blood with too great momentum
towards the brain  through the arteries,  or impeding its return
through the veins,  in both contingencies tending  to determine an
attack of apoplexy.
  Apoplexy has been strangely asserted  to be occasionally epi-
demic in its prevalence.  The frequency of occurrence, at par-
ticular  periods, however, and in  certain localities, from which
this notion was derived, is easily accounted for without reference
to any imagined atmospheric  influence of specific character.   It
is in  the  relaxing heats of spring and early summer, that we
meet with  these terrible affections of the head chiefly.  Here we
have not only the exciting or stimulant affect of elevated tempe-
rature upon the solids of the body, but doubtless an actual aug-
mentation  also of  the volume of the fluids from expansion by
heat, and thence a proportional distention of the vessels, which
of course will be more likely to yield at any weak point.  It is
at these seasons that headaches are most complained of, and that
hemorrhages are apt to break  forth, from whatever  surface.
  In all hot climates it is dangerous, for the above reasons, to be
exposed unsheltered to  the direct rays of the sun at and about
meridian.  Coup de soleil or insolation is  one of  the most fre-
quent and  violent  forms of apoplexy.  On one glowing  day of
the remarkably hot summer of 1824,1 myself saw no fewer than
five cases of this sort.  The majority of such cases, which were
very numerous in  June and July,  were among the intemperate
of the lower classes of society, but this  was by no means true
of them exclusively; as the most  orderly females and even
children were attacked.  In  the  bill of  mortality for that year
(1824,) we find the deaths set down from apoplexy at twenty-
       34* 
402
APOPLEXY.
five, to which, if we add, as should be done, those noted as "coup
de soleil, sun struck," insolation, nine, we have the total, thirty-
four ; a strikingly large amount:  In 1822, there were but eleven
such deaths.
  The  predisposition  from age  has been much  dwelt on, but
there has been some difference of opinion as to the precise time
of life when it is most fully developed.  From the era of Hippo-
crates to the present day, the period of most frequent access has
been commonly assumed to be between the fortieth and the sixti-
eth year.  Cullen, however,  regards the  cases happening after
sixty as more numerous than those of previous date.  Rochoux,
who paid much attention to  the  subject,  gives a table of sixty-
tlftee cases ; in which we find seventeen between forty and sixty,
and thirty-five  between  sixty and eighty.   This agrees  with
Cullen's view of the  matter, and  it shows more than  half the
whole number of cases occurring in the more advanced  stages of
life.  In our climate, attacks  of apoplexy are, I think, in the ma-
jority  of instances, earlier than the earliest of the dates above
referred to.  In my own  practice, the  greater number of cases
have been between  twenty-five and forty  years of age.   Of the
thirty-four deaths in 1824, we have seven between  twenty and
thirty; ten between thirty and  forty ;  and after forty we  have
seventeen; just the moiety of the entire number.  This seems in
accordance with the ancient Hippocratic doctrine; but it must be
recollected that apoplexy is of necessity more fatal, in proportion,
in old than young subjects.  No  age is exempt from it.   I have
myself seen a well marked instance in a child of less than three
years, and several others between the tenth and twentieth year,
especially from insolation.  In some tables you will be surprised
to find the greater  number of deaths among females; here at
least the proportion  is reversed, as we would expect, both  from
the greater exposure, and from  the less regular habits of the
other sex.
   Symptoms and history.  The  attack of apoplexy may be and
often  is sudden and without warning.   The patient falls to the
earth senseless and motionless, as  if, according to the belief of
the ancients, under the influence of some malignant star, or thun-
derstruck.  The face  is  usually flushed, and of a dark red or
livid hue, with  a singularly dull and heavy expression.  The 
APOPLEXY.
403
eyes are prominent and fixed, the pupils being at first for a short
time contracted, but  soon dilating  permanently and widely, in-
sensible or nearly so to light.  The skin is commonly hot and
dry, but I have more than once seen it bedewed with abundant
perspiration;  the pulse in ordinary cases  is full, hard and rather
slower than natural; the breathing  slow and  deep, becoming
stertorous, a circumstance upon which some stress is  laid as a
diagnostic; occasionally the cheeks are distended  and the respi-
ration is performed with a  puffing noise. From this  state the
patient  cannot be  roused;  yet it is rare  that he  will  not give
some slight and equivocal evidence of sensibilily to the  irritation
of pricking, pinching or burning.   You  will be touched to ob-
serve also that, at the voice of a friend uttered in pitying sympa-
thy, the lid of the dilated eye will  slightly twinkle, or  the start-
ing tear will find its way slowly over the cheek of the moribund.
There is almost always a difference in the condition of the two
sides of the body, one being more completely paralysed than the
other ;  or perhaps  one side  will be affected  with  twitch ings, or
convulsed.
  After an uncertain lapse of time—it may  be  from four to ten
or twelve hours—the  muscular relaxation  or loss of power is
more notable,—the limbs and Seek are  flaccid—the  mouth is
open—the tongue lolls  out, and the saliva flows over the chin ;
or the  countenance  is fallen and distorted—the lips slightly
contracted, so that respiration is performed with a sort  of blow-
ing,  and  the saliva  ejected in a frothy state.  The extremities
now become cold—the pulse loses its  fulness and force, and is
more frequent; if not  absolutely deprived of the power of
motion, the  patient  is excessively restless, tossing, moaning,
sighing, and  perhaps yawning languidly;  the face is deadly
pale—the cornea dull and opaque—a cold, clammy sweat breaks
out—the urine and foeces are discharged involuntarily, and death
closes the distressing scene.
  Sometimes the access of the disease is more gradual,  and pre-
ceded by a train of not unfamiliar  warnings. There is vertio-o
with nausea and oppression  of the stomach,  amounting perhaps
to vomiting, followed by transient  relief;  the vertigo returning,
soon ushers in an unequivocal stupor.  The patient,  at other
times, complains of unsteadiness of vision, and  extremely un- 
404
APOPLEXY.
easy sensations, becomes alarmed and agitated, utters indistinct
sounds  and sheds  tears, before  absolute coma supervenes—or
paralysis of some nerves may precede indefinitely the  develop-
ment of apoplexy ;  the hand grasps feebly objects attempted to
be laid hold  of—the  feet  trip  or fail—articulation is difficult.
In plethoric subjects, a  fixed head-ache, a flushed and hot face,
a sparkling before  the eyes in  the  dark, a ringing in the ears,
numbness of the tongue or of the arm  or leg, a  confused state
of the memory, a  peculiar  degree of torpor or sleepiness, form
a series of premonitory symptoms, calling for prompt relief, and
affording opportunity of warding off the threatened attack.
  It is  not rare, that the  disease steals upon  its victim with
imperceptible approach—its profound  coma forming the transi-
tion state.between sleep and its "twin brother, death."  This mode
of access is particularly observed in corpulent persons who eat
full suppers, and sleep heavily and deeply.
  In a majority of apoplexies, the fatal  termination takes place
in a few hours—from twelve, perhaps, to twenty-four—but the
patient may die within a shorter period, say three or four hours,
or may linger for  several  days  in  a condition  of helplessness
and insensibility, varying considerably.   In a young lady about
twenty-one  years of age, I  saw it protracted for  a week, during
which time she more than once eat and drank, and spoke pretty
distinctly.   Or, whether by reason of a less degree of intensity
in the paroxysm, or of a  greater capacity  of resistance in the
constitution, or, it  may be, of the energy and efficiency of our
remedial management, the patient may recover completely.  It
is, however, more  usual to  witness but a partial  restoration ; he
awakes slowly and gradually from his stupor with hemiplegia—
palsy of one side of the body,  a state  of disease  which shall
hereafter receive from us the careful consideration it deserves.
   Of the  Diagnosis.   From  sleep  however profound, noise,
light, and  external irritants,  will awake the sleeper; but the
apoplectic  is  not  to  be aroused by shouting in his ear, or by
striking or beating him.  From  syncope, we separate it, by the
full, slow pulse, and  the stertorous  breathing.  From  epilepsy,
we discern  it, by the absence of muscular  convulsion of active
character—from the hysteric  paroxysm, which counterfeits it
sometimes very closely, by  the  degree of duration of the insen- 
APOPLEXY.
405
/sibility to light and irritants, and by the labored circulation and
\ stertor in breathing.
    In such cases of asphyxia, so called, as resemble  apoplexy,
 we must refer to the previous history of the case.  It will gene-
 rally appear,  whether the patient  has inhaled  the  fumes  of
 burning charcoal, or has descended  into a well or vault, or has
 been exposed to extreme  cold.  The torpor from  this latter
 cause, may give very nearly the symptoms of apoplexy, as in a
 case well-described by Dr. Kellie, in which  sense and  motion
 were gone, while respiration and circulation continued.   I shall
 have occasion to refer to a similar instance shortly.
    In the oppressive sleep which ensues upon intoxication, and
 which is produced  by opium as well as by ardent spirits, the
 diagnosis is exceedingly difficult—nay, many maintain, that the
 case  comes  fairly  and properly under the head of apoplexy,
 when  considered in  reference  to  the actual condition of  the
 patient.  As a general rule, however, the pupil in the eye of one
 narcotized by opium in large quantity, will be  found contracted—
 contracted  closely and permanently—that is, until death ; while
 that of the  true  apoplectic is  as generally relaxed and dilated.
 1 will not venture to affirm, that there are  no exceptions to the
 condition thus stated, in regard to either case, but I am sure the
 fact will almost uniformly be found to be as I have asserted.
    The smell of alcohol about the mouth or clothes  or in  the
 breath of the  subject, will usually serve to show us the actual
 condition of the drunkard ; yet this test is in  itself somewhat
 doubtful, and besides, it may be altered, modified and disguised,
 in  a variety of modes.  Here the stomach-pump is an invalua-
 ble  auxiliary, and  should be  applied, at  once,  to decide  the
 question.  It  can, in no  case, do any  injury, and if there be in
 the stomach  either alcohol or  opium, our first step, doubtless,
 should be  to  remove them.  Even when there is a strong spiri-
 tuous odor exhaled in the breath, we shall not  be safe in neg-
 lecting the patient as merely intoxicated.  He may have taken
 but a little alcohol, enough to act  as exciting cause of the apo-
 plexy, or just enough to  taint his breath.  I well  recollect a
 poor fellow  who was suffered to remain in this state for twelve
 hours, in the belief that  he was  "only drunk," and  with  the
 expectation  that  "he would sleep himself sober;" he awoke  no 
406
APOPLEXY.
more.  Gregory observes, that a fit of apoplexy perfectly resem-
bles a state of extreme intoxication, from which, he  says, "it
cannot be distinguished, but by the  actual cautery, which will
rouse,  in  some degree,  the  inebriate, but  not the apoplectic
patient."   Of the extreme uncertainty of this test, which indeed
might  have been  affirmed beforehand, accident once afforded
me striking proof.   On the evening of one of the  coldest days
of the cold winter of 1828-29, I was called to see a negro fel-
low who had been found on a wharf  in a state of insensibility.
He was habitually intemperate, but there was no proof that he
had been drunk on that day, nor was his breath affected by the
odor of any spirit.  His  body  was  exceedingly cold, and he
presented, in other respects, the usual symptoms of apoplexy.
I had him placed near a large  fire, which, during my absence,
was increased so as to burn the soles of  both feet, one of them
very severely.   He that night recovered so  far as to move and
speak,  but felt no  pain  in his feet  until next  day.   He has
always persisted in saying that he drank no spirits, but being
much  fatigued and very cold,  he swallowed a large draught of
water,  which produced violent  cramp in  the  stomach, and the
subsequent insensibility.
   A transient  cerebral affection, which like  intoxication simu-
lates apoplexy pretty closely, is well-described by Dr. Hall.  I
have never met with  it, and  shall, therefore, give you his des-
cription of it in his own words, as  presenting  a  good view of
the points both of similarity and difference.—"A gentleman fell
from his horse insensible ;  he was carried home and put to bed.
The pulse was natural—the  tongue loaded  and swollen—the
breath foetid—the bowels constipated ; but the countenance was
not distorted nor  flushed, and the limbs  all moved on being
pinched.  A cathartic  and a  purgative  enema were  exhibited,
and the patient soon recovered without any paralysis."
   Insolation has been regarded  by the great majority of practi-
tioners as  a condition uniformly apoplectic.  This is undoubt-
edly an  error.  Russell, of Madras,  in  1836, laid  before the
college of physicians some  cases tending to show  that fatal
exposure  to the heat of the  sun affects  rather the  pulmonary
than the cerebral circulation.   A year or two since, Dr. Dowler,
of New-Orleans, published in a New-York journal some striking 
APOPLEXY.
407
observations on  this subject.  He demonstrated, in several in-
stances of insolation, the  existence of "pulmonary apoplexy,"
as it  has been strangely called—engorgement and effusion of
blood  extensively within  the pulmonary  tissue.   Hence, he
denies altogether  the correctness of the views formerly enter-
tained, and proposes that  the phrase "solar asphyxia" be em-
ployed to denote this condition.  I think he has been led some-
what into an  extreme.   I do not doubt his facts—nor, in  a
properly restricted way,  the correctness of his inferences.  Ex-
posures to solar  heat may be fatal  in  both  modes;  and the
pulmonary asphyxia may  be  distinguished from true apoplexy
or cerebral congestion by exploration of the thorax.
  The  general Prognosis in apoplexy  is  decidedly bad;  the
proportion of recoveries is small, and of these the majority remain
paralytic.  Under the most favorable circumstances, there is left
a strong tendency to recurrence  of the attack, which requires a
great  degree of care and watchfulness on the part both of the
patient  and  his   physician.   Your best  hope of ultimate and
permanent restoration is in the young and temperate, and such
as have been affected by some transient cause or very peculiar
exposure—cases of insolation for example—and those which in
children arise from the irritation  of dentition  or the excitement
of some violent fit of passion.  But in the aged and infirm, the
prospect is gloomy; and  to  the glutton and the  drunkard, a
brief  paroxysm  of apoplexy  is  usually  a happy substitute for
more tedious and annoying modes of disease and death.
  Autopsy.  In  few instances shall we  find  so large a mass of
observations collected and recorded, as in the case before us, and
the appearances after death from  apoplexy, have been minutely
described by pathologists of the highest authority, from Bonetus
and Morgagni  down to Abercrombie and Andral.    The brain is
almost uniformly found  to present some morbid  condition, as
would indeed be anticipated from the history  of symptoms.  It
is true, that both Abercrombie  and Clutterbuck  declare that
there  is a form of apoplexy called by Dr. A.  simple apoplexy,
and by other writers, nervous apoplexy, in which  no change can
be detected in the cerebral mass.   All agree, however, that these
cases  are  rare.  For my own part, I doubt  whether  they are
correctly arranged here.  The  diagnosis, in   certain cases,  is 
408
APOPLEXY.
confessedly very difficult, and these are among  them ;  sudden
deaths from disease of the heart are often misplaced  here, and
besides, in so delicate  an organ as the  brain, I would rather
trust  myself to the  general  analogical  rule, than venture to
affirm the absolute  non-existence  of  lesions, which, however
slight, may serve to give rise to fatal results.
  The morbid appearances familiarly noted are of three kinds—
1.  A  turgescence  and  preternatural  fulness  and distention of
the vascular  structure of the brain—both  arterial and venous.
Now  it is possible that the elasticity of these  vessels may so far
relieve them from this condition after the death of the  patient,
as to afford grounds for the opinion of Clutterbuck and Abercom-
bie, just  now commented on.  2. The lesion most commonly
met with is a true hemorrhage ; an effusion of blood from some
portion of the membranes or within some part of the  cerebral
mass, either from transudation, rupture of some vessel, or actual
laceration of  the soft, fibrous tissue  of  the organ.  Andral gives
a case, where it was found between the  pia  mater  and  arach-
noid ;  it  has  been met with between the dura mater and the cra-
nial bone; arteries have been seen  ruptured; the lateral sinus
has been torn;  the substance, both of the cerebrum and cere-
bellum fissured or lacerated, most  frequently the corpus stria-
tum : and 3. An  effusion of serum within  the  ventricles, or
from  some point of the surface of the meninges.   These pheno-
mena, which if ever undetected, are so seldom wanting, that it is
not unfair, I  think, to assume their uniform presence, have given
foundation to the belief, that  pressure applied  to the contents of
the cranium, is the essential and constituent cause of the apo-
plectic paroxysm; there is little or no pathological  difference,
whether  such pressure be occasioned  by engorgement of the
cerebral vessels, or by extravasated blood, or by effused  serum.
This  opinion, however, supported as it seems  to be, very strong-
ly, by the similarity of the symptoms of the disease under dis-
cussion, to those induced by mechanical injury of the skull,
with  depression of the bone, and the very general and  prompt
relief given by the removal  of such depressed fragments,  has
not been received universally, or unquestioned.   It is denied by
many, that the brain can be subjected to undue pressure, in any
manner,  protected as it is, within a bony case of uniform ca- 
APOPLEXY.
409
 pacity—always equally full of incompressible substance.  Upon
 this, I remark—1st.  That blood, and pus, and serum, are actu-
 ally poured out in large quantities within the cranium, whether
 there is room for them or not, and whether the  brain  is com-
 pressed or not: and, 2d. Even allowing that no addition  can
 be made to the absolute contents of the skull, on  account of its
 unyielding form and unvarying capacity, it is easy to conceive
 that one portion of the brain shall be subject to undue determi-
 nation, vascular  congestion—intra-vascular pressure therefore,
 or to extravasation of blood on its surface, or within its lacerated
 tissue, or extra-vascular pressure by serum or pus effused, while
 other portions shall suffer under a deficiency of circulating fluid.
 In reply to Clutterbuck's suggestion, that this latter condition,
 defect, or irregularity of circulation, may be  the cause of the
 symptoms of apoplexy,  it must suffice to say,  that numerous
 observations  have established a definite relation between  the
 part of the brain subjected to direct lesion and pressure of unac-
 customed fluid, and the parts of the  body whose  functions  are
 deranged—a point much and not unfruitfully labored by phre-
 nologists.
   Some pathologists, admitting the  coincidence of pressure on
 the brain, either  intra-vascular or extra-vascular,  represent it as
 merely  an unessential concomitant, rather to be regarded  as
 consequence than as cause of apoplexy, and altogether incapable
 of giving rise to or explaining the symptoms of the disease.
   In the investigation of this question,  M. Serres  instituted a
 course of experiments upon oxen, horses, dogs, rabbits and birds,
 whose  heads he  opened with a trephine, making pressure upon
 the surface of the brain, and within the ventricles, by the blood
 effused in his operations, and  also by the insertion of pieces of
 cork  into  excavations of the cerebral  substance.  He affirms
 that apoplexy was produced in no instance ; in none was there
 somnolency; in some there was hemiplegia.   He dwells upon
 the cases in which,  as in hydrocephalus, large  quantities  of
 serous fluid have been found in the head without apoplexy, and
 others similar, in which, after death, sanguineous  coagula and
 effusions have been found lodged in different parts of the brain
 and in the ventricles.   But it is surely unnecessary to examine
in  detail, a  course  of argument so illogical as this.  His  facts
      vol.  n.—35 
410
APOPLEXY.
giving them their full weight, only prove that pressure does no6
always produce paralysis  and  apoplexy.  Now every tyro in
surgery knows that the coma, which is the general consequence
of fracture of  the skull with depression, is sometimes wanting,
and  that the bones may be actually beaten  in  upon  the brain
without this effect.
  Serres divides apoplexy into two varieties—the one simple;
the other  complicated with  paralysis partial or general.  The
simple form he supposes to depend on an irritation  of the mem-
branes, the pia mater  or arachnoid, which  may  result in serous,
sero-sanguineous or purulent effusion.   This he calls meningeal
apoplexy.  In the second, which he terms  cerebral apoplexy,
the encephalon itself  is the principal seat of the irritation ;  the
substance of the brain undergoes some alteration, or suffers
some lesion ; excavations are found in it filled with blood, while
the surrounding structure is indurated, and assumes a yellowish
or reddish hue.
  Abercrombie's  reasonings on this subject contain a singular
mistake.  He  contends,  that  apoplexy does not depend upon
pressure or determination, "but merely upon interrupted circula-
tion ;"  and goes on to observe, that "there exists  such a derange-
ment of circulation in the head, that  more  blood enters by the
arteries than  can be transmitted by the veins."   But, if more
blood enters the head by the arteries, than leaves it  by the veins,
such determination, of course,  implies  congestion and conse-
quent pressure.   It is not easy, however, to explain clearly what
is meant  by the pathological phrase, determination to a part.
We  can create a mechanical "determination" to any portion of
the external surface by the  application of a cupping glass, and
the  exhaustion of its cavity, thus removing the weight of  the
atmosphere, which is left to press upon every other  exposed
point.   But there is no analogy here to aid us in the enquiry
into the nature of morbid determinations to internal organs, and,
least of all, to the brain, protected as  it is against all change in
the  degrees and modes of atmospheric pressure.
   If we consider the heart  as the sole  moving power which
propels the fluids in the vessels, as we cannot surely suppose it
endowed with any elective disposition or propensity, we cannot
thus account for the unequal distribution of the blood.   We 
APOPLEXY.
411
  must suppose the phenomenon to depend, then, upon some local
  condition of the vessels,  which  either expand spontaneously,
  thus inviting  a flow into  their augmented calibre, or they must
  yield  passively, having  become, in some mode, weakened or
  atonic, so as to be dilated  by the  current, passing through them.
  Both these conditions may happen ; the former I think the most
  frequent of  occurrence.   Those who attribute the arterial con-
  gestion to venous  or  capillary obstruction, ought to show that
  the veins are empty or imperfectly filled ; but this is not alleged.
    I must not omit to notice  the old  distinction of apoplexies
  into serous or sanguineous, which ran through  all the discus-
  sions and influenced all the  practice in  the case.   For  these
  phrases  Good  attempted  to substitute  the terms entonic and
  atonic,  referring merely to the state of the pulse and counte-
  nance.  They are  both  becoming obsolete, being unconnected
  with our improved pathology, and of no importance practically.
   To conclude, although I differ from Serres  in believing pres-
 sure on some part of the brain, either vascular or extra-vascular,
 to be an essential constituent of apoplexy in  all its forms, I am
 willing to recognize the correctness of the division offered by
 him into  simple and complicated,  or,  as he has denominated
 them, the meningeal and  cerebral.   In apoplexies from insola-
 tion generally, I have found  no appearances of paralysis—no
 distortion of the countenance; among'■'subjects thus affected,
 many are aroused into a phrenitic condition.  They are  much
 more under the control of  proper  remedies, and much more apt
 to recover perfectly.  In  these cases, then, I am inclined  to
 admit the strong probability, that  the vessels of the membranes
 were affected, and not the substance  of the brain.
   Of the Treatment.  The suddenness of the invasion of this
 terrible malady—the rapidity with which it progresses to a fatal
 issue—the delicacy  of structure of the  organ affected, and the
 importance of its perfect  integrity, combine to demand  from us
 the promptest and most impressive interference for the relief of
 the  patient.  We have seen that, in a  very  large majority of
 instances, there is either actual  or impending  haemorrhage, and
 unless some  distinct contra-indication present itself in a given
case, the most efficient preventive  or means of arrest is to be
found in venaesection.   The  resort to it,  is matter of almost 
412
APOPLEXY.
universal  consent,  though  in ancient times  it was strongly
opposed by Hippocrates and Forestus ; and some of our modern
practitioners, among whom are the respectable names of Fother-
gill, Heberden, and even Clutterbuck, have expressed concerning
it an unreasonable hesitation and timidity.  As a general reme-
dy, there is no doubt of its propriety.  Place your  patient in a
cool, airy situation, and in a convenient posture, elevating his
head and  shoulders, but  allowing  him  to  recline; remove all
ligatures about his  neck  and body, and open the largest vein
that presents itself.  By  some physicians,  the jugular  is pre-
ferred, but  there  is very seldom any difficulty in  procuring a
sufficiently  full  stream of  blood  from one or both arms.  I
scarcely need remind you, that there is no limit to the quantity
which you are to take away, but  the production of some sensi-
ble effect  upon  the pulse or general  system.  "It ought to be
known," says Cheyne,  "that from six to  eight  pounds of blood
have been taken from a person by no means robust, before  the
attack, which terminated favorably, began to yield."  You will,
it is true, occasionally meet with instances in which  the face is
pale, the features shrunken, the pulse weak,  compressible and
fluttering, and the  whole frame at once prostrated before  the
force of the attack.  Here,  whatever  else you might do, you
certainly would not detract blood ; it has been  said, that such a
case would be a desperate one, and that the lancet could do no
harm.  It is certain it could be of no  service.   We have thus
spoken of the extremes;  there  are  examples of a medium cha-
racter,  in which you will have need of all your judgment and
discrimination to direct  you aright.  The necessity of free de-
pletion here, however, is for the most part so clear and urgent,
that in all doubtful  cases,  I would open a vein, and keeping my
finger  on  the pulse, watch carefully its effect upon the circula-
tion.   If this seemed to  sink  or  fail  without a compensating
amelioration of the symptoms, I would abandon this mode of
depletion as unsuited.  "I confess," says Dr. Cooke, commenting
upon  the  peremptory recommendations of unyielding perseve-
rance in regard to this matter, which have been  urged by some
of our brethren, "I  confess, that  notwithstanding their positive
opinions and directions, I would not venture  to  persist  in the
detraction of blood,  if,  after  free  and  repeated bleedings, there 
APOPLEXY,
413
  was no  apparent advantage, and a fortiori, if symptoms of de-
  bility should supervene."
    Arteriotomy is extolled by certain writers, who promise us an
  obvious advantage from opening the temporal  artery.   There is,
  however, great irregularity in the  flow of blood from this vessel
  when  divided.   If the determination to * the  head  be of recent
  date or sudden, the discharge is small and slow; if of longstand-
  ing, the artery will have become dilated, and the jet will be diffi-
  cult to restrain,  requiring bandages and ligatures of inconve-
  nient application.   I  have twice met with this state of things.
    Topical  bloodletting is  almost  universally  indicated.  Cups
  should be applied to the temples, the sides of the head, and back
  of the  neck. Leeches may be of use also in protracted cases.
  The scalp should be shaved  entirely, and after  cupping  and
  leeches, subjected to the influence  of cold.  Affusion of cold
  water, in a stream  from  the  height of a few feet, is the most
 efficient mode of  applying cold, and is indeed often productive
 of immediate benefit.  I can scarcely account for the prompt and
 decided impression which I have often seen made by this remedy,
 in cases which, to use the phrase  of Abercrombie, "I conceived
 to be perfect apoplexy," especially  in that form of it produced by
 insolation.   Its effect upon the pulse is striking—reducing it to
 a mere thread, with remarkable alleviation of the coma; nay, I
 have more  than  once witnessed rapid and complete recovery
 when nothing else was done for the sufferer.
   In proceeding to  speak of the use of emetics, we enter upon
 debateable  ground.   The advocates  for their administration
 dwell upon  their acknowledged efficacy in removing the gastric
 oppression consequent upon a full  meal—the  presence of undi-
 gested crudities in the stomach—and  the evil influence of sti-
 mulating liquors;  all  of which have  been  already mentioned
 among the exciting  causes of an attack.  They remind us too
 of the determination to the cutaneous surface, and the diminu^
 tion of morbid vascular action which follows free vomiting.  On
the other hand, there can be no doubt of the risk incurred during
the effort to vomit,  especially  if attended by much straining
from the force with  which blood is driven to the head, and the
impediment  offered  to its  easy return.  If any of the  cerebral
vessels have been  ruptured or lacerated, an increased flow from 
414
APOPLEXY.
its open mouth will take place under such  circumstances;  and
as we  cannot discriminate true hemorrhage of the brain  from
simple apoplexy, with intra-vascular pressure, I would warn you
to be very cautious in prescribing emetics.   It has not happened
to me  to witness  any benefit  from them.  Dr.  Cooke  advises
"the exhibition of an  emetic of speedy operation,  if after free
and repeated evacuations of blood, both general and local, and
the  administration of clysters and other revellents, no signs of
amendment are perceptible."   The indications for vomiting are
most clear  when the patient has been  attacked  after a large or
improper  meal, and when there are signs of nausea with retch-
ing.  Yet Dr. Cooke gives us two cases of this very description,
in which he prescribed emetics without any apparent advantage.
Here, however, I acknowledge I should be desirous to get rid as
quick as possible of the contents of the stomach.
   The utility of purgatives in apoplexy is undoubted; but there
is much difficulty in procuring their operation in time  to be of
service.  The patient is unable to swallow, or swallows but little
and slowly.  Hence we should select the quickest cathartics, and
those which act in least  quantity.   As their  revulsive  effect is
sought for, we may choose those which irritate somewhat—cas-
tor oil with turpentine, croton oil, elaterium if at hand, gamboge,
scammony, colocynth ;—either of  these may  be given, and if
the patient cannot swallow, may be introduced into the stomach
by the stomach pump.  They should  be assisted by enemata of
energetic quality, Glauber's salts  in solution  with soap, or the
turpentine emulsion.  It is always a  favorable circumstance to
procure  free  evacuation of the intestinal canal, and to  find the
patient sensible  of the irritation  aroused  by medicines which
affect that extensive surface.   In  this  expectation we are how-
ever often disappointed.  The sensorial system, which supplies
with life and excitability every portion of every tissue of which
 the body is formed, is under present circumstances, invaded, op-
pressed and unfitted for the performance of its important  and ne-
 cessary functions;.and the nervous influence which is demanded
 incessantly to renew or sustain the sensibility of the living fibre,
 is cut off at its  very source.   Hence  arises not  only a more or
 less complete insusceptibility to the specific action of all purga-
 tives ; but owing to this deficiency of vital power, the  internal 
APOPLEXY.                     415
mucous tunic of the stomach and bowels becomes incapable oc-
casionally of supporting the local excitement caused by their
presence.
  Among the observations of M. Serres, we have an account of
the morbid appearances, after  death, of four apoplectics, who
had been treated with the antimonial emetic, but in whom it had
failed to bring on vomiting.  In these he found the stomach and
upper intestine in a state of most  intense inflammation, the vil-
lous membrane coming off in  flakes with black spots scattered
here and there over the colon.   In eight subjects who had been
unable to swallow, and who had been treated  with purgative
clysters, there was no perceptible  lesion of the stomach or small
intestines ; but all  the large intestines from the  valve of the co-
Ion to the extremity of the  rectum, were contracted, the internal
membrane being of a deep black color, with flaky lamina float-
ing in them.
  He contrasts with  the above  cases those of seven apoplectics
who were brought to the Hotel Dieu moribund, and who died
from the thirtieth  to the fiftieth hour after the invasion of the
attack, without any remedies having been administered to them.
In these there was not the least trace of  inflammation either in
the stomach  or intestine; and  hence he concludes, reasonably
enough, that the inflammatory appearances found sometimes in
the primae viae of apoplectics, and much dwelt on by the advo-
cates of the gastric pathology of this disease, are merely inciden-
tal ;  foreign  to the development  of the apoplexies themselves,
and  mere effects  of the treatment  and the  attendant circum-
stances.   These remarks, however, are not made here with a
view to impugn  the practice  of  administering  cathartics,  but
simply as throwing light upon  the nature of the case, and  the
difficulties which surround  us in its management.
  In the  meanwhile, strong and repeated frictions should  be
applied to  the whole  body,  sinapisms  laid to the extremi-
ties, and vesicatories  successively to  the back of the  neck,  the
epigastrium, and all  along  the  spine.  These counter-irritants
are doubly remedial,  as revulsives and stimulants.  They deter-
mine from the brain to the external surface,  and tend to rouse
the patient from his comatose condition, by exciting his dormant
susceptibilities, and  spurring forward the circulatory organs, 
416
APOPLEXY.
which from their comparative independence upon the sensorium
commune, by direct nervous connection, are the last to fail and
yield.  If these irritants are  ineffective,  we  must endeavor to
impress the cutaneous integument with agents of prompter force.
Cloths soaked in hot water or hot turpentine may be  wrapped
about the limbs, or the ammoniated  embrocation of Granville
laid to the abdomen, or on the spinal column.
  In proportion to the  great  mortality of apoplexies, of what-
ever form, in whatever  class  of subjects,  and under  whatever
mode of  treatment, is the value and  importance of a judicious
prophylactic management of  such as are known  to be  liable to
its attack, either from the warning of the premonitory symptoms,
formerly detailed, or from having been once assailed by it.
  I have already mentioned, that convalescence from it is rarely
perfect.   Whether simple or complicated,  whether followed by
paralysis, or not so attended,  apoplexy leaves behind it a strong
tendency to repetition  or recurrence.  I will not repeat what
was  said in the early part of our course,  on the  subject of ple-
thora, the principal source of many of our most serious maladies,
and  of this terrible disease among the number, any farther than
to remind you of what was then argued, as to the true  means
of correcting this morbid condition of the constitution.  Much
may be learned by physicians, from observation of the different
modes of training in use  among sportsmen and pugilists, by
which so much is added  to the muscular  vigor and general
energies  of the human and inferior animals, while the  apparent
mass of  fluids, and the entire bulk  of the body, undergo cor-
responding diminution.  Exercise and strict temperance in all
the habits and conduct, with  a diet regulated, both as to quantity
and  quality, are the means by which these objects are  attained,
and  would answer our purposes as well, if we  were possessed
of the means and power to institute and enforce  them.
   Where the proper prophylactic regimen is enjoined in vain,
or imperfectly followed, we must watch our patient with assidu-
ous  care.  Any increase of the ordinary signs of what is con-
sidered and spoken of as determination  to the  head, must be
relieved  by the occasional exhibition of a laxative, or the loss of
a few ounces of blood.   Let  me  again warn  you, however,
against the too frequent use of the lancet, as likely to add to the 
PARALYSIS.
417
evils which we are anxious to remove.  Low diet may be  also
employed for  transient  reduction of the force of the cerebral
circulation, and for its tranquilizing influences, but must not be too
long persisted in.   It is an old aphorism, that "diseases of inani-
tion are worse than those of repletion," and I have already  had
occasion to refer to Sir Gilbert Blane's assertion deduced from
tables kept with minute attention,  "That there is a larger  pro-
portion of apoplexies and palsies among the lower classes, than
in the  higher ranks"—a result which he attributes to "the spare
and exhausted habits of the former."   Inanition, it  is obvious,
must detract as much from the tone or contractile power of the
living  vessels, as it does from the actual force or momentum of
their fluid contents.
   Many practitioners place great confidence in the revulsive in-
fluence and derivative effects of issues and setons.   These are
inserted in preference, in the back of the  neck and the upper
part of each arm, and are specially attended to, so as to keep up
from them the most abundant discharge, in the season of spring
and the early months of summer.
                       CHAPTER L.

                        PARALYSIS.

   Paralysis or palsy, is a term very generally used, and em-
ployed with so many different meanings, not. only by the com-
mon people, but even by profesional men,  that it has  become
doubly necessary to define accurately the signification intended.
For example, it is not at all  uncommon to  speak  of  any organ
as paralyzed, when it has ceased to perform its peculiar function,
either wholly or in  part; and this vague language, however
incorrect, has become so completely matter of ordinary usage,
that we can scarcely avoid it.   The vulgar application  of it, is
less objectionable.  Perhaps it would be  best to confine  the use
of the word, so as to appropriate it to the loss or notable impair- 
418
PARALYSIS.
ment of the power of voluntary motion, in muscles  controlled
by the will.  I propose thus to limit it at present, and shall pro-
ceed to treat briefly of the several varieties usually recognized.
  Paralysis is divided into general  and partial.  It is  general,
when the muscles of  all the limbs are  affected;  locomotion  be-
ing thus prohibited, and the prehension of food.  Partial paraly-
sis is subdivided according to circumstances.  A single muscle
may be palsied; a few muscles ; a single limb, as in the paralysis
from lead, already treated of;  both the lower limbs, when it is
called paraplegia ; the upper and lower limb of the same side,
when it is called hemiplegia.
  Very commonly,  loss or impairment of the touch and the sense
of feeling, attends the loss of the power of  motion, in a part;
but the coincidence is not uniform.  A few  striking examples,
may be given you, out of a great number upon record, to prove
this.   Dr. Cullen mentions a gentleman, who had  loss of mo-
tion without loss of sense of one arm, and  loss of sense  without
loss of motion of the  other.   Dr. Ley gives a case of a  lady in
a similar condition,  who could hold her child to her breast with
the arm of one side,  in  which  the  muscular power was  still
sufficient, though the  feeling  was so  completely lost, that it was
necessary she  should keep her eyes fixed on it, or she would not
know whether it was  pressed to her or not; the other arm  felt,
but was powerless.  In two hemiplegic patients of my own, the
sense of touch, in the palsied arm, was very defective,  though
feeling was not lost, as was unfortunately proved by the suffering
of intense pain in each. You are no doubt aware that the nerves
of sensation and the  nerves  of motion are distinctly separate,
from their origin  in the spinal chord to  their  extremities.  The
power of  motion is  connected with,  or  derived  from  the  ante-
rior ; sensation, with or from the posterior columns of the chord.
  Our definition of  paralysis forbids the confusion made by
some, who would  regard apoplexy as nothing more than an
universal palsy.  But apoplexy implies the cessation  of action,
not only of the voluntary muscles, but of those engaged also in
the  functions  of organic life.
  Of general  paralysis,  there are  several cases on record, to
which I may add two, from my own observation.  One  of these
was a very stout, robust boy, of about three years of age.  Here, 
PARALYSIS.
419
 there was sudden and complete loss  of muscular power of all
 the limbs, without obvious cause, and unattended with any ap-
 parent derangement of the general health, or any impediment to
 the performance of the vital functions.  There  was no stupor,
 no distortion of countenance, no  affection  of the face,  mouth,
 eyes or tongue.  This child was treated unsuccessfully, by emet-
 ics, cathartics and tonics, of various character, but finally re-
 covered entirely, under the employment of electricity,  frequent
 shocks being given him, for more than a fortnight.   The second
 was a woman, who  became  paralytic after a  violent attack of
 puerperal convulsions.  She also, after a  long illness, having
 bid defiance  to every other mode of treatment, was perfectly
 cured by the persevering application  of electricity.
   Among the cases of general paralysis in the books, is a highly
 interesting and  singular one, in which palsy  was gradually
 progressive,  involving,  as it advanced, the organs of  sense;
 yet long after he was "thus shut out  from all means of com-
 munication with others, his  speech and intellect continued un-
 impaired."
   The Causes of such paralysis as this, are very obscure;  per-
 haps it would be more proper to say,  unknown.   In a case given
 by Dr. Abercrombie, the case began as  paraplegia,  but after
 some time, became general paralysis, which lasted twenty years ;
 the health, aside from the loss  of motion from  the head  down,
 continued good.   Examination was made with  the utmost care,
 by Drs.  Abercrombie and Pitcairn,  but no lesion discovered,
 either in the brain or spinal chord.   To these  parts it is  cer-
 tainly reasonable to refer all  the forms of palsy, the most local
 and limited of the partial paralyses excepted ; which we are dis-
 posed to attribute to  some local affection of the nerves  of the
 part.   But as yet, our knowledge on  these points is not clear.
   No successful inquiry seems, as yet, to have been made,  into
 the condition of  the nerves supplying the parts  affected in local
 palsies, where the injury or loss of function has been confined
 to one or more branches of any nerve, but has  not  extended to
all the parts which it supplies.  When more general,  we refer
the morbid state  to some injury, as before said of the brain, or
of the spinal  chord.   The nature of the changes met with, may
be very much varied. Compression, ramollissement, thicken- 
420
PARALYSIS.
ing, absorption, infiltration, deposition of many forms—examples
of all these are on record; but there are many cases which, on
the minutest examination, betray no cognizable change.   In such
instances, and in a majority of the more local  paralyses, we are
accustomed to lay some stress  upon  the  observed  connection
with remote disease; as in colica pictonum, where the palsy of
the wrist and hand seems obviously to depend upon  the poison-
ous influence of the salts of lead upon the digestive  system.
It is usually taken for  granted, unhesitatingly, that  the excita-
bility or susceptibility  of the nervous tissue, is lost or impaired
notably.  But we shall by and bye have to speak of one thera-
peutical fact, at least, which throws a shade of doubt over this
opinion, and which seems to imply the  possession of an in-
creased nervous susceptibility or irritability.
  The  condition of the paralyzed part, is  also matter  of  inter-
esting investigation.  As a general rule, it may be affirmed that
a palsied limb is of lower temperature than  formerly, and that
it soon  becomes affected  with atrophy;  the pulsation, even of
the larger arteries within it,  sensibly  diminishes in force, and
from want of free circulation  in  the  smaller vessels, it is apt to
be swollen and oedematous.  There are exceptions, doubtless, to
the truth of these remarks, but they do not often occur.
  Of general palsy I  have little to say, in  addition to what is
set down  above.  It is so rarely met with, as to deserve to be
considered rather as a pathological curiosity,  than as a point of
practical importance.   Its causes, as you were told, are very ob-
scure.   Its treatment  is, of course, uncertain,  and must depend
on the particular circumstances of each  individual case.  Look-
ing to cerebral  disorder as its probable source, we may resort to
cautious depletion, both general  and local.   To  the latter we
may add local  counter irritation, by  setons, issues and vesicato-
ries.   If there  be no vascular excitement, or the system seem
feeble and reduced, tonics should be resorted to, and  a  fair and
persevering trial made of the efficacy of electricity and  galvan-
ism.  The former, I have already spoken  of,  as the only ser-
viceable remedies made use of in the two best marked cases that
have occurred to me, and as having been in both,  entirely suc-
cessful.
  Among, the  several forms  of partial  paralysis, I  shall  treat, 
HEMIPLEGIA.
421
 first, of Hemiplegia, or palsy  of  one-half the body, longitudi-
 nally divided.   Like apoplexy, hemiplegia  has its seat in the
 brain, and is, in a vast number  of cases, connected  with that
 terrible affection, either as antecedent or consequent; a hemiple-
 gic dying at last of apoplexy, or an apoplectic  being roused
 from stupor and coma, recovering with loss of voluntary motion
 of the limbs of one side.  There has  been  some  dispute as to
 the nature of the cerebral affection which produces paralysis.
 Concussion may, for a time, impair or destroy the powers of
 motion.  Lesions of various kinds may produce similar effects,
 but, for my own part, I regard the connection as being definitely
 made out between pressure upon, or compression of, one side of
 the brain by an effused clot of blood,  and the symptoms which
 constitute hemiplegia, affecting the opposite  side of the  body.
 I lay down the proposition broadly and distinctly; the apparent
 exceptions are not clearly designated, and if they were, are quite
 as rare  as are adduced in relation to any other general rule what-
 ever.  The reference thus made exclusively to cerebral pressure,
 as the cause of the whole train of effects noted, is here, as in
 apoplexy, objected to, on the ground that pressure often occurs
 without occasioning palsy, as in alleged instances of injury of
 the head, and in the collections of fluid found  within  the cra-
 nium, as in hydrocephalus.  As to the first class of cases, I
 would observe, that no cause seems, in its agencv, to be infalli-
 bly efficient, or independent of concurrent  contingencies; and
 that such instances are too few in  number,  to  weaken  the rule
 to which they are exceptions.   With regard to serous or hydro-
 cephalic accumulations, they form parts  of the history  of well
 defined morbid states, of which it is one of the best marked con-
 tingencies, that the  substance of the' brain  is  readily  absorbed,
 thus escaping compression, and that an attendant impairment of
 the voluntary motions of the whole body, is so  uniform that it
 would be  difficult to decide on the presence  of any local paraly-
 sis.  "For many years," says John  Hunter,  "I have been par-
 ticularly attentive to those who have been attacked with a par-
alytic stroke, forming a hemiplegia.  I have  watched them while
alive, that I might  have an  opportunity to open them when
dead, and  in all, I found an injury  done to the brain, in conse-
quence of the extravasation of blood."
      vol. n.—36 
422
HEMIPLEGIA.
   The seats of this extravasation are varied—1. It  has been
found between the dura mater and the cranium.   2, Between
the pia mater and arachnoid.  3. It has been met with  as the
result of rupture of the lateral sinus.  4. As the result  of rup-
ture of the communicating  artery of Willis.  5.  As the  conse-
quence of laceration of the  centre of the cerebellum.  6. As the
consequence of laceration of the corpus striatum, perhaps the
most frequent  locality of the clot.  7. It has been seen  effused
by simple diapedesis from the vessels of the membranes, without
rupture or laceration.  The local lesion, whatever be the nature
of the injury, is found upon the side of the head opposite to the
hemiplegic half of the body ; a rule which, if ever, is very rarely
broken by any  exception.
   M. Serres has given us a very full account of the precursory
and concomitant phenomena connected with hemiplegia conse-
quent upon  apoplexy, to note which, he has watched whole days
and nights, at the bed-sides of apoplectics.   His first observation
is, that in attacks of cerebral or  complicated apoplexy, the pa-
tient falls down upon that side which  is to become paralytic.
He remarks a contrasted state of the performance of  the func-
tions  of circulation and respiration, as being  presented  during
the fit; the action of the heart being quickened, as the respira-
tory  process is retarded.   In an uncertain  period, a few  hours
perhaps, the laceration of the brain,  by rupture of some  vessel
and extravasation of blood,  takes  place;  the  pulse, until now
slow, laboring but firm and full,  becomes  quicker, small and
concentrated.   The symptom, which most immediately precedes
the other hemiplegic phenomena, is, he says, a  flattening and
inactivity of one side of the thorax,  which cavity is, of course,
unequally dilated  in breathing.   The sensibility  is obtuse on
both sides of the body, but sometimes more evidently so, on the
side which is about to become paralyzed.
   I have seen a distinct interval between the  apoplectic  parox-
ysm and the occurrence of hemiplegia.  In the case to which I
allude, the patient fell upon the  floor,  and lay for a while mo-
tionless and insensible.   He recovered  from this state so far, that
when I reached him I found him conversing intelligently with
his attending physician.   While examining him, and after he had
spoken several  times to me,  and moved freely each of his limbs, 
HEMIPLEGIA.                     423
I observed, as he lay before  me  on the sofa, a  slight shudder
agitate the whole body, and the limbs of the right side sink or
subside heavily. On enquiry, they were found quite motionless,
but he still  spoke  and understood  clearly,  expressing himself
forcibly in reference to the horror he felt at the discovery of his
situation.   In about half an hour,  articulation became impossi-
ble, but was gradually, and  with extreme slowness recovered.
At least an hour must here have elapsed,  between the access of
the fit and the  supervention of hemiplegia.   This patient sur-
vived for years, helpless and miserable.
   You must not fall  into the  erroneous belief of a necessary
connection between apoplexy and hemiplegia.  I have witnessed
two cases of fatal apoplexy,  in  which death came on  without
paralysis,  after  apparently complete relief of the first appalling
symptoms.  In one of these, a young lady,  the  interval lasted
for a  week, during which the patient spoke,  eat. and drank,  but
gradually sunk into death, as if exhausted.  In the other, a very
old woman, ninety-one years of  age, at least, all the  apoplectic
symptoms disappeared, the motive powers were  fully restored,
but with great complaint of languor and debility, and she died
in about twenty-four hours from the attack.
   As hemiplegia and  apoplexy  arise  very frequently  from  the
same cause—compression of a portion of the brain by  extrava-
sated blood, it is clear that either may precede  the  other, and
paralysis may occur without the terrible consequence of apoplexy,
as the latter may take place  independently of the former.
   The first steps of the invasion of hemiplegia, are occasionally
very  insidious,  and may be observed by others,  before they are
noticed by the  patient himself.   The foot is perhaps  likely to
trip against slight obstacles, to be insufficiently raised  in going
up stairs;  the hand does not close as firmly as usual, and small
objects are let fall;  the eye is not perfectly shut in sleep, or the
act of winking being imperfect,  it is inflamed by  the  intrusion
of motes.   An  embarrassment in the pronunciation  of certain
words, or in articulation generally,  may  be  the first in the train
of symptoms.  In the celebrated Dr. Samuel Johnson, this indis-
tinct utterance  gave him the earliest alarm.   In  the farther en-
croachments of the disease, one set of muscles after another is at-
tacked ; there is loss of the usual  expression of countenance, with 
424
HEMIPLEGIA.
some distortion of the visage ; one cheek hangs flaccid, and de-
glutition and mastication are impaired, from the imperfect mo:
tion of the tongue, lips, cheek and pharynx.  There is often a
numbness and  tingling in the limbs, a sensation which  some
patients complain of as exceedingly distressing.   Hemiplegia,
however, is not always  thus gradual and progressive in its inva-
sion; but not unfrequently, even when unpreceded by apoplexy,
assails suddenly and with  prompt development of its peculiar
traits.  Here we are apt to have the same  premonition, as  in its
kindred affection;  and warning of the approaching evil is given,
by pain in  the head, with or without nausea, and vertigo, numb-
ness of the fingers, ringing in the ears and  flashing of light be-
fore the eyes—circumstances which betoken, clearly  enough, a
morbid determination to the brain, with turgescence  of its  ves-
sels  and derangement of its circulation.
   Hemiplegia, when fully developed, has been already defined to
consist in privation of voluntary motion on one  side of the body.
The face loses its symmetry, from the  flaccid  condition of one
cheek;  the mouth is distorted; the tongue,  when protruded, is
thrust to the affected side, and is apt  to  tremble; articulation,
mastication and deglutition,  are  difficult, slow and  imperfect.
The diseased limbs lose their muscular  fulness and roundness;
the fingers gradually put on a waxen  appearance,  are stiffened
and drawn inward; the nails are colorless or livid.
   It is usual with authors,  to  describe paralysis as  implying a
•complete and entire abolition of sense and motion; but this is
an error.   "I never saw a case of palsy,"  says  Dr.  Cooke, "in
which sensation was entirely  lost."  Nor  have I ever seen an
instance, in which the power of motion, however impaired, was
altogether wanting.  We observe, sometimes, irregular or spas-
modic contraction of the paralyzed  muscles, and sometimes
irregular, depraved sensations; heat is complained  of, or cold,
or dampness, or formication.   I do not pretend to  account for
the fact, but I have repeatedly remarked, that sensation is soon-
est lost and restored most slowly in the  lower limb; and the
power of motion most readily and completely  abolished in the
arm, to which it is much the most rarely restored.  This greater
aptness to paralysis, is shown in the palsy from lead and other
poisons, whieh almost exclusively affect the  upper limb.   Time, 
HEMIPLEGIA.
425
  which so often  brings  back,  in a certain  degree, the  motive
  power of the leg, so that the hemiplegic is almost always able
  to limp about, (whence the  frequent reports of cure  or  partial
  restoration, by strychnine,  etc.,) seldom, comparatively, effects
  any restoration of the arm and hand, which remain  useless.
  Such is the permanent condition of a large number of my own
  patients.  The arm, too, is  almost exclusively  the seat of the
  morbid sensations, which, in so many  paralytics, rise to  ago-
  nizing pain.
    In the condition thus pourtrayed, the patient lingers through
  an existence of protracted misery, a burden  to himself,  and an
  incessant source of grief,  anxiety and  distress  to  his friends.
  But dreadful as is this description, it is  by  no means the dark
  side of the picture.  The loss of the  corporeal powers,  is an
  evil  not to be estimated; but physical deprivations are compara-
  tively little in  the  account.   In a  great majority  of cases,  the
  mind becomes affected, no less than the body.   The  memory
 chiefly, is impaired, but all the faculties are  weakened.  "The
 paralytic  patient,"  says Dr.  Parr,  "cries and  laughs without
 adequate cause;  is timid, irascible, violent.   The distortion and
 vacancy of countenance give an air of fatuity to his  look and
 manner ;  the tongue hanging from his  mouth, the saliva drop-
 ping from his chin,  contribute  to render him an  object truly
 pitiable.   It is the most dreadful lot of  humanity."
   The duration of hemiplegia is altogether  uncertain, but may
 be said to bear a sort of  relation to the age of the subject.  That
 is to say, if the attack occur in early life, the powers of accom-
 modation  which form so obvious a part of the animal constitu-
 tion, are more likely to be favorably exerted,  than if the patient
 be aged.   Thus, Andral  gives a case of a man se. 72,  who  be-
 came hemiplegic at  eight years of age. Of my own patients,
 one who was attacked in  1819 with apoplexy, from which he
 arose paralytic, still drags about a stout body upon a limping
 leg, but with no motion of his  arm or hand.
  The general  Prognosis in hemiplegia is certainly unfavorable.
 Instances of cure are  found on  record,  and  do now and then
 occur, but they must be confessed to be very rare ; and even of
 these, but  few can be fairly attributed  to the powers of medi-
cine.  The laceration or extravasation to which we ascribe the 
426
HEMIPLEGIA.
symptoms, is  scarcely within  reach of our  remedial  means.
The effused blood, which, by its mechanical pressure, is believed
to give rise to the train of subsequent symptoms, however varied
and complicated, must either be absorbed, or the organ  injured
must, in some manner, accommodate itself to the unnatural and
morbid condition in which it is placed.   The former process,
absorption of the clot namely, is affirmed to be effected in some
instances, and Messrs. Riobe and Bricheteau describe the mode
in which  it is  carried on.  A peculiar membrane, they say, is
formed around it, on whose inner surface is secreted a serous
fluid, which dissolves the  coagulum; thus  melted down, it is
resorbed, and in proportion as it is removed, the palsy which it
has occasioned, gradually  and  progressively disappears.  You
need not be told, that we have no means of hastening or promo-
ting this process, beyond the very indirect  method of restoring
the system as far as it is  in our power, to its proper condition of
energy and vigor; thus  affording the best opportunity  for the
ready and perfect performance of all the functions.  If the pa-
tient be young, then, and have previously enjoyed good health,
we may venture to hope for this favorable result.   Amendment,
when it does take place, is said to  commence with formication
or creeping sensation in the paralytic limbs.  There is occasion-
ally violent pain, which some suppose to arise from the disten-
tion of contracted vessels.   There is a glowing heat of  the sur-
face; irregular contractions of the muscles become more  and
more frequent, and gradually fall more readily under the control
of the will.  The general health, which has of course suffered,
perhaps chiefly from want of exercise, also  improves ; the me-
mory regains its capacities ; cheerfulness and hope at last return;
the muscles atrophied and  shrunk for want of use,  fill out again,
and are once more symmetrical.
   Of the Treatment.  In recent  cases of hemiplegia, when the
patient is not beyond middle  age, the constitution of ordinary
firmness,  or the subject robust, it will be proper to  resort at once
to the use of the lancet.  The view which  we have taken of the
nature of the morbid affection which gives rise to the symptoms
present, so closely analogous with the circumstances of  the apo-
plectic paroxysm, would of itself lead us to the unhesitating and
hopeful  employment of the remedy.  Yet we should entertain 
HEMIPLEGIA.
427
 no very confident expectation of immediate and striking benefit
 from it.  Nay, it will in many cases seem rather to diminish the
 general force of the circulation and  reduce the  strength of the
 patient, than to remove the congestion in the brain, or the tumes-
 cence of  the cerebral vessels.   Speaking generally, however, of
 such  subjects as I have above  indicated, it will not be safe to
 omit  venaesection;  for although it may possess no influence to-
 wards effecting the removal or absorption  of the blood already
 effused, if laceration and effusion have taken place, its tendency,
 even here, is favorable, as lessening  the likelihood of any addi-
 tional  hemorrhage.   It  is easy to  carry the detraction of blood
 too far, even in the most robust subjects, and you should be cau-
 tious not to fall  into this  extreme.   When you are doubtful of
 the propriety of farther depletion by the lancet,  resort to topical
 bloodletting by cups and leeches ; the former of which may be
 applied upon the back of the neck, or upon  the shaved scalp,
 the latter to the temples and angles of the jaw.-
   The persevering  employment  of purgatives constitutes an
 important part  of the treatment  of  hemiplegia.   At first,  the
 drastics deserve a preference, as the bowels seem to partake in
 the general torpor of the  system, and the intestinal irritation to
 which  they give rise is useful, by its revulsive effect, beyond the
 mere depletion.  Jalap,  scammony, aloes,  gamboge, elaterium,
 croton  tiglium, furnish us with sufficient variety of this active
 class of cathartics ;  and by the proper regulation of the doses
 administered, we may keep up a permanent drain  from the alvine
 canal, as freely and  as long as the condition of the patient may
 require, or his strength of constitution enable him to sustain. It
 is my habit, however, to  intermit from time to time, the exhibi-
 tion of purgative drugs, and to substitute for them irritating and
 laxative enemata ; by which proceeding we leave the stomach
 and alimentary tube an opportunity of resuming their natural and
 healthy functions, while we keep up the revulsive determination
 to the lower bowels,  long known to be a powerful means of re-
 lief in all affections of the head.   Solutions  of the neutral salts
and emulsions containing spts:  terebinth:, may be used  in this
way.
  Emetics have been highly recommended under these unhappy
circumstances.  They are alleged to be doubly serviceable; by 
428
HEMIPLEGIA.
arousing the general system from its torpor and depression, and
also by directly promoting absorption.   I cannot say that I have
ever seen them productive of any very decided benefit.  On the
other hand, I do not shrink from their occasional administration,
when the tongue is loaded and the stomach  uneasy,  and have
seen no reason to fear  the ill effects which some have ascribed
to them.
   In the  deplorable cases of protracted hemiplegia, which  so
often embarrass the practitioner, and wear out  the sympathy and
patience even  of the friends of the  paralytic,  an extensive and
indeed a fair field  is offered for rational empiricism, and  an al-
most  infinite  series of experiments* has been made, in the hope
that something may be found which shall enable us to rouse the
torpid or renew the exhausted  energies of the sensorial system.
With this purpose,  the whole catalogue of tonics and stimulants,
internal and external,  have  been in succession resorted  to; it
must be acknowledged with no very gratifying results.   Some
advantage has been occasionally derived from  the use of certain
pungent vegetables as food, which have therefore long been in
repute ; such  as onions and garlic, the horse raddish, cresses,
mustard,  which, with  others of the same class, may have done
some good, as well by their  diuretic  as their stimulant power.
Cantharides have been prescribed and eulogized, and I should
hope something from them, if carried far enough to produce a re-
vulsive irritation of the urinary organs.   Camphor and ammo-
nia also have their advocates, but they have disappointed me
entirely by their uselessness.
   I am disposed to arrange under  this head  of stimulants the
strychnos nux vomica, which has within a few years been intro-
duced into the treatment of hemiplegia, and has had assigned to
it by some very respectable authorities, the highest place on the
list of remedies for this very intractable  disease.   One among
the most powerful of vegetable poisons, it  seems to exert, when
properly managed,  a peculiar influence upon the muscles of vol-
untary motion ;  and what  is singular and extraordinary, this in-
fluence is for the most part  directed exclusively  upon those
affected with the paralysis.  When given  in sufficient dose and
repeated with proper perseverance, it excites contractions,  usual-
ly transient, convulsive and spasmodic, startling to the patient as 
HEMIPLEGIA.
429
  being entirely independent of the  will.  Fouquier, to whom we
  are indebted for  its introduction  into regular practice, has seen
  it produce general tetanic contractions, without any consequent
  mischief.  These contractions, as  I have  said, if not altogether
  confined to the paralytic muscles,  are  certainly much more vio-
  lent and frequent in them;  and hence  has arisen the opinion,
  intimated to you above, that the nerves of the parts palsied are
  by no means, as  was formerly supposed, in a state of torpor or
  impaired excitability.  Indeed, the inference seems well founded
  and reasonable,  from the greater susceptibility of the muscles to
  which they are distributed, to be thrown into contraction, whether
  convulsive or tetanic, by the agency of the  nux vomica, that
  they  are rather in a state of increased,  undue,  or morbid irritabi-
  lity.  The dose of the nux vomica, as given  by Fouquier, was
  four grains of the powder, or two grains of the alcoholic extract,
  repeated from two to four, or even six  times a day, as the patient
  could bear it;  for the  susceptibility of different individuals, to
  its peculiar effects, varies very much in degree.  It is at present
  used very little in this crude state, a  deserved preference being
 almost universally given to the active  principle obtained from it
 by chemical analysis, and entitled  strychnine.   It is an alkali of
 chrystaline  form, excessively bitter taste and  inodorous.  The
 dose is from 1-20 to 1-2 grain, and its repetition requires caution.
 It is very irregular in its operation, and will often disappoint you.
 In inordinate amount, it produces intoxication,  stupor and violent
 convulsions, to  relieve which Orfila advises the  vitriolic aether
 and ol: terebinth.  I have not been fortunate in the experimental
 employment of strychnine in hemiplegia, but  numerous  cures
 are reported by Fouquier, Prof. Geddings, and others. It deserves
 a fair  and persevering trial from you in every obstinate and pro-
 tracted case.
   I have lately seen singular contractions  in paralytic muscles
 excited by veratrine.   It was used externally,  the  ointment
 being  rubbed upon the part.   The  patient, himself a physician,
 unhesitatingly ascribes to it#the recovery of his powers of  arti-
 culation, mastication and deglutition, which  had been  impaired
 in an  uncommon degree.  I am so far satisfied of its efficacy,
 that I have  determined to repeat  its application  in my future
cases, and to make use of the tincture also internally. 
43-0
HEMIPLEGIA.
   None of the vegetable tonics, properly so called, have retained
any of their ancient reputation in the case before us; but much
stress is still laid on some of the metallic preparations.  A pre-
ference is accorded  to  the sulphate of zinc, which is  perse-
veringly administered, in  minute doses, for a  great length of
time.  The white  oxyde  or sub-nitrate of  bismuth,  and the
preparations of iron, are also employed.   Mercury has not been
neglected; but I have seen no good effect from  it, unless where
gastric or hepatic derangement has supervened.   In such condi-
tions, we  may obtain  from it very evident benefit; it is best
prescribed in small doses and at long intervals, persevering with
it until we procure its usual alterative influences.
   Nothing is more  unanimously agreed on than the propriety
and necessity of the persevering employment of irritants and
stimulants externally applied.   Friction with  the hand, with a
flesh-brush, or, as some  think  peculiarly effectual, with rough
tow, is affirmed of itself to have restored life and  motion to a
palsied limb.   The baths are much confided  in.  Some choose
the  cold bath, the  shock of which may be very  serviceable,
provided  there  remain locally, and in the general system, suffi-
cient vigor and capacity for re-action, to occasion a glow on the
surface after  its use.  When the degree of  debility, local or
general, has exceeded this point, the warm bath is to  be pre-
ferred.  Natural hot baths, I know not  clearly why, have  been
found more efficacious in paralytic cases, than water artificially
heated.   The hot waters of Bath and Buxton in England, and
of the Virginia and  Buncombe  Springs, have acquired  some
reputation  for  their  alleged influences  over paralysis.   The
cutaneous inflammation from mustard, applied  in  dry powder,
or in poultices, or  in watery,or  spirituous  infusion, is said to
have been productive of excellent effect if persisted  in.  So also,
the peculiar inflammation from spts: of turpentine and moxibus-
tion, are affirmed to have been followed by recovery. Scourging
the affected limb with nettles, is an ancient remedy.   The erup-
tion from tartar emetic and from croton tiglium, the insertion
of setons and the opening of issues, and the repeated application
of vesicatories on successive portions of the hemiplegic side, are
all reported to have wrought cures.
  From  galvanism  and electricity, I am disposed, however, to 
PARAPLEGIA.
431
 anticipate, with more confidence, a restorative operation in the
 present condition of the patient, than  from any or  all other
 means above enumerated, as excitants of the  deficient  nervous
 energy.   The well known results of the physiological investi-
 gations of Wilson Philip, demonstrate an analogy, a similarity,
 perhaps, in nature, between  the electric fluid  and  that  peculiar
 principle  whose agency is exhibited  through the nerves.   In
 one of his experiments, the eighth pair of nerves being divided
 and folded back, digestion ceased to be carried on in the stomach
 until this viscus was aroused to action, or fitted for it, by passing
 to it a stream of electrical or galvanic influence, thus proved to
 be, at least, an available  substitute, if  not  a kindred agent.
 While I thus assume, with the chemists,  the identity of galvan-
 ism with  ordinary electricity, I by no means intend to affirm,
 that their modes of action upon  the  animal body are  precisely
 the same—nay, I am rather disposed to regard them  as distinct
 and different, although I am unable to explain the nature of this
 difference, or to point  out  distinctly the cases to which either
 may be best adapted.  Some paralytics shrink from  the electric
 shock, and  feel very uncomfortable upon the insulating stool,
 who  nevertheless bear well, and  with evident advantage, the
 whole force of a powerful voltaic battery or  trough.   Experi-
 ment alone will teach you the  least objectionable and most
 satisfactory  method of applying in  practice  these  useful re-
 medies.

  Paraplegia—the paralysis of the lower  limbs, or  of  the
 lower half of the body transversely divided, next demands from
 me a few remarks.  As an  idiopathic affection it  is extremely
 rare,  but  is every now and then met with in consequence of
 some mechanical injury to the spine.  To some lesion or other
 of the spinal  cord, it  is, indeed, almost  unanimously referred.
 Drs. Baillie  and  Earle, however, with some  other  respectable
 pathologists, regard it as attributable also to causes which  ope-
 rate at least primarily upon the  brain.  In a case occurring in
Georgia, and reported  to me minutely by my friend, Dr. Wad-
del, no injury or morbid  change was discovered in either  of
these organs, and the disease was regarded as the ultimate effect
of very severe  and long continued  gastric and  intestinal  de- 
432
PARAPLEGIA.
rangement.  In one of the  few instances that have presented
themselves to my observation, it appears to be the consequence
of protracted neuralgia seated in the lower limbs, no prominent
spinal affection having been at any time connected with the loss
of muscular power.   The  instance of Couthon,  one of the  ob-
scene birds of prey  which  hovered round  the carcases of  the
victims of the reign of terror  during the French  revolution,
is of some interest, as briefly referred to in the history of  the
times.   He is  said to have been paralyzed in the lower extremi-
ties by exposure to damp and cold locally applied, having fled to
a marsh at night to escape the anger of a jealous rival in a love
affair.   Farther than the loss of power over the lower extremi-
ties, neither his intellectual or physical capacities seem to have
been impaired.  His case furnishes an example, too, of the lesser
degree of paralyzation of the flexors than the  extensors, giving
rise to contraction of the limbs obstinate and permanent, and
embarrassing  the  executioner when the wretch  became, in  his
turn, the  subject of  the guillotine ; a doom far too mild for his
savage crimes.  A similar contraction of the flexors of the arm
is often noticed in hemiplegia.  It is  more rarely met with in
the lower extremity.
   A patient was  brought to the Infirmary of  the College in
1834, (Feb.,) the history of whose symptoms was peculiar and
interesting.  He was a negro boy about ten years of age, a very
intelligent, good  looking little fellow, plump and  healthy in
appearance. *  Pie  had lost  the use of both his lower limbs,  but
one of  them was  more nearly motionless than the  other.  His
left arm was muscular and strong; his right arm was  useless
from palsy,  but his right  hand  was capable of action when
supported, though he could not lift  it.  His removal from  the
Infirmary unfortunately deprives us of a knowledge of the pro-
 gress and results  of the case.
   I have  little to say concerning the Treatment of paraplegia.
 So many circumstances concur in  establishing  the relation be-
 tween  some morbid condition of the spinal cord and  this form
 of palsy, that it would seem proper in every case to direct  our
 attention, and apply our  remedies, to the lower portion  of the
 vertebral column. Cups should be put on the  loins at intervals;
 blisters laid over  the sacrum and to the upper part of the thighs; 
PARAPLEGIA.
433
 setons should be inserted in the same neighborhood, and issues
 kept open.   It would  be difficult to lay too much stress upon
 the spine along its whole course, regarded as a mere centre of
 revulsive influence.   In this respect, it is at least equally, if not
 more deserving of selection, for the application of counter-irri-
 tants, in abdominal and other diseases, whether well understood
 or obscure, than the epigastric centre  so much and  so justly
 dwelt on.
   A persevering  course  of purgatives  has been insisted  on ;
 mercurials administered for their alterative influence ; the cold,
 hot and vapor baths have  been  strongly recommended.   Fric-
 tions of both  limbs, and the long  continued use of a  great
 variety of irritants, of which mustard, turpentine and ammonia,
 may be mentioned.  Strychnine has seemed well adapted  here,
 from the apparent analogy with hemiplegia;  but  the result  of
 the experiments made with it has not been flattering. An instance
 of success with it is related to me by my friend, Dr. Jervey.
   A very recent report of the utility of the secale cornutum  in
 paraplegia, has  appeared in one  of  our journals.  Its modus
 operandi is  supposed to be, by stimulating the lower portion of
 the  spinal column,  to  which,  indeed, the  writer attributes its
 action on the uterus and bladder.  The dose  prescribed was,  in
 one case, an infusion of 3i. daily (every morning ;)  in another
 from  15  to  60  grains.  Four cases of  cure, thus made, are
 stated to us.
   A singularly interesting case of paraplegia, is detailed in the
 London  periodicals, (1840,) as  occurring  in St. Bartholomew's
 Hospital, under the care of Mr. E. Stanley.  The disease com-
 menced  three  years before the patient's  admission  into the
 hospital, with impaired motion of the lower extremities, progres-
 sively increasing,  and  ultimately  becoming complete in  both
 limbs.  There was no defect of sensation  in any part.  Autopsy
 showed no  disease except in the spinal  cord.  Here, contrary
 to all anticipation, the  anterior columns  were  found healthy.
 From these, you are aware, the  nerves  of motion are derived,.
 On the other hand, an extensive change of structure was mani-
 fested "in the posterior columns, from the  pons to the lower end
of the cord."1  A similar case was related at the  Westminster
Medical Society by Dr. Budd.  Mr.  Shaw confessed that he
      vol. ii.—37 
434
PARAPLEGIA.
 could  not explain away the difficulties of these cases, which
 really  appear contradictory to the present received  opinions of
 the structure and functions of the spinal cord and its nerves.
   Under  the  present head of partial paralysis, I will bring to
 your notice an insidious form of Local Palsy, which has scarcely
 been mentioned by any of the numerous writers on  the subject.
 It is usually met with in children, in whom I have seen not less
 than four cases of it.   Twice have I known it  occur in adults.
 The muscles of one side of the face are exclusively  affected; it
 is not  attended with pain or uneasiness of any kind, and hence
 the patient is  seldom,  if ever, the first to be aware of its  exis-
 tence.   It shows itself by a singular and unpleasant distortion
 of countenance, the effect of  a loss of associated action between
 the muscles of the opposite sides of  the face, the paralyzed side
 remaining at rest and flaccid, while the other is contracted natu-
 rally, the  symmetry of the visage being thus destroyed.  This
 is, of course, more notable in laughing and crying, and it is on
 some such occasion that the  discovery is made.  On examina-
 tion, one side of the face is found deficient in sensibility as well
 as nearly motionless.   The eye cannot be shut completely ; the
 corner  of the mouth is either fixed or drawn somewhat  down-
 ward, and  the  cheek is soft, rounded and a little swollen.   The
 tongue, in  some, is pressed  to the  affected side when put out.
 The child is  low-spirited, and  readily sheds  tears when  dis-
 tressed by the notice taken of the distortion of his countenance.
Yet, the general health is good, the  appetite as usual, and the
 pulse natural.
  In the two adults above alluded  to, as suffering  under this
 Facial  Paralysis, there were, however, some symptoms of consti-
tutional disorder.  Both were dyspeptics.   One had complained
 much of vertigo before the  countenance became distorted.  In
 neither was there  palsy of any other muscles than those of the
 face.   Both were distressed during convalescence with a quiver-
 ing1 sensation in the affected cheek, and one with tinnitus in the
 ear of  the diseased side.
   This form of local palsy has been  by some regarded as a mere
 affection of the nervous trunks and branches distributed over the
 cheek and face.  I think it safer and more reasonable to ascribe
 the symptoms rather to cerebral determination and turgescence 
paralysis agitans.
435
  of the vessels of that  part of the brain whence these nerves
  arise.
    The Treatment which I have pursued, is founded on this
  view of the matter, and has been uniformly successful.   It con-
  sists in the Hamiltonian use of cathartics; a gentle but constant
  operation upon the bowels being kept up for two or three weeks,
  regulating, at  the same time, though not very much reducing,
  the diet of the patient.   The amendment in every case, though
  slow, has been steadily progressive.
    During the dentition of children, and associated with the
  varied disorders of  the  digestive  and sensorial system which
  attend that condition, we meet occasionally with local paralysis
  of a most indefinite form, attacking one or more muscles of the
  limbs. An instance of this sort is now (1840) under my obser-
  vation.  A child of  about one year old has lost  the  use of the
 deltoid and pectoral muscles of the right arm, which it  cannot
 raise.   It grasps with the hand firmly enough.   Otherwise, it
 seems well.  As it  recovers the muscular  power of the upper
 limb, the lower extremity of the same side seems  affected with
 a general impairment of power.

   Paralysis  Agitans is best defined, I think, as  that condi-
 tion of the muscles of voluntary motion, which  consists in  a
 continued  shaking, the result of imperfect and interrupted con-
 traction. It is shown especially when certain muscles are called
 on to bear the weight of any part, or to perform their accustomed
 actions in  any way.  It is sometimes habitual, as is seen in the
 shaking of the hands of many persons during their whole lives;
 it is common during convalescence from severe illnesses ; it is
 almost characteristic of extreme old age, whose tremulous voice,
 nodding head, and tottering knees,  are to be thus  accounted for.
 I  have seen a very striking case of it  in a  stout and robust
 young woman  ae. 20, who could not, for some weeks, raise  her
 head from a pillow without being distressed and agitated by its
continual shaking.   Here, it seemed dependent  on  menstrual
and  alvine  irregularities, and  disappeared  under the  use of
steady  purgation  by  rhubarb combined with  the  carbonate of
iron.
  Our hope of a cure, in such cases, must obviously be founded 
436
CHOREA.
upon our knowledge of the cause.  If this be transient, evident
and removable, as in the above example, and in subjects debili-
tated by recent disease, we shall probably be able to afford relief
by appropriate  remedies.   Such is not the fact, however, in a
majority of instances.  They  result  from  some peculiarity of
constitution, and are incurable; or depend upon the inevitable
wearing out of the powers of the  system in the decline of life.
  And this seems to me the proper place to  call your  attention
to a pathological principle, which,  if ever alluded to by medical
writers, is  by no means sufficiently dwelt on—I mean the close
connection or absolute intermingling of the two conditions of
the organs of voluntary motion, at first sight seemingly contras-
ted and opposite, Convulsion and Paralysis.  The first, either in
the shape of spasm, a permanent  contraction, or of convulsion
familiarly so  called, where  contraction of transient  form  alter-
nates with frequent relaxation, is  often, indeed, combined with
the latter.  Sometimes we account for  the  permanent contrac-
tion  of  certain  muscles,  by supposing a more  perfect  paralysis
of their opposing muscles, as in hemiplegia when the arm is
forcibly bent and the fingers closely drawn into the palm of the
hand.   Here the flexors have retained more of their contractile
power  than  the extensors, and act  unopposed.   Again,  some
muscles of a paralyzed  limb retain  a larger portion of their
irritability, and are excited by agents  or influences which fail to
affect the rest.  One of  the subjects of paraplegia to whom I
above referred,  tells me, that he has been  more than  once  sur-
prised  with  the irrepressible force shown  occasionally by the
extensors and  sometimes by the  flexors of his legs, which act
involuntarily and without any obvious excitement.   This takes
place sometimes when he is lying passive—sometimes when he
is sitting still, and sometimes when he is walking, supported as
usual by his  arms.  Under these latter circumstances, the mus-
cular movements resemble those characteristic of our next sub-
ject,  viz.:

  Chorea, which  I  will term  Paralysis Vaccillans.   This
strange malady, which fortunately is not often met with, has many
names, and has been arranged under  both heads of convulsion
and  palsy.  From certain  fanciful associations, it is known as 
CHOREA.
437
  St. Vitus' Dance, the Dance of St. Guy, and has been associated
  improperly with the tarantella of Italy and the hysterical affec-
  tions of fanatic enthusiasm, which however have occasionally
  given rise to it.
    Chorea does  not by any  means, consist  in  a simple loss of
  power in the muscles affected, but essentially depends upon the
  impairment of the control or volition over the voluntary motions.
  Paralysis agitans,  is almost  always a local affair, confined to a
  few muscles; chorea is always,  as far  as I have seen, general,
  nay,  universal ;  the whole voluntary motive system being dis-
  ordered, though the affection of one portion, may be more promi-
  nent than that of others.  The obvious diagnostic of true cho-
  rea, is this, that in  all cases  at first, and in a majority through-
  out, the cause of involuntary or irregular contraction of the mus-
 cles, acts  upon them only at the  moment when the will is di-
 rected upon them, and when they dispose themselves to respond
 to volition, leaving  them at  other times tranquil.  In the most
 violent cases that I have ever seen, I have always been able to
 succeed, in greater or less degree, by soothing language and gen-
 tle repression, in restoring comparative tranquillity to the patient,
 agitated by a most painful  consciousness  of his condition, and
 ever anxious and still hopeful to regain the lost control over his
 movements.  These movements are singularly awkward ; nay,
 the books  shamefully  describe them as "ludicrous."  Though
 sometimes violent, they are never painful, though they may hurt
 the patient, by collision against adjacent objects. Copeland says,
 it is "more frequently partial than  general;" but I have never
 seen a partial case.   The movements cease, during sleep; but
 the rest of the patient is apt to be easily disturbed.  In all cases
 that I have met with, there has been obviously a coincident im-
 pairment of the general health.   The  appetite is defective, the
 breath foetid,  the bowels irregular; as  the  attack goes on, the
 patient is more and more  restless, desponding, anxious, and agi-
 tated, sheds tears often, and profusely ; walks insecurely, or can-
 not move about at all; in the worse examples requires to be re-
 strained from  injuries inflicted on the head, hands  and feet, by
violent concussions; deglutition is difficult and uncertain, mas-
tication impossible, and the  articulation  indistinct.   The eves
       37* 
438
CHOREA.
are red, and wild looking;  the temper pettish and irritable; the
mind unsettled and imbecile.
  Chorea is, happily, so seldom fatal, that no light has been shed
on its  pathology by autopsies.   I am, however, convinced that
the whole sensorial system, and  chiefly the  brain, labors under
some morbid  condition, the nature of which is by no means
purely inflammatory, as some have supposed.   This sensorial
disorder may be, in  some  cases, primary, but in general, seems
to be secondary and sympathetic, resulting from gastric or intes-
tinal  derangement, in the greater number.  The disease occurs
almost  exclusively in childhood ; exceptions,  it is true, are re-
corded, but you will hardly meet with it in an adult.   Girls are
oftener attacked  than boys, as being, from original constitution,
and education also, more mobile and susceptible.   It leaves be-
hind  a strong tendency to recurrence.   I am farther convinced
that  it scarcely ever fails to produce a most unfortunate influence
upon the youthful  intellect, with whose development it sadly
interferes.   Convalescence from it, is seldom, if ever, free from
notable imbecility, amounting occasionally to absolute  fatuity,
from which  the patient recovers very slowly.
  The greater number of authorities have fixed upon the brain,
indeed, as the seat of the disease, but they differ as  to the por-
tion  of the cerebral mass which is morbidly affected.   Copeland
found, in addition, inflammatory appearance of the spinal cord,
but with proper caution, refuses to refer chorea to that condition,
as its cause.   Serres detected morbid changes in the  corpora
quadrigemina, in four cases, and with less reserve, considers these
bodies as the   seat of chorea.  Others  still,  from physiological
analogies, refer it to the cerebellum.
   The Causes of chorea are  uncertain.  I saw it in one case
supervene,  during recovery from scarlatina, and in  another, it
came on while  the child  was convalescent from a severe attack
of catarrhal fever.   It seems to have resulted, occasionally, from
verminous irritation. I  recollect an instance, in which  it appeared
to depend upon the presence of a needle in the body,  which had
been swallowed, and many months after, found its  way out of
the buttock, the child laboring throughout all this time, under
chorea. 
CHOREA.
439
   The General Prognosis is favorable.   I  have seen no death,
 and but once a return of the disease ; and such is the testimony
 of a majority of writers.   Brown saw three fatal  cases.  Cope-
 land, three or four.  Prichard four.
   The Treatment  must depend upon the apparent or supposed
 cause of the attack.   Hamilton,  attributing it uniformly to de-
 rangement of the primae viae,  as the primary and prominent con-
 dition, recommends in the strongest  terms, the persevering em-
 ployment of mild  purgatives.  And, indeed, whatever may be
 said of the theory, his practice has been eminently successful.
 Cathartics are always  indicated, in the first  instance, by the foul
 tongue and foetid breath,  and if they do no other service, they
 tend to relieve the obvious determination  to the head, which an-
 noys the patient.
   There are often  reasons to suspect the presence and irritation
 of worms, when some anthelmintic remedies, judiciously selected,
 should be added to our purgative formulae.  After a certain pe-
 riod, it becomes necessary to combine  some  tonic  also, and of
 these, I decidedly prefer the carb: ferri.   Sulph: zinc: is highly
 eulogized, and may be exhibited in very large doses.  EUiotson
 says, that beginning with a grain, you may increase to six, seven,
 or eight grains, which children will bear, (after meals,) three or
 four times a day, without nausea.  He goes on to tell us, that he
 has given to adults, as much as twenty  to twenty-five grains,
 three times a day.   Arsenic  and quinine, have also  been used
 with advantage.  The latter has been prescribed in very large
 doses, and is urged upon   our attention with strong expressions
 of confidence ; but for my own part, I select and depend upon
 the mineral, rather than the vegetable tonics.
   The  cimicifuga racemosa or black snake root, is  much  used
 in the middle  and  northern  states, having been brought  into
 vogue, I think, by Dr.  Physick. The cold bath has been resorted
 to.  I have found it beneficial in one instance ;  but the shock is
 more than can be well borne by most patients. Cold should, how-
 ever, be assiduously applied to the head, from time to time.  The
 lancet does not seem to me, to be at all adapted to the disease, as
 I have met with it.   So also  I pronounce  as to the irritative re-
vellents recommended  by some authors,  blisters, setons, issues,
moxas, and the like. 
440
CHOREA.
  Narcotics and sedatives are occasionally beneficial.  I have
derived advantage from very minute doses of opium, with alkali,
as in the diaphoretic  mixture.  A weak  aromatic infusion of
camphor, may also be of service.   With belladonna,  stramoni-
um, digitalis and  prussic  acid, I have no experience.  They
have each  of them been eulogized.   I must make  the  same
avowal as to musk, electricity and galvanism.
  In the course of my practice, I have met with but a few cases,
not more than thirteen in all.   These have,  without exception,
yielded to the treatment that I have above  indicated, as  deserv-
ing your preference.  The children have  been kept  secluded,
under the care of a quiet nurse, upon whom the injunction was
strongly laid, to endeavor constantly,  by every gentle  influence,
to repress all emotion or agitation, bodily or mental.  The head
has been kept cold by moist napkins, the hair  having been cut
closely.  The bowels have been constantly acted on, but never
violently or painfully; at first, by rhubarb and calomel, after-
wards leaving out the  mercurial, and  combining the carb:  ferri,
This course has been patiently persevered in.  If the  bowels
became soluble or too loose, the cathartic  was abandoned, and
the  diaphoretic  mixture  substituted,  a few drops of Fowleri
min: solut: being added to it.   If necessary, means of restraint
were used, to prevent injury to the hands,  feet, and head of the
patient.  The food consisted  of  light farinaceous articles, in
fluid form, with milk and eggs.  Every imaginable indulgence
was bestowed on  the patient,  if not absolutely  injurious, and
every wish complied with; care being taken to  avoid excite-
ment, and as far as possible to prevent depression and  dejection.
  Hitherto these assiduities have been crowned with uninter-
rupted success; a gratification which I trust, you, in your future
labors, are  destined fully to share with me. 
EPILEPSY.
441
                       CHAPTER  LI.

                          EPILEPSY.

    Convulsion has  been ranked  by Cullen, Good, and other
 nosologists, as a separate class in the system of each, and  made
 to include several  orders or varieties.  I cannot find sufficient
 reason  for following them in this  arrangement.   Convulsion
 appears to me, in all cases, a mere  symptom, varying widely in
 its combinations, modes of access,  extension, etc..  relatively to
 the circumstances of predisposition, and also to the specific irri-
 tations which give rise to it.  It may be defined  to  consist in a
 series of involuntary,  rapid,  and forcible contractions  of the
 muscles of voluntary motion, alternating  with transient  relaxa-
 tions of the  same;  or  of alternate contraction of muscles  op-
 posed in their action,  as of the flexors  and  extensors.   Most
 commonly, the flexors predominate, both  in vehemence and
 steadiness of contraction, especially in the  hands, which  are
 almost universally clenched, the thumb  being drawn into  the
 palm.   Yet the arms and legs are  not  unfrequently thrust out
 or extended, with such abruptness  and  vehemence, as to  over-
 throw and injure the bystanders and assistants.
   These rapidly alternating muscular contractions  and  relaxa-
 tions, serve clearly to distinguish Convulsion from Spasm, pro-
 perly so  called, which consists in a protracted  contraction of
 muscular fibres, without alternate or contrasted relaxation, or a re-
 laxation  occurring gradually, if at all.  Some of the authorities
 arrange  both  convulsion and  spasm, under one general  head
 of spasm;  the convulsive being distinguished as chronic, and
 the rigid or permanent, as tonic spasm.
   Of all  the morbid affections which present themselves, as part
 of the inheritance of our frail and afflicted race, Convulsions are,
 in appearance,  the  most horrible and revolting.   The violent
 agitation of the frame, the writhings and twistings of the body,
 seemingly so expressive of unutterable distress, and the  fright-
ful distortions of "the human face  divine," form a scene which 
442
EPILEPSY.
it is impossible to contemplate without  the  most profound and
heartfelt sorrow.
  No one can fail to remark the excessive  force  exerted  by the
muscles, when contracting under the various irritations  which
give rise to convulsion ;  a degree of power extraordinary in-
deed, and vastly beyond all that they are capable of, when stim-
ulated by the most determined and vehement volition.  Feeble
women, debilitated invalids, and young infants,  draw up and
extend their limbs with a violence scarcely to be resisted or con-
trolled, by the vigorous efforts of robust men.   I am not dis-
posed to agree with Good or Cullen, in affirming stupor or coma
to be essentially connected with this particular condition of the
nervous  system,  as  an uniform rule.  Nay, I doubt whether
there is necessarily any disturbance of the intellectual  functions.
In the earlier stages of chorea  sancti viti,  (paralysis vacillans,)
a strange compound of  paralysis and convulsion, there is often
no disorder of the mind whatever; and I have seen a very athletic
man, while laboring under an attack of what was  known for-
merly as "the Kentucky jerks," a form  of convulsion brought
on  in  great numbers by religious excitement,  directing Avith
great intelligence how he  should be held, so that he might suffer
no injury, and apologizing humbly  for  the  blows  he inflicted
upon those who were attempting to aid him.  I have repeatedly
seen hysteria attended with  the  most  vehement convulsions,
while there was present no mental affection, or,  to  speak with
correct precision, not the slightest  "tendency  to stupor or leth-
argy," as Cullen has it, no evidence of "diminished sensibility,"
to use the phrase of Good.
  In the disease now to be treated of, however, both these circum-
stances are present, as forming elements  of characteristic  occur-
rence.   In Epilepsy, the patient falls suddenly, loses all con-
sciousness and sensibility, and is agitated by convulsions, which
after a time, subside, leaving him  languid  and  soporose.   The
disease becomes habitual or periodical, regularly or irregularly;
recurring with a violence greater or less, and after  an interval
shorter or longer, in proportion  to the intensity of the causes
which have originated the attack, and to  the mobility and irrita-
bility of the system of the patient 
epilepsy.
443
    Early known, and recognized by the oldest writers on medicine,
  Epilepsy has had a long list of names, and as it would appear,
  has selected for its subjects some of the greatest among the sons
  of men—Julius Caesar, for example, Mahomet, and  Napoleon.
  It was looked on by the ancients, as a peculiar infliction from the
  gods; hence the phrase  denoting it as "morbus sacer."  Aris-
  totle, from its violence, terms it  morbus herculeus.  About  the
  commencement of the Christian era, it was looked on  as  the
  effect of demoniacal possession ; as a singular contrast to which
  opinion, we may notice, that in our times, its occurrence is hailed
  with shouts of  joy,  in many assemblies of religious enthusiasts,
  as evidence of  incipient or impending conversion.  May  it not
  have been produced at Rome,  by political, instead of religious
  excitement, and thus come to be called by Pliny  and Seneca,
  morbus comitialis ?  Its common English, title, for an obvious
  reason, is the "falling sickness."
   The proximate Cause of epilepsy,  the intimate and essential
  condition upon  which it depends,  is as yet  unknown, and  its
  pathology, notwithstanding the numerous attempts made to elu-
  cidate it, is still exceedingly obscure.  We refer, with some con-
  fidence, to the brain, as its immediate seat, because we know it
  in certain instances, to have been produced by lesions of the cere-
  bral  substance,  and alterations within the cavity of the cranium
  and  to have arisen from the  action of causes  adapted to affect
  this  organ, and  determine locally and primarily  upon  it.   The
 nature of  the morbid change is, however, unknown; because,
 in many instances, it seems  to be a purely functional  derange-
 ment, its often repeated seizures during a long life, havino- left
 no observable traces in any portion  of the cerebellum, cerebrum,
 medulla oblongata or spinalis, or the membranes investing these
 parts.
   The remote causes of epilepsy are exceedingly various, and
 by reason of their adaptation to the several systems, physiologi-
 cally considered, of which the  body is composed, they suggest
 a natural division of epilepsies, into the idiopathic  and  sympa-
thic.   Epilepsy is Idiopathic, when it arises from circumstances
 which directly affect the brain,  or are specially and originally
determined to, and  act  upon  that organ.   It  is Sympathic or 
444
epilepsy.
symptomatic, when it arises incidentally from,  or  becomes en-
grafted upon irritations which affect,  in the first instance, other
organs, or tissues, or systems of parts.  A great variety  of ex-
amples of this form, will present  themselves to  us,  as we pro-
ceed in the consideration of the causes of epilepsy.
  Among the  several lesions  of the brain, which  have been
found in the subjects of epilepsy, are recorded  fractures  of the
skull, with  depression of some part of the cranium; the pre-
sence of bony tumors, or other protuberances within the  head;
Dr. Parr mentions in this connection, obstruction  of the  veins
from polypous  concretions, and Dr. Pritchard gives us a case, in
which "the  left lateral sinus was found filled up by a substance
very different in its nature from a recent  coagulum,  and  appa-
rently consisting of a deposition of lymph,  which  had become
organized.   "It seemed," he says,  "so completely to occupy the
calibre of the sinus, as to have impeded entirely, the transit of
blood through it."   Similar fibrinous concretions, adhering to the
inner surface of the sinuses, have also been noticed, by Greding,
Wagner and Copeland.  It would be tedious to enumerate the
great diversity  of appearances,  said to have been noticed  in the
cerebrum, cerebellum, etc., of epileptics;  and it is  unnecessary,
as none of them are .repeated sufficiently often, to indicate even
a general connection of the disease,  with any change of  condi-
tion of the sensorial  organs.  Under  this  head of Idiopathic
epilepsies,' I would include those  which arise from the  abuse of
alcoholic liquors, as  these poisons act most directly upon the
brain and nervous system;  those also, which have followed in-
solation, or  blows on  the head, or falls; those which  have origi-
nated in the passions  and emotions  of the mind,  terror  being
especially fruitful of such consequences; those which have com-
menced in the  diffused excitement of public assemblies, whether
religious or political.   Much stress has been laid by some wri-
ters, upon the principle of imitation, an instinctive propensity so
strong in its influence upon our species, from  early  infancy to
ripe manhood.   To this principle has been attributed, not only
the  spread  of  the disease from  one individual to another,  as
occurred among the children in the Orphan  House, at Haerlem,
under the care of Boerhaave, and in the frequent examples just 
EPILEPSY.
445
 alluded to, but as is affirmed by  Cullen,  "it may  even fix the
 disease, in good earnest, upon a knave  who, for whatever  pur-
 poses, simulates it."
    In Sympathic epilepsy, as I have said above, the  original and
 primary irritation to which we ascribe the whole train of conse-
 quent symptoms, is not located in the  brain, but,  commencing
 elsewhere, it  affects this organ by means of some  of the pecu-
 liar, universal, close and indissoluble sympathies, by which it is
 united to, and reciprocally acts and is acted upon by, every, the
 most remote portion of the system.  It is convenient to  subdi-
 vide these various sources of irritation, and I shall  refer to them
 under the heads of the digestive, the genital, the metastatic, and
 such as develop themselves  by a  peculiar phenomenon known
 as the aura  epileptica.
   And,  1st. Of the  Digestive.  Nothing is better known, or
 more generally acknowledged, than that  almost  every mode
 of derangement of the  organs  engaged  in the function of di-
 gestion, may  give rise to epilepsy.  In  young children  we meet
 with it every day, during the process of dentition,  and observe
 its total disappearance when that  process  has  been completed.
 Worms in the alimentary canal produce it frequently,  not only
 in these young subjects, but occasionally in adults also, a fact
 affirmed to be especially true of taenia.
   Hepatic disorder is said to have  produced it.   Johnson quotes
 the observation of Hippocrates, and confirms  its  truth, that
 "even a morbid secretion of bile itself, will determine epilepsy."
 Morgagni  gives us the case of a priest,  whose epileptic attacks
 were preceded by  pain in the right hypochondrium, and removed
 by bilious dejections,  there having been previously  no token of
 disease in the head.
   2d.  Of Genital  Epilepsy.  It is in the female sex that  we
 most obviously remark the connection of this malady with the
 morbid states  of the  organs of reproduction.  Sudden obstruc-
 tion or suppression of the catamenia, will often give rise to  it •
 and indeed, it seems susceptible of being excited, like hysteria
 with which it is in these cases  nearly  allied and  liable  to be
confounded, by any mode or variety of uterine irritation.  It is
more frequently developed in young girls at the age  of puberty,
who, being of sanguine temperament  and plethoric habit,  men-
       vol.  n.—38 
446
EPILEPSY.
struate scantily, or with difficulty, or tardily.  But the influence
of this set of causes, is by no means confined to females exclu-
sively.   "The organs of reproduction, speaking generally," says
Jourdan,  "are the seat upon which the  epileptic cause exerts its
force, and from which the first phenomena of its access spread
themselves, as by a sort of irradiation."  Numerous records are
to be found  among the  authorities, of its origin  in ordinary
venereal gratification.  Copeland gives us a case, in which ex-
cessive indulgence produced it, for the first time,  in a man of
forty years of age;  nay, the venereal orgasm has  been known
to occasion even a fatal paroxysm.   A solitary vice,  almost too
brutal and degrading to be  alluded to, is affirmed  to develope
epilepsy, as one of the most frequent of the terrible evils which
are its just penalties.
  3d. Of Metastatic Epilepsy.  Under this head,  we arrange
such attacks as follow the disappearance of cutaneous eruptions,
or the sudden recession of the exanthemata. In children, epi-
leptic convulsions very generally attend the "striking  in,"  as it
is called,  of measles and other  eruptive  affections.   They are
often, we know not why, among the earlier symptoms of small
pox and the exanthemata generally,  disappearing as  the disease
developes itself, if it progresses with regularity.
  Obstinate epilepsies are affirmed, though it has not happened
to me to witness any example of this kind, to succeed the  sud-
den subsidence of gouty or rheumatic inflammations, the drying
up of old ulcers, and the suppression of habitual hemorrhoidal
discharges.   It is said, too, that  they sometimes supervene, on
the rapid diminution of dropsical effusions, and after the removal
of large tumors from any part of the body.
  4th. The last variety  of sympathic epilepsy which I have
distinctly recognized, is that coincident, or perhaps I should say
connected with, what is  called,  the "Epileptic Aura."  This is
a peculiar and indescribable sensation, beginning at  some par-
ticular spot, and moving, passing or extending thence upwards to-
wards the head, the patient being seized with a fit, immediately, as
it seems to reach the brain.   There is no  part of the body from
which it has not issued or originated.  Some allege that it fol-
lows the course of the nerves in its ascent.  Cullen denies this,
and affirms that it generally passes along the integuments.  My
patients describe it as taking the  shortest route  from the point 
EPILEPSY.
447
 affected, to the brain; but have not been able to  answer  defi-
 nitely, the inquiry, whether its transit is along the surface, or
 deeper.  Most persons compare the sensation to the motion of
 a "cold creeping vapour," whence the phrase "aura."  Copeland
 speaks of it as follows:  "The sensation of a cold or warm aura,
 proceeding from some part and ascending to the head, but  very
 rarely descending from the head to another  part, is  one of the
 most common precursors of the fit.  In some cases, the aura has
 been felt to terminate  at the epigastrium.  Fernelius mentions
 its occurrence at the vertex;  and Schelhammer, a case in which
 it commenced at this part, and proceeded to  the arm."
   In certain  instances, local affections, lesions  of the part, or
 change of structure have been discovered, on  minute examina-
 tion of the spot whence the aura usually ascends.  In the  case
 of the priest, formerly alluded to, Morgagni tells  us, "that the
 accessions were generally preceded by a feeling compared to the
 ascent of vapour from the hypochondriac  region to  the  head."
 Dr. James gives us a singular history  of "a case of frequent fits,
 which, after resisting  various means  of relief, was effectually
 cured by amputating the great toe ; the operation  having been
 proposed, on the supposition that the  sesamoid bone was dislo-
 cated, whence the fits  arose."  He relates another  similar case,
 which he says, "seemingly depended  also,  upon  some  injury
 done to  the sesamoid bone of the great toe.  When the  patient
 was first hurt, he was  seized with a fit; and this was repeated
 whenever he moved that toe." This last mentioned subject died,
 it appears, of  these attacks.
  The majority of writers regard this  aura  epileptica,  as "no-
 thing more than a manifestation of" what they call,  "reflex sym-
 pathy ; the irritation of some internal  part, affecting some por-
 tion of the encephalic organs, the affection being reflected  in the
 course of some nerve belonging to  the cerebro-spinal system."
 Some infer, that this reflected irritation always  exists in the part
 whence the aura  arises; and I  confess  that  the notion is  not
 without plausible grounds.   Not to repeat the mention  of in-
 stances, in which some organic  or structural change has been
detected  in that point,  there are cases on record, in which a liga-
ture applied above it, or between it and the brain, has generally 
448
EPILEPSY.
arrested the upward  progress  of the  aura, and prevented the
access of the paroxysm.
   A fit of epilepsy may be conveniently divided into three stages,
the premonitory, the  convulsive and  the soporose.   These are
not uniformly present in every paroxysm, but  they  very gene-
rally concur, and  in such  subjects as are long  affected  with
habitual epilepsy,  either of  them is rarely  wanting.  Even in
the worst cases, however, there occur,  not unfrequently, acces-
sions which go no farther than the first stage,  termed by some
writers, "sub-epileptic seizures."  Instances are given, to which
I can add two from my own practice, in which there happened,
but once or twice in many  years,  the  falling  and convulsion,
which are characteristic of the malady.   Each of my patients
was affected with a modification of the aura, or a morbid sensa-
tion, which I could not but  refer to that condition.
   Among the phenomena of this first stage are, intense pain in
the head; vertigo ; vomiting ; great mental excitation, with or
without confusion of ideas; great mental depression,  often with
weeping;  a disposition to syncope; petulence and fits of cause-
less anger; unsteady gait; a disposition to run  forward; cramps
in some muscles, and paralysis of others; roaring in the ears,
or flashing of light before the eyes;  morbid perceptions of odors,
tastes and colors;  one of my patients was always sensible of "a
green taste,"  as she phrased  it, by which I  understand a  con-
sentaneous impression made upon the optic nerve, presenting the
color, green, and an undefined impression on the gustatory nerve,
which she confusedly connected with it.  The whole paroxysm
has been known to consist of a suspension of the faculties of the
mind, during which,  for a  brief period,  the  patient put on a
fixed look, sat rigidly, or perhaps fell  to the ground,  occasion-
ally muttering over and over, the last  word or syllable of the
interrupted conversation.  These imperfect or sub-epileptic seiz-
ures, will  comprise, I am disposed  to  think, the cases of Cata-
lepsy, so called.   Of these I have seen two.  One of  them  was
always aware of the aura, which, in her, originated in the inside
of the thigh, near  the groin, and  was attended with vertigo,
some nausea, and great general distress, mental and bodily.  She
became aware that this uneasiness was always  diminished,  and 
EPILEPSY.
449
 the full development of an attack prevented, by  pressure  made
 on this part; and this pressure, she affirmed, not  only gave such
 ne«ative relief, but was productive of a high degree of positive
 pleasure.   She would request from her attendants, therefore, the
 most violent pressure, and although, for days  after, the limb
 would be bruised and swollen from the force applied, she always
 declared her anxiety at the time, that it should be continued and
 increased.   In this case, the attack sometimes advanced into the
 second  and third stages.   It never occurred to  me, however,  to
 see her convulsed.  Her limbs, and trunk, and neck were rigid.
 The arms, legs and fingers, if bent into any position, retained it
 steadily;  and though she  occasionally spoke, in  milder  parox-
 ysms, she always stated that she was sensible  of the total ina-
 bility of her will to move or contract any muscle.  Prichard
 regards cases of the kind I am describing, as "partial epilepsies;"
 Heberden speaks of them as "antecedents or substitutes for true
 epilepsy," (quasi vicem ejus implet.)   Some  French writers call
 them "petit mal," "vertiges epileptiques," etc.
   A fully formed  epileptic paroxysm, however,  often invades
 without any warning.   Suddenly, or as the case may be, after
 the occurrence of some of the  symptoms above recounted, the
 patient  utters a scream, or silently falls to the ground, generally
 backward.  The body and limbs are for a moment rigid, perhaps
 strongly curved backward; the eyes opened wildly and vacantly,
 and the countenance fixed ;  the complexion pale  or livid for the
 most part, though sometimes flushed. Convulsions now come
 on with horrid distortion of the visage, and rapid rolling of the
 eyes, or strabismus;  the head is rotated or tossed in every direc-
 tion; the hands clenched;  the limbs drawn up and thrown out;
 the tongue protruded and caught between the teeth, the lower
jaw being sometimes moved quickly up and down, and at other
 times the mouth forcibly closed.  The patient moans piteously,
 or utters abrupt screams ;  the breathing is quick  and loud, and
a  bloody foam gathers upon the lips.   The pulse is felt with
difficulty ;  I have usually found it very frequent.   Urine, flatus
and foeces are often  discharged; and, in  males, there  are very
often erections, with  ejaculation of semen or prostatic  mucus.
Gregory says, even in  infants "erigitur quoque penis ; in ado-
lescentibus semen ejicitur,  et soepius, urina ad magnam distan-
      3S* 
450
EPILEPSY.
tiam prorumpit."   He refers here, specially, to what he calls the
tetanoid form.  The violence of the convulsions  is such, as to
have broken the teeth ;  Van Swieten saw the jaws dislocated;
Burserius and  Cheyne, each, give  a case of dislocation of the
arm.  The strabismus  is said to have remained incurably per-
manent.   The  duration of this horrible state is various, from
one minute to ten or fifteen being, perhaps, the average.  Cope-
land, however,  says he has seen it  last  more than four hours,
and  quotes Esquirol as having witnessed  a duration of five
hours.   These  I suppose to be  instances of rapid repetition of
the fits, which may, indeed,  be  indefinitely prolonged in succes-
sion to seven, and, as in one case, to ten hours.
  The third,  or, as I have denoted  it, the soporose stage, comes
on with an  abatement of  the  convulsions;  the patient sighs,
moans, tosses restlessly, perhaps regains partially his conscious-
ness, but generally sinks into a deep, yet apparently uneasy slum-
ber, often with  stertor and subsultus tendinum.  The sleep gra-
dually becomes more profound and natural—the breathing easier,
fuller and less noisy—the pulse  slower and softer.   On awaking,
he complains of headache and vertigo ;  his eyes are suffused,
with enlargement of the pupil  and some difficulty in directing
their motions ;  the tongue is lacerated and sore ; the  muscles of
the limbs and trunk, fatigued and stiff.
  Epileptic paroxysms  are seldom  fatal ; they occasionally ter-
minate, as we are told,  in apoplexy  or paralysis; but I have seen
nothing  of the kind.   The  habitual repetition and  permanent
establishment of  the disease, however, in general produces the
most serious  and melancholy  results; imbecility and insanity
being recorded  as among the most  common.  Yet many escape
these  evils, and retain,  as did Napoleon, Mahomet  and Caesar,
their mental powers  unimpaired.   Cheyne gives an example of
a friend  of his, "whose comprehensive, well stored and active
mind, remained unclouded for seventy-three years."
  Epilepsy may commence  soon after birth, in early childhood,
at puberty, in adult years, in advanced life.   Copeland gives an
instance of its invasion  after forty.   "I have noted," says Heber-
den, "several who had begun to be  epileptic at almost every year
between twenty and fifty; a few have fallen into it at sixty, and
I saw one whose first attack was in the seventy-fifth year of his 
EPILEPSY.
451
life, and from that time, he was often  visited with it for at least
five or six years, and probably as long as he lived."  Heberden,
Soemmering, Cheyne and EUiotson, regard males as more sub-
ject to epilepsy than females.  Esquirol and Foville, with whom
I am  disposed to agree, hold the opposite opinion.
   Nothing can be more uncertain than the recurrence of these
paroxysms.   In some instances, the periodicity, which forms so
remarkable and obstinate a characteristic of this formidable ma-
lady,  seems at once established, and the attacks return monthly,
weekly, nay, daily.   Some assert, that they most regularly come
on at the  moment  of  falling asleep.   I have observed, on the
other hand, that a very common point of attack is the moment of
rising; whether  this be from change  of posture, or connected
with  the transition from the sleeping to the waking state, I can-
not decide.  Some patients are so fortunate as to pass months or
even  years between the fits;  in these  the invasion seems casual,
and has  arisen, probably, without definite  predisposition, from
the influence of transient  causes; or,  perhaps, great caution has
been instituted, or early and persevering resort to  proper mea-
sures  of prevention or cure.
   The general Prognosis of epilepsy is, on the whole, unfavora-
ble ;  and it is seldom allotted to the physician, to enjoy the sat-
isfaction of  controlling  definitely, or  entirely putting an end to
this terrible disorder.
   In  the particular Prognosis, we are  to be guided  by  a careful
consideration of all the contingencies.   Congenital and heredita-
ry epilepsies are  almost  hopeless, as  depending on original de-
fect of organic structure, tending to imbecility, idiocy, insanity
and palsy.   Epilepsy is much more within the reach of medical
means when sympathic than idiopathic;  when the invasion can
be traced  to some well defined and transient  influences;  when
the paroxysms are mild and of short  duration ; when the inter-
vals are long, and when  they are  irregular.  Intemperance is
doubtless, one of  the most ordinary causes of epilepsy, but if the
subject take warning in time,and reform his evil practices before
the attacks  have  become  habitually periodical, he may recover
altogether.   So those, .who, in early life being subject to violent
anger, or addicted to any forms  of excess, which have brought
on the disease, if they can be taught the wholesome lessons of 
452
EPILEPSY.
self restraint and self government, should by no means be al-
lowed to  despair of absolute cure.   The most curable form of
epilepsy, is  that which we  can clearly connect with abdominal
irritation, intestinal irregularities, the presence of worms, etc.;
next in order, that which we have termed metastatic, and thirdly,
the genital.  So great obscurity hangs over  the aura, that no
general rule can be fairly laid down in relation to it.   Epilepsy,
of whatever nature, sometimes disappears spontaneously, or un-
der the influences of unknown agencies,  depending perhaps,
upon  changes  in  the  constitution,  from age, or  alterations of
habit and modes  of living.   Other violent  diseases have been
said to remove it; fever for  example, though  this must be rare,
as Esquirol affirms that he did not notice it.
  Of the  Diagnosis.  Writers comment strongly on the difficul-
ty of distinguishing epilepsy from several other forms of convul-
sion, of which, hysteria  is perhaps the  chief;  and propose tests
for their separation, which seem to me unsatisfactory.  I would
regard as  epileptic, all periodical convulsions, attended  with a
stage  of stupor or coma. Cheyne and Copeland offer as diagnos-
tics, the invasion with a scream ; the loss of sensibility ; the spas-
tic rigidity of the muscles, in the first stage ;  the foaming at the
mouth ; distortion of features and lividity ; the laceration of the
tongue; the priapism and unconscious discharges; and the con-
sequent sopor or mental alienation.   But we must  not forget
that both  these writers refer to cases, in which most if not all
these  phenomena were  wanting.  In the various  grades of vio-
lence, presented by the more or less  full  development of the
attack in the several classes of cases, I confess I am not prepared
to say where we shall draw  the line.   In religious extacy, for
example,  some fall suddenly, and lie as if comatose  for many
hours;  others  are violently excited  previously to the superven-
tion of convulsions ; some retain a portion greater or less of ra-
tionality and consciousness, while others lose at once apparently
all sensibility.
  During the prevalence of  the  "Kentucky jerks," the minister
and congregation of-------, were highly scandalized at the tu-
mult and confusion thus introduced into the Presbyterian Church,
which, as is well known, never recognized such exercises as de-
votional or connected with true conversion.   Among those who 
EPILEPSY.
453
  denounced them most  loudly, were the minister and one of the
  elders.  The former was actually seized by them, one day, while
  preaching, and the elder was attacked in the aisle on his way to
  his pew.  This latter gentleman was so ashamed of his parox-
  ysms, that it was his custom,  when admonished by the precur-
  sory symptoms, to go out into the  woods that he might suffer
  there without any witnesses of his infirmity.
    Autopsy.   Post-mortem examinations of the bodies of epilep-
  tics have exhibited a great variety of morbid appearances, which
  it might be useful, but  would  not be easy, to separate into such
  as acted probably as causes of the  disease, and such as were
  better regarded as mere coincidents, or  perhaps consequences or
  effects of the deranged actions in which it  consists.  Some of
  these have been already mentioned ;—we may add here, simple
  turgescence of the cerebral vessels; effusions of serum within
  the ventricles and upon the surface of the brain;  softening of
  the brain—Morgagni mentions two such instances, portions of
  the substance of this viscus being discolored and of a gelatinous
 consistency ;  ossifications of irregular shape within the laminae
 of the dura mater—I found several irregular shaped  pieces of
 bone between the laminae of the dura mater in a female criminal
 executed here.  She had not,  so far as I could learn, been an
 epileptic.  In several cases examined by Esquirol, some part of
 the spinal cord was found to deviate from its natural appearance
 either in its medullary substance or its membranes.  We should
 never overlook this portion of the sensorial system in our inves-
 tigations into the seats and causes of disease.   I am  inclined to
 think, that it is frequently the point of primary change in the
 convulsive affections.  In one such instance, Morgagni says he
 found  "the vessels of the pia mater of the medulla spinalis so
 exceedingly turgid with blood, especially on its posterior surface,
 as to resemble an injected part: even the  minute vessels of the
 spinal nerves participated in this turgescence."  In tetanus I
 have met with this engorgement and apparent inflammation.
  Alterations  in the condition of the sphenoid bone and the
pineal  and  pituitary glands have been so often detected, that the
Wenzels conclude that these  form  the true  seat  of epilepsy.
Esquirol, however, in the  Diction: des  Sciences Medicales, de-
cides,  on the other hand, that "the  labors of pathological  'ana- 
454
EPILEPSY.
tomy have not hitherto thrown  any light on the immediate seat
of epilepsy," and affirms, from Wepfer  and Lorry,  that "the
same alterations have been developed in  individuals who were
not epileptic."
  In the enquiry farther  into the Pathology of this formidable
malady, its constituent or proximate cause, it is  but too obvious,
that we have been  unable "to lay hold  of  the first link in the
morbid catenation."  Yet Parry, and, after  him, Pritchard, de-
clare it to consist merely "in a preternatural influx of blood into
the vessels of the encephalon, or an  unusual fulness of  some
part of the  vascular  system of  that organ."   Allowing this
statement to be correct  as to  the  fact, and  it probably is  true,
that at the time of access of a paroxysm,  there does exist a
greater or less degree of turgescence of the cerebral vessels, yet,
the full acceptance of the doctrine will not  advance us a step
towards  an intimate knowledge  of  the  nature of the disease.
What is the condition of  these vessels in  the intervals between
the  paroxysms ?   If permanently engorged, why do the fits
intermit ?  If not always turgid, why are  they  relieved, and
why filled, at definite periods of time /  Besides, an  analogous
influx  and distention of the vessels of the head takes place in
simple fits of anger without  convulsion—in intoxication, apo-
plexy,  delirium, paralysis; how and  in what physical circum-
stances does each of these differ from every other ?   This is the
true difficulty of which we  are seeking  an explanation;  yet
this  most essential question  is  evaded or  neglected  by Parry
throughout  the whole of  his ingenious and laborious works on
pathology, in which almost all  morbid affections are resolved
into mere mechanical effects of the mass and momentum of the
blood.   Pritchard seems  to  have been less insensible to  the
insufficiency of his theory in leaving unexplained the  source or
efficient cause of "the  local  influx and fulness"  of which he
speaks; for he goes on to  say, in addition—"It is obvious, in-
deed, that the  last step in  the process which gives rise to the
determination of blood towards a particular organ, is a dilatation
of the vessels of that part."  This is probably true; but whence
arise the peculiar  and characteristic  symptoms ?  In phrenitis,
where we have  the  same determination, the  same  dilatation
whether spontaneous or forced, the same fulness and turges- 
EPILEPSY.
455
cence, there are no convulsions.  Why not ?  And how account
for the prompt, and, in many cases of epilepsy, the total  subsi-
dence of all symptoms of cerebral disorder 1
   1 make these remarks here, in  order to open your eyes to the
defects of this specious mode of philosophizing in our science;
a  candid confession of ignorance of what we  really do not
understand, is far more manly and honorable than the assump-
tion of an  important  air of  discovery  and intelligence, when
nothing has been added to our knowledge.  In a similar  spirit
of unsatisfactory generalization, Dr. Cheyne announces the doc-
trine, that epilepsy is uniformly to be classed among the deve-
lopments of strumous disorder, and  professes to regard it as no
less  exclusively one  of the manifestations of scrofula, than  tu-
bercle itself.  For my own part, I have no doubt of the frequent
connection of the two, and have witnessed the  consentaneous
prevalence of epilepsy and consumption in the same  family in
different  members of it; yet,  I have  seen epilepsy produced, in
numerous instances, by occasional  causes, as, for example, by
intemperance, by terror, by venereal excesses, and especially  the
first, where  there was not the least reason for suspecting  a stru-
mous constitution.
   I shall offer but one farther observation on this subject.  It is
to predict, that we  shall hereafter  find  many of the cases of
epilepsy, hitherto arranged among the secondary or sympathetic
varieties, truly idiopathic, i. e. dependent directly and immediately
upon cerebral disorder, organic or functional;  and shall trace
many of the digestive and other derangements, which are now
looked on  as the origin of epilepsies, to be  merely incidental
effects  of the same  local lesion or morbid action, whether ner-
vous or  vascular, in the encephalon, which  gives rise  to  the
more uniform and essential phenomena of epilepsy.
   Of the Treatment.   During the fit, generally  speaking, little
can be done for the patient.   Care should be  taken to prevent
his injuring  himself by his  struggles.   A pillow should  be
placed under his head; a wedge of  soft  wood, or  a  pledget of
cloth, introduced  between his teeth, to prevent the  laceration of
his tongue, and all ligatures and tight clothing about the  body,
and  especially the  neck and head, promptly loosened.   The
practice,  so common among attendants and nurses,  of endeavor- 
456
EPILEPSY.
ing to force open the  clenched hands of the epileptic, is highly
applauded and strongly urged  by Dr. Reid, who, in the Dublin
Transactions, declares that the paroxysms may always  be  thus
shortened.   In a case recorded in one of our periodicals, I find it
incidentally mentioned by a patient in her account of her symp-
toms, that if, at the approach of a fit, her  hand is  unclenched
and the fingers forcibly extended, the attack will be warded off.
If the face is flushed  and turgid, I employ  cold affusions to the
head, or lay upon it  cloths wrung out  of cold water.  When
the convulsions subside, I endeavor to render the patient's posi-
tion comfortable, that the sleep into which he  falls  may refresh
and restore him, and  take care that his extremities are warm,
and that he has free air about him.
   Instances occasionally present themselves which require more
active interference, though I think not often.   In recent cases or
first attacks, in young and plethoric subjects,  and where a dila-
ted pupil, an inordinate degree or protraction of insensibility
after the convulsions have  ceased, and a  stertorous  noise in
breathing, give reason to dread an apoplectic tendency, venae-
section must  be resorted to, and blood  drawn  as  freely from a
large vein as the pulse will permit.   I need  not inform you, that
this  operation  is not  to be  indiscriminately or carelessly per-
formed, however.  "To open a vein upon account of the fit,"
exclaims Heberden,  "is  a  needless waste of blood, which may
weaken the patient, but not the disease,"—a statement of opinion
somewhat too universal, but containing  a proper warning; when
we reflect upon the common prejudice which so loudly demands
the opening of a vein  in all cases of convulsions and sudden
seizures of almost every character, and which so  few young
physicians have the courage to resist.
   I have had occasion to mention to you two cases  in which I
saw violent convulsions brought on by the  use of the lancet.
Copeland gives two  instances of decided injury inflicted in the
same way.   The best rule is, not to  meddle too  much with
the epileptic  paroxysm in any  stage of  it.   A young lady, long
my patient, had  one  day passed  through the convulsive stage,
and was lying tranquil and soporose, when  a friend entering
and being  much alarmed by her ghastly aspect, seized a pitcher
and dashed water forcibly in her face.   She was immediately re- 
EPILEPSY.
457
 attacked with a violent  and protracted  convulsion, the worst I
 ever witnessed.
   The management of the epileptic, in the intervals, is  next  to
 be considered, and constitutes vastly the most important portion
 of the Treatment.  It may be properly divided  into two parts,
 the rational and the empiric, and we cannot be said to have done
 our  duty fairly to our patient, until we have exhausted ah1 the
 resources referred to under either phrase.  As it is by all patho-
 logists acknowledged, that we have  not hitherto succeeded in
 detecting the intimate nature of the morbid action in which the
 disease consists, or upon which its train of symptoms is imme-
 diately dependent, our first endeavor  should be to  ascertain, if
 possible, the true condition of the patient, from which we may
 infer  the predisposition under which  he labors;  and to procure
 an accurate  history  of  the  remote or  exciting causes which
 develope the attacks.  The  predisposition may be  transient or
 permanent.  The exciting  causes may  be  such as we  can re-
 move, control, modify or counteract.   All these points are to be
 duly considered.   When these causes are apparent, something
 can always be done for our patient; when they are  remediable,
 we  may, with some confidence,  endeavor to  inspire hirn with
 cheerfulness and  hope; and even when they are beyond the
 reach of our means of cure, we must still strive to diminish the
 intensity of their  influence upon the constitution.
   The first of the rational measures is indicated by the general
 condition of  the subject.  If of full, robust and plethoric habit,
 his diet and  mode of living must be  carefully regulated.  His
 food should be chiefly of vegetable material, and no more than
 is necessary  to sustain a due degree of animal vigor.  It may,
 in such instances,  be proper to abstract  a little blood.   I prefer
 the lancet; others choose to cup  the  back of the neck  or the
 temples,  or apply leeches  to  the angle of the  jaws.   These
 measures are more  clearly called  for  under  such premonitory
 circumstances as sometimes  give warning of the  approach of a
 paroxysm—pain or throbbing  in  the  head—tinnitus aurium—
 flashing of light before the eyes—vertigo, etc.  A total abandon-
ment of all stimulating drinks is necessary as the very first step
to be taken.   Intemperance is, perhaps, the most fruitful cause
of epilepsy, both predisponent and exciting.
       vol. n.—39 
458
EPILEPSY.
  In  the contrasted  class  of cases to such  as I have  been
describing, those, namely,  which  present  paleness, muscular
feebleness, general  debility and apparent anemia, an  opposite
course is required.  Here, a generous and even stimulating diet
must  be prescribed—habits of exercise—tonics—change of air.
Some advise wine and malt liquors ; but I  am, on the whole,
persuaded, that the chance of injury from these,  is greater than
the prospect of benefit.  Iron has appeared to me the best of our
tonics  here.  Zinc has been highly eulogized; the oxyde, or
flowers of zinc, is most often used.   It is given in as large doses
as the stomach will bear, without nausea or vomiting—from 5 to
20 grains.  Gaubius, Perci val and Hufeland report favorably of it.
Rush states that he cured a case of ten years  standing with it.
The sulphate is also employed.  Two of the salts of copper are
said to have been exhibited with success.  Cullen recommends
the sulphate ; and we have satisfactory testimony to  establish
the claims of  the  sub-sulphate of copper  and  ammonia, the
cuprum  ammoniacum.   The cases of a father  and  his  two
daughters cured  by the  use of  this triple salt in  combination
with valerian, are authentically given us.  The vegetable tonics
seem less adapted to our purpose here than  the metallic, and
have been abandoned after fair and persevering trial.
  An almost universal approbation  is given  to the  use of pur-
gatives upon the Hamiltonian system.   Their  influence, I  sup-
pose, is chiefly revulsive, though they probably act as alteratives
and deobstruents, removing any obscure visceral affection which
may have disordered the sensorial functions.  The drastics have
been generally preferred ;  they are given in small dose and with
great perseverance—jalap, scammony, aloes, gamboge, and elate-
rium, are thus  used.   I  select  rhubarb, combining it  with an
alkali, and adding some aromatic, or moderate doses of camphor.
Under this course, adhered to with constancy for months and
years, have occurred the most satisfactory examples of  cure and
of relief  which I  have witnessed among epileptics.   I have said
that these cathartics are to be administered in  moderate doses,
and a gentle but uninterrupted action on the bowels maintained.
If  properly managed and  duly watched, this  treatment  will
improve the health  and condition of every patient—instead of 
EPILEPSY.
459
  debilitating, will be found productive of increased strength, and
  will at least protract the intervals between the fits.
    The impression entertained by some  physicians, of the fre-
  quent dependence  of epilepsy upon  scrofula, which  indeed
  Cheyne  regards as  its essential predisponent condition, has led
  to a full  and persevering course of experiments with iodine and
  its combinations.   I  am  not aware of any decided results ob-
  tained as yet, but I confess myself to entertain some hopes  of
  advantage from these remedies, and would recommend for far-
  ther  trial, the dilute  solution of Lugol, and the  deutiodide  of
  mere: and potassium.  This latter, especially, is one  of our
  most efficient alteratives, and seems particularly well adapted to
  cases occurring in scrofulous families, or connected with  any of
  the familiar signs of strumous degeneracy of constitution.
    Next, we mention under this head of rational  remedies, the
 several modes of counter-irritation.   Of these, each practitioner
 has his favorite, and indeed  a preference among  them will be
 occasionally indicated by  the circumstances of the patient and
 the contingencies of each case.  The hair should be worn short,
 or indeed, in bad  cases, shaved  from the  head.  Blisters are
 advised to be applied over the scalp, behind the ears, to the back
 of the neck.   While  some  keep them open with stimulating
 dressings, others allow them to heal, and repeat their application
 successively to different parts of the surface.  Issues and setons
 are established and inserted,  not only about  the head and neck,
 but in the arms and breast.   Caustics of various kinds are eulo-
 gized—the nitric acid, pure potash, etc.
   Under  this head  of the rational  treatment of  epilepsy, we
 may next speak of the management of cases regarded as pro-
 perly sympathic or symptomatic.  While such attacks are recent,
 we may hope much from the removal of the original or primary
 affections upon which they depend ; far otherwise, however,
 when they are of long standing, and have been allowed to  be-
 come habitual.   The associated cerebral  disorder here, at first,
 doubtless, merely functional,  seems to throw off its parasitic or
secondary character, becoming independent, whether by habit or
by  its conversion into a  structural  affection.  This state of
things is  almost beyond  the control  of our art, yet, as we can
never distinctly pronounce upon this  change of circumstances, 
460
EPILEPSY.
we are  bound ever to trace back the disease to its beginnings,
and attack it in its most accessible seats.
   1.  In epilepsy connected with  depraved  conditions of the
digestive  system, the purgative  course  above  advised, is spe-
cially  indicated.  Mercurials should  be occasionally exhibited
for their alterative effect.   Emetics also have been found useful.
Turpentine is said to be serviceable, not only as  a purgative but
specifically, being affirmed to exert a peculiar sedative  or  tran-
quilizing influence over the nervous system generally.  It  is, as
you well  know, one of our best anthelmintics, and verminous
irritation is a frequent cause of convulsions.   It should be given
in doses large enough to purge moderately, jii.  ter die, in  milk
or mucilage.   I  think  favorably of  it; it will rarely fail  to
better  the  condition of the patient, more or less.
   2. It is  not always  an easy task to ascertain the nature  or
degree  of  the disorders of the genital system which  produce
epilepsy. Amenorrhoea and dysmenorrhoea must be removed by
the appropriate means.   When  the organs appear to labor under
morbid excitement, it will  be necessary to deplete freely by the
lancet and purgatives, of which aloes  and  turpentine are most
confided in.   This  latter  is well adapted here, and seems,
strangely enough, admissible in the most opposite and contras-
ted cases,  exciting when the  determination  is defective, and
controlling it when too great,  by  its revulsive and  secretory
effects.  When this system is in a state of exhaustion or torpor,
or the extreme debility which follows  "self-abuse," tonics must
be perseveringly exhibited, a generous and  nourishing diet al-
lowed, the cold bath frequently used if it  can  be borne, and a
long journey undertaken.  The patient must never be left alone,
and every  effort made to lead him  to habits of correct self-con-
trol and prudent caution.   In the worst examples of this sort, it
may be well to blister the sacrum and the thighs, and administer
the tinct: lyttoe to the production of strangury.
   3.  In metastatic epilepsies, such as  arise  from repelled erup-
tions, dried up  ulcers, etc., we must  endeavor, if possible,  to
restore the original disease as the lesser evil of the two.  If we
fail in this, we must substitute  some other drain or counter-irri-
tation  by issues, setons  or caustic, or  moxa.  If the attack has
followed the disappearance of habitual or periodical haemorrh- 
EPILEPSY.
461
 oids, leeches should be applied to the anus.   If connected with
 the removal of tumors, we  must  bleed  generally, if it  can be
 borne ; if not, the head should be shaved, and leeches  or cups
 applied.  The free use of purgatives here is also beneficial.
   4. When  the fits are foreshown by the  aura epileptica, we
 must closely investigate the condition of the part of the body
 where this sensation seems  to  originate.  If any morbid pecu-
 liarity present itself there, it must  be  remedied or removed.  If
 nothing be detected, we are, nevertheless, advised not to neglect
 the part thus affected.   Some keep a  ligature applied on a limb
 above the source of the aura, tightening it when the sensation
 commences.   This, we are  told, occasionally succeeds.   Some
 blister the part; others institute issues there, or insert setons, or
 burn with moxa.  Accidental scalding of such limbs, is said to
 have cured epilepsy.
   On the supposition that some irritating influence was conveyed
 along the nerves  to the brain, the  branch, leading from the spot
 at which the aura took its rise, has been repeatedly cut, or a por-
 tion of it  excised.  The operation is  said to have succeeded re-
 peatedly,  and the  respectable  authority of Sir A.  Cooper has
 been referred to.   This distinguished surgeon related, in his lec-
 tures, a case in which  epilepsy followed a blow on the thumb.
 The aura commenced from that part,  and took the course of the
 radical nerve.  Here 5-Sths of an inch were excised.
   A woman  was admitted to Guy's Hospital, under the care of
 Mr. Key, who  made  the  following  statement.  "About three
 years previous, she perceived an extraordinary sensibility on the
 inside of the right arm above  the elbow; the slightest touch,
 even  the wind  blowing her shawl against it, would  throw the
 muscles of the arm into convulsive action, which would continue
 for several  minutes.  After this distressing affection had lasted
 about twelve months, she became epileptic.  Of the approach of
 each fit, she  was warned by a tingling  sensation,  with  slight
 pain, beginning  on the  inside of the  arm, and running up the
 course of the ulnar nerve, through the axilla to the neck ; her
 head was then twisted  round, and  she fell down insensible, in a
 regular epileptic paroxysm, continuing ten or fifteen minutes.
 The  preternatural sensibility of the arm had now disappeared,
but she constantly wore several pieces of broad tape around the
       39* 
462
EPILEPSY.
upper arm; and whenever she felt the aura indicative of the
approach of a fit, she  had them drawn as tightly as possible,
thus preventing frequently the attack threatened." After full trial
of other remedies, Mr. Key excised  an inch of the ulnar nerve,
but as far as appears, without any result.
  It remains now to speak briefly of the empirical treatment of
epilepsy;  the employment of remedies without any definite in-
dication, but merely on  the ground of alleged benefit having
been derived  from  them in  the previous management  of  this
terrible malady.   One of the most ancient of these anti-epileptics,
and one of those most trusted to, is the misletoe of the oak ; pro-
bably  introduced into practice  in those remote ages when the
Druidical  superstition  held  sovereignty over the minds of our
British ancestors ; it still retains its place, and its usefulness is
affirmed by writers of great respectability, among whom are enu-
merated Haller and  DeHaen  and Van  Swieten.   Frazer records
nine cures made with it.  He prescribed it in powder in a cam-
phor emulsion.   Camphor and valerian are both to be mentioned
here.
   Digitalis is entitled to  a more special place  than either.   In
combination with the  "polypody of the oak," it is a very ancient
prescription, which, after being long left to  empirics and the
common  people, has been lately re-introduced into practice by
Dr. Sharkey, who, in  a recent periodical, recommends a strong
infusion of it in porter, to be given until the subject is fully nar-
cotized and vomiting brought  on.  He recites several cases of
cure by it.  I saw it fairly experimented with in the case of a
young physician, who was kept fully under  its influence for
 several days, seeming  often  indeed, at the very point of death,
 with large and  frequent  vomiting,  vertigo, dilated  pupil, pulse
 thirty to forty;  but  without  any effect ultimately.
   The nitrate of silver is recommended by numerous and res-
 pectable  authorities, among whom I enumerate  Baillie, Roget,
 Johnson, Cooke and Copeland.   The  latter considers it most be-
 neficial in asthenic  cases. It is offered in increasing doses, begin-
 ning with  half a grain and going on to six or eight grains in
 the day.   I  seldom prescribe more than  one-eighth  or  one-
 sixth in each pill however.   The effect  seems to depend great-
 ly upon  our assiduous perseverance  in its use.  It sometimes 
EPILEPSY.
463
produces a particular eruption, which, when it occurs, seems to
aid or perhaps only to point out its salutary operation.   The ob-
jection to it is, that it occasions now and then a peculiar, bluish
discoloration of the skin, which cannot be removed. • Johnson
gives an instance in which, to  use his own words, "a gentleman
became blue in less than three months from the commencement
of its administration."  I have also seen it salivate slightly.  For
these reasons,  it should never be taken long, say more than five
to six weeks, without some intermission.
   Galvanism has been experimented with by several physicians,
and we have favorable reports of its effect from Drs. Duncan and
Mansford.   The latter  proposes  its employment in a peculiar
mode, which proved successful in a case detailed to me by the
late Professor Anthony, of Augusta, Georgia, as follows.  "A ne-
gro girl, aged  ten or twelve  years,  had been epileptic eight or
nine months.  After the first fortnight, she never passed twenty-
four hours without one or more fits ; often  from eight to twelve
in this  period, differing in duration  and intensity."  A fair and
persevering trial of the ordinary plans of treatment having been
made by Dr.  A. and other physicians, altogether unavailingly,
he determined upon resorting to galvanism.  "A gentle current
of the fluid was kept passing through the body for some days,
one of  the poles of the galvanic  apparatus being applied to the
back of the neck over the spine, and the other to one of the legs
a  little below the knee.  Each of these spots was  previously
blistered, to allow of the  more free communication of the gal-
vanic influence from one to the other." The plan was completely
successful.  The patient had but one fit after  the application of
the apparatus ; her general health rapidly improved, and her
intellect,  which had been obviously impaired, was  restored to
its former soundness.
   I ought not perhaps to omit the mention  of the fact,  that the
trephine has been  employed  in the  cure  of epilepsy,  in cases
where circumstances indicated lesion of the brain, from a mor-
bid condition  of the bony envelope of that organ.  The  opera-
tion is discussed and advocated by some of the  earlier writers.
In  modern  times, instances  of its  successful performance are
recorded by Blake, Guild and EUiotson; the last named of whom,
"refers to a case in St. Thomas' Hospital, where the trephine re- 
464
NEURALGIA.
moved a piece of bone with a spicula, from its internal surface,
and cured the disease."   It is affirmed that Prof. Dudley met
with entire success, in a case in  which a bony  tumor  was at-
tached to the inner plate of the piece  taken out.   From Dr.
Wells, of Columbia, I have an account of a patient, whose skull
had been fractured in childhood,  (at two years,)  by a kick from
ahorse,  and upon whom he operated  at  the age of fourteen.
Here, the result was highly promising;  there  was an entire in-
termission  of the fits for several months—from March to No-
vember; and  although the  disease, ultimately returned, it was
in a form very strikingly mitigated, the intervals being long and
the paroxysms slight.
   In concluding the  observations which with much  labor and
study, I have  thus, for your use, collected from the mass of wri-
tings  upon the subject of epilepsy, it is painful for  me  to be
obliged in candor and fairness, to state to you  the melancholy
rarity of recoveries from this terrible malady.  I have  had the
happiness to witness the removal of the disease, in a few recent
instances;  after  some months  standing, the cases become ex-
ceedingly difficult and unmanageable; when their duration has
extended into years, they seem  almost beyond the reach of our
divine art.  What wonder then, that  the  ancients,  with their
meagre list of remedies, should look  upon them as  altogether
hopeless, and  regard the wretched subjects of a disease so dread-
ful, as the  living monuments  of the wrath  of  Heaven, or the
helpless victims of magic and sorcery.
                      CHAPTER LII.

                        NEURALGIA.

  As in  physiology the functions of the sensorial system are
topics of unsettled discussion, and the uses of its  several  parts
still constitute subjects of warm debate,  so in pathology, it will
be found that  the  diseases of that system,  except when they
exhibit manifest lesion from organic  change  or  mechanical de- 
NEURALGIA.                     465
 rangement, are exceedingly ill-defined  and imperfectly under-
 stood.  Indeed, until very recently, no minute or careful inves-
 tigation of the morbid affections of the nervous system, has ever
 been conducted upon proper principles ; and the credit of direct-
 ing our attention to the true modes of enquiry, belongs to a few
 modern writers exclusively, among whom, Marshal Hall and
 Ludwig should be first named.  Perhaps the English physician
 just mentioned, carries somewhat to an extreme, his disposition
 to ascribe the more doubtful and ill-ascertained forms of disease,
 to inflammation and irritation  of the spinal chord and the nerves
 issuing from it; but  he even attributes to this source many com-
 mon and familiar maladies.
   In the warfare which has been aroused, on all these points, I
 shall take no share,  nor become a partizan  of any of the  con-
 tending authorities.  I propose merely to set  before  you  such
 views as I have been led to entertain, and direct you to the best
 results I have been able to arrive  at,  in the earnest  hope that
 every day will bring us more and more light upon these obscure
 and difficult topics.
   It has been found impossible, thus far, to agree even upon the
 language to be used.  Neuralgia is a vague term,  which simply,
 and etymologically,  signifies nervous suffering; and what suffer-
 ing is not nervous?  It is applied here, I  suppose,  for no other
 than a negative purpose, being intended to imply  the absence of
 inflammation of the  diseased tissue, in any of its obvious forms,
 or as tending to any  of its ordinary consequences; the  pain
 which is referred to, being attributed to some undefined  change
 of action or condition  in the  nervous filaments  distributed  to
 the part.  The preference of this  term would seem to imply
 farther, that the extremities or expansions of the nerves, are ex- *
 clusively affected.  On the other hand, the phrase Spinal Irrita-
 tion, is used to denote such derangements of the nervous function,
 wherever displayed,  as originate and have their principal seat in
 the spinal chord,  and are thence  radiated  by some law  or im-
 pulse.  It often happens, that  the most careful examination fails
 to detect any change in the condition of the medulla or any  of
 its envelopes, or in the roots  of the fasciculi of nerves which
 spring from or terminate in it,  and the word irritation is care-
fully and properly chosen and  dwelt on, as signifying something 
466
NEURALGIA.
characteristically distinct from inflammation, which, it is taken for
granted, would impress some notable alteration upon any struc-
ture subjected to it.
  A third phrase, by which many of these affections of particu-
lar branches of nerves have been long designated and familiarly
known, is derived from the French, and seems to  me to be ex-
pressive enough to deserve to be retained.   By Tic douleureux,
we mean the painful sensations which shoot along the course of
some nerve, giving rise to the most intense  suffering,  transient,
intermittent, and recurrent.
  I shall preserve each of the above terms,  and  attempting to
indicate some natural lines of distinction, which  shall aid us in
separating and dividing properly into classes, the array of neu-
ralgic and spinal disorders, I shall,  very briefly, treat  of them
under three heads, as follows:
  1.  Under the  appellation of tic douleureux, I shall  comprise
the  painful affections  of  particular nerves distributed to the
limbs and upon  external surfaces, and attacking, so  far as they
can be traced, the branches or extreme filaments only, leaving un-
disturbed their common source—the brain and medulla spinalis.
  2.  I shall recognize under the head of spinal  irritation, the
painful  affections of whatever parts, which  give  distinct proof
of their being essentially connected with, or derived from some
morbid condition of the spinal chord.
  3.  Lastly.   I  shall reserve the word neuralgia,  to designate
painful  affections of the internal  viscera, whether permanent or
intermittent;  provided it can be clearly made out, that there is
no inflammatory disorder nor any organic change in the  struc-
ture of  the viscus assailed.  Pain is, indeed, the only constant
symptom of this class of maladies, and all their effects and  re-
sults may  be very reasonably attributed  to the influences of
severe pain upon the  system generally.  In many of them, it is
important to remark,  there is not any proof of the impairment
or arrest of the  special function  of the part affected.  The  se-
cretion  of a secreting organ or surface thus attacked, may go on
as if in health, or with no notable modification, as  in gastralgia,
gastrodynia, hystero-dynia, nephralgia, many examples of which,
are apparently purely  neuralgic.
  To describe any of the diseases,  included  under  the general 
NEURALGIA.                     467
 head of neuralgia, is no easy task; I must, nevertheless, endeavor
 so to pourtray them, as to enable you to recognize their promi-
 nent features, and to distinguish them when you  meet with
 them; and guide you in the adaptation of the remedies required
 in each.
    And first, of Tic douleureux.  The fifth and seventh pairs, of
 all the nerves in the body, seem most liable to  be  thus affected.
 Its most frequent seat is, doubtless, the face  and jaw.  Patients
 complain loudly of the intense severity of the suffering they en-
 dure'—speaking of the morbid sensation sometimes, as though a
 current  of fire had been  transmitted  with electrical rapidity
 through the nervous filaments, renewed again and again, after a
 brief interval; at others, as a dull aching, slowly increasing and
 extending until  it  becomes intolerable anguish,  and  then  as
 slowly subsiding for awhile.  I have seen a stout and intrepid man
 under this torture, succumb and fall at last from his chair, in a
 state of almost complete incapacity, with his eyes deeply red-
 dened and protruding from their sockets, and  his face flushed
 and turgid.  At times, the  nerves  of the teeth  alone are de-
 ranged, probably constituting the very worst and most obstinate
 variety of tooth-ache.
   The female mammae are among  the  seats  of  this disorder,
 which may also assail  both the upper and lower limbs.  Of this
 last, I have seen two instances, one of which corresponds near-
 ly enough, with Good's case of neuralgia pedis,  occurring also
 in a clergyman.   The calf of  the leg was,  in this gentleman,
 attacked with occasional paroxysms of intense  pain,  which be-
 came so  frequent, that it was difficult for him to stand or  walk.
 He had  undergone a very persevering course  of  treatment for
 rheumatism, with no effect.   Suspecting a gouty  origin in the
 case, I advised the use of guiac and colchicum, which benefitted
 him promptly, and with a view to the improvement of his gene-
 ral  health, which had become somewhat impaired, he made a
 voyage to England.  Among numerous  men of note, whom  he
 saw and  consulted  there, was Sir Benjamin Brodie, who ap-
proved the plan of treatment he was following, and stated that he
had met  with several similar cases, and that he regarded  them
as gouty  neuralgia.   The second to which I alluded, was a phy-
sician, whose case presented this peculiarity,  that he was never 
46S
NEURALGIA.
attacked, except in the erect  posture, and that a paroxysm was
invariably put an end to, on his lying horizontally.  At my de-
sire, he frequently rose,  and  attempted to  continue standing;
but the pain in the calf of the leg would become so excessive and
intolerable, that his face would grow pale, and his  whole sur-
face relax with a cold, clammy sweat, and it  was evident that
syncope would quickly ensue.  He was, after  a  tedious time,
relieved by the free use of opium, with the mercurials, and wear-
ing a bandage tightly from the toes up above the knee.  This
last measure was instituted under  the impression, that  an  ex-
citing or aggravating cause was found in the distention and dila-
tation of the vessels of the limb.
  The  cause of tic  douleureux is very obscure.  Some  writers
affirm its connection with cachexy  or  general impairment of
health; but this connection  though frequent, is by  no  means
uniform.  I have known two  or three instances of it in persons
of apparently robust constitution. Many imagine it to arise from
malaria; but this opinion seems to me untenable, for the  simple
reason that it is by  no means of more  frequent  occurrence in
malarious regions  than elsewhere.   Nay, if I may judge from
its comparative infrequency  in our  own district  of country, I
would say that  malaria, so far  from being  its efficient source,
does not exhibit any obvious  influence in its production.   Cold,
both in  itself and  as alternating abruptly with heat, has been
suggested, but appears inadequate and irrelevant, as no definite
relation has been made out between the intensity of its applica-
tion  or the frequency of exposures to it, and the development of
this alleged effect.
  The narrow extent and circumscribed locality of the disease,
is shown in the  repeated instances  of entire  and permanent re-
moval of the pain, after excision of a portion of the nerve with
its envelope.  Some of these operations  it  is true,  have been
only partially successful, the relief afforded having been tempo-
rary.   Here, the return of suffering has been accounted for, by
supposing the excised portion  of nerve to have been reproduced;
or some other route of nervous communication with the sensorial
centre to have been established ; or better still, perhaps,  by the
suggestion of an extension of the diseased condition to the por-
tion  of nerve higher up,  and  in connection with  the centrum 
NEURALGIA.
469
  commune.  It is true, that several  failures  have occurred, the
  excision having been unattended with any benefit, and this has
  happened in such a proportion of instances,  that physicians are
  less willing to advise it than formerly.   Many and various are
  the methods of medical treatment proposed, but none of them
  are entitled to much confidence.   The  general health should be
  attended to. Venesection and topical depletion are advisable, if the
  subject be robust and plethoric.  The opposite or  anemic  con-
  dition is, however, more common, and tonics are  required.  Of
  these, iron is doubtless the best, and should be prescribed freely.
  The common rust or carbonate, deserves a preference.  Cincho-
  na has been often employed.  Large doses of sulph: quinine are
  indicated, as some suppose, both by the malarious origin  of the
  disease, and by its periodical character—a  pretty regular inter-
  val being often observed.  Both Pereira and Watson have  spo-
  ken very highly of aconitine, which is  directed to be applied in
  an ointment, to the course of the painful nerve.  The very pow-
 erful and expensive preparation of it, made  by Mr. Morson, of
 London, has indeed effected wonders, in a few reported cases of
 great severity and  obstinacy.   The ointment  of iodide of mer-
 cury, has also been extolled; and I should expect at least  equal
 benefit from a similar employment of veratrine, which, like the
 alkaloid from wolfsbane, may be both narcotic and counter-irri-
 tating.
   2. Of Spinal Irritation.   The vertebral column is the seat of
 many sympathetic sufferings, with which every practitioner is
 familiar.  In fevers of every type, in many  intestinal ailments,
 and in uterine complaints,  reference is continually made  to the
 back and loins;  and in lumbago and some sciaticas, there is abun-
 dant proof, not only that the spine is affected, but  that it  is  the
 principal seat of disease.
   The symptoms of spinal irritation vary with the part of the
 column in which it is fixed.  If high up, the fingers feel  more
 or less benumbed,  and often tingle very unpleasantly.  There
 may be occasional  palpitation of the  heart, and thoracic uneasi-
 ness.  If lower down, there is prompt fatigue in  standing and
walking, with aching  of  the  thighs.  Micturition  sometimes
attends, or a troublesome feeling of fulness of the bladder.   If
the back be carefully examined  with  the fingers, pressure will
      vol. n.—40 
470
NEURALGIA.
give more or less pain,  when applied to the spinous process
pretty firmly, and if the patient have not felt  uneasiness there
previously, he will now become aware of it.
  A gentleman who had been spending the summer  in  one of
our northern cities, had all the while been under the care of one
of the most eminent physicians of our country, and  though at
first relieved somewhat, by the remedies employed, had  at  last
ceased to derive any benefit from them.   He had been treated
for tic douleureux, and complained  of very frequent and  ago-
nizing flashes of pain along the left  side of his neck and face,
attended sometimes  with  perception  of light  in the left eye,
and  occasionally with a quick contraction of the muscles of that
side of the neck, and of  the lids of that eye.   But on examin-
ing him, I found that the spine between, and at the second and
third cervical vertebrae, was permanently and exquisitely sensi-
ble to pressure.  To this spot, then,  I directed my attention, and
made frequent and free application of leeches,  with immediate
relief.  Besides this,  I put the patient upon the  large use of car-
bonate of iron.   His cure seems to be  permanent, although he
was for a long  while so fearful of the  return of his sufferings,
that on the least uneasiness occuring in  that part of the neck,
he was prompt to use the leeches and iron of his own accord.
The severest counter-irritation to the nerves of the face,  which
seemed chiefly  affected, was  in this case ineffectual.  He had
been very  frequently  subjected to  moxibustion,  among other
things, yet with little or no relief.
  I was applied to for advice, in 1839,  by a physician, who was
annoyed by a constant sense of formication  in  the arm and leg,
specially troublesome on the right  side, but  not entirely want-
ing on the left.   At first, he dreaded hemiplegia and  apoplexy,
and  was largely bled twice, purged several times,  and blistered
extensively.  He still grew worse, the morbid sensation disturb-
ing  the function of touch, and harrassing hirn  so much that his
fingers, as he showed me, were vesicated and sore, by his per-
petual friction and percussion  with  them upon objects within
his reach.   Upon inquiry, I found  that  he was frequently at-
tacked with vertigo and headache, and that the upper portion of
the  spine was tender on pressure, and  sometimes ached sponta-
neously.  His  digestive system was  so much out of order,  and 
NEURALGIA.
471
 a series of gastric affections had so long preceded his other ail-
 ments, that I was led to attribute them all to that source.   Coun-
 ter-irritants were applied perseveringly, along the course of the
 spine and to the epigastrium ; his diet was  carefully  regulated ;
 he remained at rest for a time, and avoided all exertion  and ex-
 citement ; the nitrate of silver was internally administered, and
 no other medicines given.   Under this treatment, he rapidly, and
 thus far, permanently recovered.
   Let me here guard you against an error likely  to become a
 common one.   Practitioners having of late, had their attention
 emphatically called to the spine, as the source and centre of a
 great variety of diseases, find, upon manual examination, that in
 a very considerable proportion of cases of chronic ailment, how-
 ever commencing, and  wherever apparently  fixed and promi-
 nent,  some portion  or portions of the vertebral column are tender
 upon  pressure.  In all such, the inference is at once drawn, that
 these  are instances, hitherto  undetected, of  true primary spinal
 irritation;  and this inference is  more strongly drawn, and con-
 sidered to be clear, when very great relief or absolute cure  has
 followed the application of remedies locally, to the spine, after a
 failure of the ordinary  course of management.  This process of
 reasoning is often  fallacious, however, and  seldom  altogether
 satisfactory.   Spinal irritation, it should be  remembered,  may be
 either secondary or original,  and in a great number of chronic
 disorders, it ensues, either as the result of  the  maladies them-
 selves, or from the causes which produced them becoming more
 influential, by prolonged action; or possibly, as  the effect of
 remedies or remedial management instituted and unduly perse-
 vered in.  Several of the examples of  "spinal irritation" offered
 by Dr. M. Hall, in his valuable work, seem  to me to be thus se-
 condary ; and it does not appear to me to be a rare accident by
 any  means, that an affection of the spinal chord shall  take place
 as a coincident result of some common cause, with the general
 affection of the widely distributed nervous filaments on the sur-
 face.   This is, perhaps, most likely to happen in renal diseases,
and in inveterate dyspepsia.
  "I have very frequently met with cases," says  Hall,  "where a
very high degree of organic disturbance existed, yet there was
present little or no irritation of the spine;  no complaint of pain 
472
NEURALGIA.
 there, having been made, and manipulation causing no distress;
 nevertheless, a careful and persevering application of local reme-
 dial treatment terminating  in a  perfect cure,  gave irrefragable
 evidence that the source of disease had been rightly apprehend-
 ed; but that the sympathetic, par vagum or phrenic nerves, and
 not the spinal, had been the primary seat of morbid  action."
 From the  successful "application  of local remedies" in such
 cases, we are, indeed,  apt to believe that the part thus aimed at,
 was the "source" of all  the symptoms.   But before we settle
 down upon this conclusion, it behoves us to reflect how import-
 ant a centre of action, influence  and sympathy,  is the medulla
 spinalis, and therefore, how very efficient a point for the agency
 of revulsives in general.  On the very same grounds as above
 indicated, one of our western brethren has formed  and main-
 tains the opinion, that intermittent fever consists  in, or is a mere
 consequence of spinal irritation.   He has been, he tells us, very
 successful in arresting the  formation of a chill,  and thus pre-
 venting  a paroxysm by the  application of long strips of mustard
 plaster down the back, on both sides of the spine.  He general-
 ized too  hastily, and did not carry his experiments and investi-
 gations far enough.  Had he done so, he would have found that
 the same effect will follow the application of counter-irritants to
 the epigastrium,  favoring the theory of its gastric origin; and
 sometimes their application  to the extremities, whence has been
 derived support to the  idea of its  dependence upon vascular con-
 gestion.   And if  he had still found the spinal  column the best
 adapted point for such local applications,  it would only  have
 proved, what is at once admitted, that it is the most  influential
 centre of revulsive movements.
   Again, it was ascertained  by Dr. J. K. Mitchell, of Philadel-
 phia, and our profession is much indebted to him for the useful
 observation, that some rheumatic attacks, entirely unmanageable
 by the ordinary modes of treatment,  gave way readily on the
 application of depletants and counter-irritants  to the vertebral
column,  and near it.  But if, reasoning like Dr. Hall, we should
hence conclude that rheumatism is merely one of the exhibitions
or modes of spinal irritation, we should fall into a great mistake.
For experience will soon convince you, that not all rheumatisms
are curable by cupping the back ; nay, that some are not in the 
NEURALGIA.
473
least degree relieved by this operation, and that others are easily
removed by general measures alone.
  Spinal irritation is much more frequently met with in females
than males.   It does not very often develope itself before puber-
ty.   It  belongs  to  what  is called the nervous  temperament,
though not exclusively.   It is apt to be associated with more or
less cerebral affection, and great  mental excitability.  In two,
among my male patients, it was attended with obvious and dis-
tressing determination to the head.  Its connection with hyste-
ria, has been  matter of familiar remark; or rather, physicians,
with Watson, have  dwelt on the frequency and closeness with
which it is simulated by  this  protean disease.   Every practi-
tioner should be  careful  to  avoid error  here; yet I am rather
disposed to differ from  such as lose  sight of the very natural
and possible coincidence of the two affections—a combination
that I have often met with—and regard the  apparent tokens of
spinal irritation as unreal.  No reason is given, except their sud-
den disappearance in certain instances; but lam not aware of any
thing in the nature  of the case, that shall prevent its immediate
subsidence and its periodical return.   I repeat then,  that while
in your observation of all cases of this nature, you are to be on
your guard against  deception, voluntary and involuntary, on the
part of the patient,  yet you  are  not  to allow your suspicion of
female cunning  to  carry you beyond the limits  of reason and
humanity.
  Two  of my female  patients have  been somnambulists,  not
naturally, but while laboring under  the  spinal  irritation.  In
another, there was  not only phrenitis or cerebritis, but  a prodi-
gious and inexplicable exaltation of the powers of the organs of
sense equally, fully, if not surpassing all that is   related in  the
books.   This symptom only appeared  in the somnambulistic
condition, during which the case very much  resembled that of
Jane Rider, so well  told by Dr. Belden.  In two instances now
under  my observation, there is extreme susceptibility and exci-
tability, both physical and moral—in one heightened occasion-
ally to  insanity, intermittent, but tenaciously recurrent, though
not at any regular interval.  Such associations, which, as I have
affirmed, are  by no means unfrequent, render the cases of the
       40* 
474
NEURALGIA.
disease under discussion always  highly interesting—an interest
enhanced, too, by the uncertainty and difficulty of cure.
  These two offer such well marked and distinct pictures of this
unfortunate malady, that I will  describe  them  briefly to  you.
The first has  been long a  martyr to severe suffering.  There
was from the beginning considerable pain in  the back—of course
aggravated by exercise and by the erect posture ; but as this is
a common symptom of a long catalogue of diseases, it attracted
little  attention.  Frequent  headaches  next  came on,  and the
heart began to act with great rapidity and  irregularity;  with
palpitations and sense of suffocation or globus hystericus.  The
digestion was  impaired, and the strength failed, so that the pa-
tient rose  unwillingly from the  recumbent  position ; and what
with her actual debility aud  the pain in  the back, increased on
rising, was readily disposed  to syncope when she sat up.   Her
sleep was interrupted, and  her  mind constantly excited, with
great talkativeness, especially at  night.  It was now discovered,
accidentally, that the  spine was at several points very tender on
pressure.  In the neighborhood of the eighth  dorsal vertebra, this
tenderness is so acute, that a touch threatens syncope, and at two
 or three other  places, pressure made with even moderate  forcei
 leaves an aching  that lasts for many hours, attended with tingling
 of the lower limbs.   This patient exhibits constant frequency of
 pulse; is readily startled and greatly disturbed by any noise; as I
 have said sleeps little ; is liable to occasional paroxysms of fever
 from slight causes, such as  the visit of a friend, a pleasant conver-
 sation, etc; is  habitually costive, and has little appetite with im-
 perfect digestion, being confined to the lightest and mildest diet.
 She always obtains relief from  leeches  to the spine, and  from
 counter-irritants—some of which indeed, when they act prompt-
 ly, tend to bring on fainting, she says, by  the suddenness and
 degree  of relief they give.   She seems to derive some advan-
 tage from prussic acid, and  the cautious use  of opiates. She
 has so far recovered  as to  enjoy for some months the ability to
 walk about and  mingle in society, but  still demands unremit-
 ting care and attention.
    The  second case which  I  shall detail, came under my advise-
 ment from the very beginning, and has afforded me the best  op-
 portunities for observation of the  history  and progress  of  the 
NEURALGIA.                     475
 disease.  The first symptom  noticed here was pain in the back
 and loins, aggravated by any use of the  lower limbs, but more
 by standing than by walking, and subsiding again when she lay
 down.  There was some general excitement of the system, with
 loss of sleep, the pulse being rather frequent and quick.  After
 a time there was constant aching  across the pelvis posteriorly,
 with pain following the course of the crural nerves, descending
 to the calves of the legs, and connected with a sense of muscu-
 lar feebleness and incapacity; sometimes  with  numbness  or
 tingling, which  has indeed,  though  not  often or in very great
 degree, affected the  arms  and fingers  also.  These symptoms
 continued to increase, until the patient, if not absolutely unable,
 was exceedingly reluctant to rise at all from the recumbent pos-
 ture ;  and when she did  sit  up or walk, complained  of great
 augmentation of all her sufferings, lasting for several hours after.
 Examination showed much tenderness along all the lumbar ver-
 tebras, and at one point higher up,  near the fourth dorsal; this
 was relieved  by mustard, Granville's ammoniacal lotion, blister-
 ing, leeching and cupping, but especially the  latter.  Cupping
 indeed, with  the preceding scarification—usually so painful an
 operation over an irritated and delicate part—gave a singular
 degree of positive pleasure, a phenomenon of hysterical character
 doubtless,  inexplicable but familiar; was eagerly asked  for and
 always prolonged as much as possible.  After long impairment
 or voluntary  disuse  of locomotive  power, this patient has re-
 covered, but perhaps not perfectly. She walks, however, quickly
 and firmly, though readily disposed to  fatigue, and frequently
 complaining of pain in the back and  loins, and of occasional
 tenderness on pressure.
  The advocates of the prevailing  doctrines as to spinal irrita-
 tion would,  however, regard  my sketch of it as  exceedingly
 meagre, if I did  not  at least allude here to the affections with
 which they affirm  it to be so often closely  connected ; nay, of
 which some of them  maintain it  to be  absolutely the root and
 source.  Among  these, under  one or the other head, Marshall
 Hall enumerates,  in his ingenious treatise, diseases of the h^art__
 of the  lungs, both phthisis and asthma—and of the liver; dys-
pepsia  ; cramp in the stomach ; diabetes, chorea, tabes mesenteri-
ca,  hysteria and  monomania.  I have  already spoken of the 
476                     NEURALGIA.
difficulty of ascertaining the nature of the connection, in such
cases as these, between  the spinal disorder and the other symp-
toms.  I am not  persuaded that they stand to each other in the
relation of cause and effect.   That such affection of the medulla
may aggravate them all—increasing the sufferings of the patient
and  the  difficulty of cure, I do not doubt, and will not deny,
That it should  always be  inquired into, and receive proper at-
tention, is an established rule  which must not be neglected.  It
is highly  probable that symptoms  of each  of the  maladies ar-
rayed above, may show themselves during the protraction of a
spinal case,  and be removed  during the progress of its cure, or
disappear when it is relieved.  In  certain anomalous  instances
recorded in  your books,  this association or simulation, if they
will have it  to be such, is very striking and impressive.
  Thus as I have spoken of a  variety of toothache,  which is
properly a tic  douleureux, so  I  have seen  instances of spinal
irritation productive of quasi  rheumatic affections, such as those
first noticed by Dr. Mitchell.  The  same may be true of hyste-
ria and chorea, and, as has been asserted, of asthma.
  3. Visceral  Neuralgia.  I heartily wish it were in my power
to throw any light on this very obscure but important branch of
my subject.   All I hope, and what indeed I chiefly aim at, is to
excite your  curiosity and  arouse your interest  in regard  to it,
that your attention  may be specially directed to the accumula-
tion of facts, and the establishment of clear, correct and useful
views concerning it.
  The ganglionic system, the sympathetic  nerves  so  called, in
which are seated the disorders  we are now about to discuss, are
asserted by  Bichat and Sir  Charles Bell to be insensible. "They
may be cut," says Bell, "or  pinched in the living body without
causing  pain."   The parts which  they  supply, however, are
capable of highly varied and  delicate sensation and  suffer in-
tensely in their morbid states.  It is unimportant to our present
inquiries, whether these morbid impressions are conveyed through
the ganglionic or the spinal system.   Most writers, however, as-
sume that the  ganglionic nerves  acquire when irritated and dis-
eased, the new power  of receiving  and communicating impres-
sions, just as is supposed to be done by the ordinary  nerves of
sensation. 
NEURALGIA.
477
   1. The first of these forms of visceral neuralgia which I shall
 mention here, is the cerebral.  Head-ache  is, perhaps, the  most
 frequent of all the sufferings  complained of  by invalids in civi-
 lized, and especially in refined life ;  and any one who has at all
 considered the subject, must be aware of the infinity of modifi-
 cations which it  presents in different individuals, and in the
 same individual at different times.   That it results from affec-
 tions of various tissues, cannot be doubted; and, it seems little
 less clear, that the same tissue may  be subject to  more than one
 mode of derangement productive of  pain.  It is well known,
 that some of  these are inflammatory, because they are attended
 by all the organic changes that are the ordinary consequences of
 inflammation.  In many varieties of what are  called congestive
 disorders, fevers, etc.,  head-ache is also a prominent symptom—
 itself of congestive character, doubtless, and not  inflammatory.
 But  these will  include  only a  portion of  the immense number
 of grievous attacks referred  to under  this appellation, some of
 which are so locally and strictly circumscribed, that they can
 hardly be attributed to any vascular  disorder, and though ex-
 ceedingly vehement, and frequently repeated, leave behind them
 no discoverable traces.  Such, for instance, is hemicrania—such
 that fixed pain, often at the very vertex, which may be covered
 with the point of the finger—such are  those generally known as
 hysteric head-aches, and those spoken  of by patients themselves
 as nervous head-aches, and  attended  by cramps  of the fingers
 and of the muscles of the legs and toes.  In  some of these, it
 is not uncommon to find the scalp itself so tender, that it cannot
 bear the touch—nay, the hair  itself,  is affirmed by Larrey, to
 have exhibited, in a soldier under  his  care, this  preternatural
 sensitiveness.
   Now,  as I set out with the pathological  doctrine, that all life
 being derived from the nervous and vascular  systems, all dis-
 ease consisting in morbid modifications of vital action, must be
 primarily seated  in these systems;  it  follows,  then, that where
 there is no change in the vascular condition of a part  or organ,
 the subject of obvious disease, such  disease  must depend upon
a morbid condition of  its nervous tissue—in  other words,  must
be a  nervous  affection, which we may  very well  denominate
neuralgia.  In obscure enquiries like these,  we  derive some aid 
478
NEURALGIA.
 by reasoning backward, and drawing our inferences, as to the
 nature of any malady, from the specific qualities of those reme-
 dies best adapted to its relief or cure.   Hence, as we find  many
 of  these "nervous head-aches" most manageable  by narcotics,
 we are entitled to regard them as probably resulting from what
 we term nervous  excitement.  Opium, digitalis, camphor, and
 certain drugs which we consider anti-spasmodics—assafoetida,
 valerian, musk,  ammonia,  are among the most common and
 serviceable prescriptions here.
  2. Passing by, as uncertain  and questionable, the suggestion
 of a neuralgic character ascribed  to croup and asthma, in cases
 unassociated ivith the tokens or results of inflammation, I would
 speak  here of gastrodynia and gastralgia, (as Barras well styles
 it,) among the well defined  examples of visceral neuralgia.  I
 need not remind you,  that dyspepsia  often exists, and is long
 protracted, without notable proof of inflammatory change or any
 vascular disorder; and it is, perhaps, in such cases especially,
 that the sufferings of the patient are intensely great.   Intolera-
 ble pains are complained of  in  the region  of  the  stomach,
 admitting of little  alleviation by art, perhaps, but disappearing
 suddenly, and recurring at uncertain intervals.  If capable of
 being controlled at all, these affections are more under the influ-
 ence of narcotics than any other  remedies.   Opium will  often
 relieve them; camphor  sometimes—wine,  tobacco, assafoetida,
 and occasionally, I know not how, oxyde of bismuth, and water
 impregnated  with  carbonic  acid  gas.   Prussie acid will, in  a
 eertain proportion of instances, act like a charm; in others, musk
 and the volatile oils, and aromatics.  It  is to be remarked, that
 the anti-phlogistic  regimen, both positive and negative, is en-
 tirely unsuited to these cases, and that  the ordinary measures
 of revulsion fail completely of any good effect.
  Some have considered the intestines also  liable  to neuralgia,
 and colica pictonum has been  selected, by writers of authority,
 as a striking  example.  It is undeniable, that the nervous tissue
 and function of the bowels  are very prominently disturbed in
 this malady; but to constitute a  separate class of diseases, we
 must  lay down specific and definite boundaries, not  to be trans-
 gressed or infringed upon.  It is the characteristic of neuralgia
proper, that the part attacked by it  is not notably  altered  in 
NEURALGIA.
479
appearance or subjected to organic change ;  nay, as I have said,
its functions often go  on, and  are performed unremittingly in
the midst of whatever difficulty and suffering.  Nay, strange as
it may seem, it is nevertheless true, that distant parts are more
likely to have their  functions sympathetically interfered with
and interrupted, than the organ primarily assailed.  In gastral-
gia, the  digestion of food may go on, and the patient be well
and substantially nourished by the aliment taken, even while he
is annoyed by double vision, or  his  mind  startled by the fre-
quent apparition of phantoms; and in nervous  head-ache, the
intellect  is often clear  and active, when the stomach is vehe-
mently nauseated, and the muscular system  thrown, by sympa-
thy, into torturing cramps.  But, in colica  pictonum,  not  only
are the physiological  functions of the intestinal  tube  impaired
or put an end  to, but organic changes of condition  promptly
supervene, which have already been  described in  their proper
place.
   3.  Neuralgia of the genital and urinary apparatus, deserves a
fuller and more extended consideration than  can  be allotted to
it here.   It is not a very frequent  form of disease, yet  you will
occasionally meet with  it, and it implies so much suffering, that
there will be great merit in adapting  to it a  promptly successful
mode of treatment.  It is  chiefly known to practitioners under
the title  of nephritic colic, for which some have recently substi-
tuted the phrase nephralgia.  The latter term would  be more
appropriately reserved to express  that condition forming a very
prominent part of  the history of renal disease in  the calculous
diathesis, in which, whether a renal concretion be formed and
passed, or not, the irritation commencing in the kidney spreads
itself, with intense agony,  to all  the parts  connected with it
functionally and  sympathetically.  True  neuralgia may and
does  exist when there is no  morbid alteration of the urine, nor
any evidence of the presence of renal  concretions; these are the
obvious tokens of nephralgia.   No one can  help  being struck,
however, with the close similarity of the paroxysms,  affording
indeed good ground for the suspicion of renal disease  in every
case of nephritic colic.
  The mode of attack may  vary somewhat in different subjects,
and  in the  same subject at  different times, but is generally 
480
NEURALGIA.
 thus.—The patient feels a deep-seated aching in the back over
 the  kidneys,  dull, heavy and oppressive, sometimes,  but  not
 always increased by pressure.  After the lapse of an uncertain
 period of time, this  connects itself with a pain far within  the
 abdomen, near the ilium and above the  pubes, fixed and intole-
 rably acute, drawing the body down to that side, and rendering
 an erect attitude impossible;  flatulence always or almost always
 attends, whence  the allusion to colic;  it  is, indeed, supposed
 that a portion of the  colon is involved  in the extension of the
 morbid sympathies, which go on  to  include the ureter and the
 bladder, with grievous micturition, and sharp pangs just above
 the symphysis.   The testicle sometimes on both sides, but usu-
 ally on one  only, is extremely painful, and, in a  majority of
 cases, strongly drawn up toward the ring ; and this sympathetic
 affection has  been regarded by some as a diagnostic of this
 special affection.   It is  not  so, however, but  occurs very fre-
 quently during the passage of a renal calculus down the ureter,
 and  I have twiee met with it in enteritis.  It is to be observed,
 that the pain in the testis is by no  means, as some  have stated,
 dependent  upon and produced by its violent retraction;  I  have
 known it intense where there was no perceptible retraction—and,
 indeed, in one case of this sort, saw it so much affected as  to
 remain swollen and  inflamed for some days after the paroxysm
 which disordered it had quite subsided.   No words can convey
 the faintest idea of the intolerable anguish  endured  by  the pa-
 tient under the circumstances  described.   Sydenham, in a para-
 graph containing  the  earliest notice  that  I have read of this
 disease, speaks of the pain as "most atrocious;" and the stoutest
 and firmest men—for as far  as my experience has extended, it
 includes  no  female—give  evidence,  by their  groans or loud
 cries, of the  tortures  they undergo.   The stomach becomes
 irritable, so that nothing  can be retained upon it. and the thirst
 is unremitting and unquenchable.  I  have once or twice seen a
 febrile exacerbation brought  on.   It is worthy of remark, that
 the function  of the  kidneys is so little apt to be disturbed.  I
have  known it continue unimpaired through  the repeated pa-
roxysms of several years; the urine, which was carefully noticed,
exhibiting  in all that time no obvious change either in quantity
or quality. 
NEURALGIA.
481
   Some patients recover  from an  attack of this  sort suddenly
 and completely, and are  never assailed again.  Others remain
 liable to a repetition of such paroxysms, which recur at  uncer-
 tain intervals and under the influence of unknown agencies, for
 nothing can be more obscure than the causative mode of impres-
 sion here.   I have not been able to trace  any source or origin
 for  it in any mode of life or state of constitution.  In one unfor-
 tunate subject, I saw the paroxysm repeated fourteen times in as
 many  successive days;  then an  interval  of forty-eight hours
 passed over,after which there was a fifteenth—since when, though
 often menaced with renewal, he has had no  formed attack. The
 paroxysms vary  in duration, as I have myself witnessed, from
 three to thirteen  hours ; they will average,  I think, about six or
 seven.
   Treatment.  Among the remedies found  most available, if
 used early, is  the  purgative.  Its  active operation is strongly
 revulsive, and will rarely fail  to give  decided relief; but if its
 administration be  delayed even a short time, the stomach will
 become too irritable to bear it, and will soon  refuse  to tolerate
 anything.   We must endeavor to quiet it with opiates, of which
 I  have found the simple  solution  of muriate of morphine  in
 water the best.   The dose prescribed must  be concentrated and
 effective; meanwhile a cathartic enema should be given, and
 the  patient immersed in the warm bath.  If a first  attack, and
 in a robust, athletic subject, the lancet may be freely used, and
 afterwards cups applied to the loins.  Stupes and fomentations
 to the back, the abdomen and the pubes, afford some comfort,
 but  our chief reliance must be placed upon anodynes, taking
 care to keep  the bowels soluble.  The combination of opium
 with calomel may be exhibited in proper doses at due intervals,
 and  the warm bath often resorted to, in which the patient should
 be detained  until completely relaxed.  Among the local applica-
 tions useful  in this especially,  but in all  the other forms  of
 neuralgia, Granville's ammoniated liniment  has received  most
eulogy,  and is well entitled to a trial.   I have seen it frequently
relieve,  but scarcely less often fail.
  In order  to prevent a recurrence of this most  distressing
malady, we must  enquire carefully into  its  probable or possible
causes, and set about to remove them or counteract their effects.
      VOL.  II.—41 
482
NEURALGIA.
It is affirmed to be often associated with dyspepsia, and the doc
trine is plausible enough ; but of the subjects  that  have fallen
under  my care,  only one  is a  dyspeptic.  Two are athletic,
sturdy men,  enjoying excellent  health, in the intervals eating
heartily  and digesting  well.  One is somewhat intemperate.
Two are specially regular, or rather abstemious in their hab-
its.  Three are of highly nervous and excitable temperament;
one  appears  as  remarkably  phlegmatic.   It  is  evident, that
the measures of prevention must differ in these  different con-
ditions.  If, as  is affirmed to be generally the case here—ma-
king closer  the  analogy already  alluded to  which connects
this form of disease with the lithic diathesis—if there be acidity
of stomach, alkaline remedies are required, of which the bi-car-
bonates of potass and soda are the best.   The bowels are almost
always costive and disposed to flatulence, a state which must be
corrected chiefly by proper attention to diet, but purgatives may
become necessary. I have found advantage  in prescribing a com-
bination  similar to the formula so highly eulogized by Dr. Rush,
of aloes, coarse turpentine soap, and opium in small amount, or
some one of the salts of morphine; pills containing these ingre-
dients in well adapted dose,  are to be taken regularly at night,
and occasionally in  the day, when any uneasiness exists in the
parts affected.
  4. Uterine  neuralgia  is the only remaining variety whose
nature is so clear  as to call for a notice from us under this head.
It is usually shown  in connection with the  periodical determina-
tion  to the organ to which the human female is subject, and
described familiarly as dysmenorrhcea, of which it is, doubtless,
one of the most  frequent modes.  I have seen it  occur after
labor, however, both  natural and premature.  One striking in-
stance  of the latter kind, presented  itself to me about  twenty-
four hours after delivery, the patient being  attacked by the most
intense pain in  the uterus, without fever or spasmodic or irregu-
lar contraction, or anything uncommon in the appearance or
amount of the ordinary discharges.  Dr. Prioleau, who saw her
with me, advised large doses of camphor, which, in the course
of a few hours, gave relief,  12 grains being taken every hour or
two for some hours, and followed by no ill consequences.
   The unhappy women who  are the victims of this painful 
NEURALGIA.
483
 malady, declare its  torments  to  be indescribable.   Some suffer
 only while menstruating,  but the majority  complain  a little
 while before and after the  effusion begins and terminates ; and,
 in others, the pelvic region is scarcely ever entirely free from an
 aching or dull sense of uneasiness.  When the menstrual period
 arrives, this  is aggravated into  intense and  acute  pain, seated
 principally in the uterus, but extending around the loins, across
 the  back, down the thighs, and over the whole  genital and uri-
 nary apparatus.   It is a common opinion among these patients,
 that the amount of the discharge is deficient, and they anxiously
 desire that it should be increased and rendered more free.  I
 have seen no satisfactory evidence that it is in quantity below
 the  average.  The attacks are  by no means confined to any
 particular  temperament or class of constitutions ; I  have met
 with it alike in the  sanguine and plethoric, and the anaemic.  In
 some it is combined with that condition of the  organ in which
 a membranous exudation  is  thrown  off; but this  is not very
 general, happening only, I think, in excitable and  full habits,
 when the blood abounds in fibrine, and there is some tendency
 to inflammatory action or true haemorrhage.
   It is usual to declare  that women laboring under  uterine
 neuralgia  are barren, and their infertility is  attributed to this
 morbid condition of the genital system.  The fact is, however,
 not  so.   I know many mothers who suffer dreadfully from this
 form of dysmenorrhoea.  The worst and most obstinate instance
 I have ever had under my notice, is in a lady who has five fine
 children, though herself a wretched invalid, worn out by tortures
 which, for  many years,  have bid defiance  to all the resources of
 art.   I  have been,  indeed, rather inclined to imagine that the
 nervous sensitiveness—morbid at least in amount it  is true—
 which forms  an essential constituent of the disease under dis-
cussion,  excites  the whole generative system, and induces a
 degree of amativeness or even salacity which fits it for concep-
 tion  and re-production.
  Again, the uterus is probably a mere receptacle for the ovum,
and  its condition, unless some mechanical obstacle  be thereby
presented, has little to do with the creative stages of generation,
as we know  that  many women  conceive while  going through
the earlier  processes of change  from  the terrible infliction of 
484
NEURALGIA.
 carcinoma of the womb.   All that can be laid  down positively
 in reference to this matter, is, that barren women are more liable
 to uterine neuralgia than such  as are fruitful; but we know
 nothing of the causes  or of the relations  of these  coincident
 conditions—coincident, but by no  means essentially connected.
 The whole enquiry into  the causation of neuralgia, in any of
 its forms, is as yet absolutely conjectural;  and not one word has
 yet been written by the numerous  authors who have  hitherto
 treated of the subject, calculated to throw a  single ray of light
 upon it.
  I  have  nothing  new  to  offer  concerning the treatment of
 uterine neuralgia.  I have succeeded best by the persevering
 employment of the vol: tinct: of guiac: so highly recommended
 by Dewees as applicable during the intervals.  In the paroxysm
 opium  should  be  freely used; the  best form, perhaps, is  the
 simple solution of some one  of the  salts of morphine—I prefer
 the muriate.  These will occasionally fail, and we  must then
 depend chiefly upon  camphor, which  is to  be administered in
 large doses and in  substance, say from 5 to 10 grains, carefully
 watching its effect upon the nervous system  and the pulse.
 The warm bath generally, from time to  time, and  more fre-
 quently the hip bath, will give  some  relief.  Sinapisms or hot
 mustard poultices, applied over the sacrum and upon the inside
 of the thighs, are good adjuvants.  After the bowels have been
 evacuated,  either under the action of a prompt purgative, or
 of irritating  enemata, these last  may  be  employed to  convey
opium or assafoetida, both of which are occasionally found  ser-
 viceable. 
RHEUMATISM.
485
                      CHAPTER LIII.

                        RHEUMATISM.

   The Motory System, constituting one of our physiological
 divisions, comprises all the organs of locomotion, passive as well
 as active.  The bony skeleton with its joints, ligaments, tendons,
 etc., and the extensive muscular apparatus with its appendages
 of fascia and aponeuroses, are included under this head.  These
 several parts, so various in their composition and structure, and
 exhibiting such diversified modes and forms of vitality, are ne-
 cessarily liable to diseased actions as extensively diversified and
 various.
   Many of the morbid conditions which find their  proper place
 here, especially  among those  located in the osseous structures,
 are  incorporated in your surgical  treatises as being combined
 with external  organic lesions, and demanding the assistance of
 mechanical art.  Others  are  rare, and deserve to be  arranged
 rather with the morbid  curiosities of nature, than  as objects of
 practical attention.
   Others still, and this  class will comprehend the majority of
 the affections of the muscular fibres, the  muscles of voluntary
 motion especially, are merely sympathic for the most part, or
 symptomatic ; never  occurring, or so seldom that the exception
 requires no notice, but in immediate connection with and de-
 pendence upon  certain other  forms of disease seated  in  other
 systems and inseparable either pathologically or therapeutically
 from these, their parental disorders.   Such,  for  instance, are
 tetanus, hydrophobia,  cramps, convulsions  as in epilepsy and
 hysteria, and paralysis, as in chorea Sancti Viti, hemiplegia and
 paraplegia.
   Under the present general head, then, I propose to treat of but
 two  maladies, singularly allied in history, seat, symptoms, and
indeed  in  every thing but cause—Rheumatism and Gout; the
first, one of our most familiar  ailments—the second, thanks  to
the prevailing spirit of reform, becoming more and more unfre-
quent annually,  and perhaps destined, within one or two gene-
      41* 
486
rheumatism.
rations, to be totally extinguished, and regarded by our succes-
sors as matter of history, like  the black death,  the  sweating
sickness and the ancient leprosy.

   Rheumatism.  If frequency of occurrence constitute for any
disease a claim  upon the notice of our profession, the  affection
recognized under this unmeaning, or inappropriate title, may de-
mand special  attention.  It implies, in many instances, very in-
tense degrees  of suffering;  is often productive of extreme incon-
venience to the patient, in addition to the pain and danger it may
occasion; and not very rarely incapacitates him,  while in the
very bloom of youth, or the vigour of manhood, for participation
in  any of the duties, occupations or enjoyments of life.  As
holding  thus a prominent place among the  "medicable ills"
which assail  our species,  it behoves every physician  to ascer-
tain and know, as far as may be, its nature and causes, and the
means of combating its influence with propriety and effect.
   Rheumatism has been, from very early times, divided into the
acute and chronic, or, in phrase  proposed more  recently to be
substituted, the entonic and atonic, to which some pathologists
have suggested the addition of  a third form, intermediate and of
mixed  character, the sub-acute.  These several  modifications
are not always so easily separable from each other as the terms
given above would seem to imply ; the line of distinction is not
drawn  in certain cases without  hesitation and difficulty: yet, in
their extremes, they really present so little in common and differ
so widely, that Cullen, although  he has  complied with custom
in placing them together, has expressed  some uncertainty whe-
ther they ought not to be considered as forming distinct genera,
while others have arranged them as different species of the same
genus.   I confess myself unable  to  resolve the doubts on this
subject, of  which I shall say more in the proper place ;  the dif-
ficulty  is, however, greater in speculation than  in  practice, and
it will be my duty to furnish such rules for your guidance, that
your patients,  at  least in an infinite majority of the cases  that
are hereafter to come under your  care, shall suffer  nothing from
the theoretical uncertainties which hang over the  Pathology of
Rheumatism.
  Various  opinions  are  strenuously maintained as to the exact 
rheumatism.
487
 seat of what is called Rheumatic Inflammation.  It affects the
 joints, whence its names Arthrosia, and Arthritic Fever; some
 assign  it to the fibrous, and  others to  the condensed  cellular
 tissues; some to the lymphatic system.  It also affects the limbs
 between the joints, and  thus gives color to the opinion held by
 Cullen, and after  him, Carmichael Smyth, that it consists in a
 true  inflammation of the muscles;  Hildebrand thought it had
 its seat in the serous membranes.  We know that it  sometimes
 implicates the skin, and occasionally attacks the diaphragm and
 heart.  I am  somewhat  sceptical as to its metastatic  invasion of
 the stomach and intestines, though  it may assail the muscular
 portion of their structure ; and I altogether disbelieve its  intru-
 sion  upon the brain and  other viscera non-muscular.  I have
 already alluded to Hildebrand's views;  his countryman, Richter,
 thought it a sort of universal modification of disease, as I men-
 tioned in treating of dysentery, which he regarded as a rheuma-
 tic affection of the bowels.  Huxham, before  the entire explo-
 sion of the Humoral notions which gave its strange name to the
 disease, wrote of it as a  "sharp serous rheum," which might be
 directed upon, and derange, in its own way, every portion and
 tissue of the body.
   For my own part, I am inclined to hold, with Craigie, that
 the chief, if not the  exclusive, seat  of rheumatism, is the tissue
 which is termed "aponeurotic"—"the aponeurosis, fascia, or ten-
 dinous  expansion, which, invariably connected with  the perios-
 teum or capsular ligaments at the  articular extremities, covers
 or supports each muscle to a  greater or less extent, penetrates
 into the substance of  the muscle and passes at each joint  from
 one part of a limb to the other, and  from the limbs to the trunk,
 forming a covering of the greatest  extent, next to the skin, in
 the human body."
   I cannot doubt the existence of a constitutional condition, a
 state of the general system with which rheumatic inflammation
 is connected, and upon which it is indeed dependent.  But this
 rheumatic diathesis, if this phrase be employed to express such
a condition, is peculiar, specific, absolutely sui generis, and does
not admit of description or definite portraiture.   It is not only
true that particular individuals are especially subject to rheuma-
tism, but this  predisposition, it is well known, may be trans- 
488
rheumatism.
mitted hereditarily, like  all other specialities of the person, the
family,  and  the race.  Beyond this, and the fact that a second
attack supervenes  more readily  upon  any  given individual,
owing not only to the building up of a constitutional  diathesis,
but probably also, in some measure at least, to obscure changes
impressed upon the parts first affected—beyond this, we  know
little of the predisposing causes of rheumatism.   Muscular fa-
tigue is, perhaps, the only one which we can  affirm to be defi-
nitely pointed out, and the malady is hence accounted for in its
aptness to attack the hard-working laborers of the lower classes.
It is also commonly believed, that  a limb  or joint which has
been previously twisted  or dislocated,  or weakened  by a blow
or sprain, is ever after more liable  to be acted on  by the several
circumstances that  tend  to give" rise to rheumatic inflammation.
   The exciting or occasional  causes  are, in general, all such
circumstances as tend to  obstruct or impede the ordinary healthy
transpiration from  the cutaneous  surface.  The application of
cold or of moisture, as in a current of cool air, in coming out of
a warm  room  into a  chilly atmosphere, especially at night, in
getting the feet or body wet, sitting on a damp floor, sleeping in
damp sheets, will  give rise  to it.   Some of its  local develop-
ments are distinctly ascribed to the local application of cold, as
in rheumatism of the  head—cephalalgia rheumatica, seated in
the epicranial aponeurosis,  and in  stiff  neck—torticollis, and in
facial rheumatism, the patient will tell  you  he sat  near  a half
open door or window, and in sciatica or lumbago, he will re-
member sitting on damp  ground, or exposing  the lower part of
the trunk.   Yet this ancient and long received etiology, is now
warmly disputed.  Chomel, an authority always to be respected,
is at the head of those who maintain the innocence  of the appli-
cation of cold to the surface, and finds, as he affirms, upon close
examination, that a very  small proportion of the cases, not more
than two in nine, are properly to  be attributed  to  this source.
And, on  a large  scale, the statistics present a  more  plausible
support to his argument than  you would imagine—that is to
say, without occupying your time by tabular statements, rheu-
matism  is  not  of such  marked comparative frequency in the
exposed professions as you would anticipate—soldiers, for exam-
ple, and sailors; nor  in  the colder  seasons of the year, vernal 
rheumatism.
4S9
 and summer attacks being pretty nearly as  numerous as those
 of winter and autumn; nor  in  the colder climates—nay, you
 will  think it singular, that  rheumatism prevails less in Nova
 Scotia than at the Cape of Good Hope.  Nevertheless, it seems
 to me clear enough, that the popular opinion on  this subject is
 well founded, and we have from Haygarth and Bouillaud, direct
 statistical facts in abundance to sustain it.  In this country, it
 would, indeed, be difficult to subvert or shake it, so universally
 is it received both by the vulgar and by our  profession.  "Rheu-
 matism," says Professor Chapman, "generally proceeds from the
 action of some evident  cause, and is never, like  gout, primarily
 seated in the stomach."  "We apprehend,"—it is Professor Cald-
 well who speaks—"we apprehend the most radical and essentia]
 difference between gout and rheumatism to be, that the former
 always, and the latter  never, originates in the stomach."  But,
 in thus  ascribing the  latter to evident causes, or external as
 contra-distinguished from internal influences, these unshrinking
 sympathists can have had reference to no  other than the agen-
 cies of atmospheric temperature in their several modes of appli-
 cation.
   Acute rheumatism comes  on with  a  sense of stiffness  and
 pain in some one  or more of the joints, or in some  muscular
 part,  attended  early with  a  greater or less  degree of fever,
 whence some insist upon regarding the disease, in this acute or
 entonic form,  pyrectic as it is almost invariably, as arthritic or
 rheumatic fever;  and, indeed, it is not  easy to say, whether the
 constitutional or local affection  ought to  be considered as  pri-
 mary and paramount.
   The local pain is of severe and depressing character; the
 part is red and swollen, and intolerant of  pressure or motion.
 The general disorder keeps pace with the arthrosial inflamma-
 tion ; the pulse is full, hard and frequent; the skin hot, dry and
 harsh; the  tongue whitish  and  furred ; there is thirst, head-
 ache, restlessness.   The pains are almost always exasperated at
 night, when the fever also rises highest;  a certain remission or
 degree of palliation being observable in  both  in  the  morning,
 with some moisture on the skin.  Hall affirms that  the perspi-
ration is of acid quality.
  Rheumatic inflammation is one of those characterised as in- 
490
RHEUMATISM.
 constant, shifting occasionally from one joint to another.  This
 metastasis not very rarely, it is said,  affects  also the  internal
 organs, the heart being most liable to such  invasion.   Some-
 times its outer surface is inflamed, pericarditis occurring—some-
 times  endo-carditis  or inflammation of its inner surface takes
 place.   These unfortunate complications are known  by the  in-
 tense pain which assails the region of the heart, attended often
 by difficulty of breathing  and always by palpitation, intermis-
 sion of pulse, and many  tokens of extreme  general distress;
 the face  and lips being livid, with great prostration of strength.
 Craigie  also  maintains, that the very substance of the organ
 may be thus attacked.
   A peculiarity of this  species of inflammation is, that, what-
 ever may be its intensity or  duration, it never gives rise to sup-
 puration in  any of the  tissues  which  it  affects.   This law is
 announced absolutely, and with no impropriety, the  exceptions
 recorded  being  so few in number  as  by  no means to affect its
correctness.  Among these, it happened to  myself, to  meet with
 two instances in the same patient, the only  fatal case of ordinary
 rheumatic fever that I ever saw.  There was in this individual,
 a youth of about twelve, suppuration of the knee joint, implica-
 ting the bursa of the ligament of the patella, and also  one of the
joints  of the right  index  finger.   Effusion  of the ordinary
 synovial fluid in undue  amount,  is  not uncommon;  when
such swelling occurs, the pain is usually lessened, the  effused
fluid being generally absorbed afterwards.
   The duration  of acute rheumatism varies,  extending  from a
few days to  three or four weeks ; if not  properly managed, it
may run into the ehronic form, or terminate in permanent stiff-
ness, or loss of power and of motion in the part attacked.
   It affects both  sexes apparently alike, and every age.   Heber-
den saw it at four years ; I have seen a  distinct and well marked
case in a boy of three.  As you would suppose, the acute or en-
tonic form is met with most generally in the young and robust;
the infirm and aged being liable to the chronic  variety. No rule
of this sort, however, is exempt from numerous exceptions; the
worst case of chronic rheumatism that ever  I saw, was  in a stout,
hardy individual  in the prime of life ; and 1 have attended many
old subjects of acute febrile rheumatism. 
                        RHEUMATISM.                   491

   Diagnosis.  "Rheumatism,"  says Heberden,  "is  a common
 name for many aches  and pains, which, though owing to very
 different causes, have got no peculiar appellation.  It is besides,
 hard to be distinguished from some which have a certain name
 and class assigned them ; it is thus often doubtful whether the
 pains be gouty or venereal or strumous."  From  all these, you
 will be able, I think, to  separate it by careful inquiry into the
 history of each case.   The  first attacks of gout are  made upon
 the smaller  joints, the great  toe especially;  venereal and stru-
 mous arthritis pronounce themselves by obvious connection with
 other local affections and with defined constitutional  disorder.
   Prognosis.  Acute  rheumatism is rarely fatal, and if treated
 with any reasonable degree of care and prudence, it will very gene-
 rally subside and disappear  without permanent  lesion.  In cer-
 tain hectic  diatheses, the fever connected with it may become
 exquisitely  irritating and exhausting,  as  in a case  already al-
 luded to.  Or the metastases, as they are denominated, to inter-
 nal organs,  so much dreaded,  may supervene and  destroy the
 patient promptly, or by tenacious organic derangement.   I have
 met with an example of each of  these modes  of death  from
 rheumatic affection  of the heart.   In one of them, a  female,
 whom I saw in consultation, the patient  died after suffering for
 a few days the most intolerable anguish.   With  intense pain in
 the cardiac region, there was a quick, abrupt, irregular, intermit-
 ting pulse, the breathing  being oppressed and laborious.   In the
 second, a youth   of fourteen, the external symptoms subsided
 somewhat hastily, leaving behind them an enduring palpitation
 of the  heart with dyspnoea.   The  organ enlarged perceptibly,
 the left ventricle  especially  being hypertrophied ;  he sunk gra-
 dually, dying in   the third year.  No examination of the body
 was permitted in  either case.  Let  me distinctly declare to you
 my belief, however, that  the frequency  of this  connection be-
 tween  ordinary rheumatism and  carditis has been enormously
 exaggerated by certain modern pathologists.  Bouillaud asserts
 that half the attacks of rheumatism are associated with, or pro-
 ductive of pericarditis or endo-carditis.  On the other hand, He-
berden remarks on the rarity  of internal rheumatic affections •
he declares these internal  metastases to  occur very rarely__
"rarissime;" and  Callisen dwells on the pertinacity of the exter- 
492
RHEUMATISM.
nal tendencies of this form  of inflammation.  With these last
authorities I fully agree.   Rheumatism  is, in these regions, one
of our most familiar maladies, and in a practice of a quarter of a
century, I have seen and known but the two cases recited above
of internal rheumatism.   I am not very anxious to explain or
account for the error.   It  is possible that original attacks of the
phlegmasia^ may be incorrectly set down as rheumatic, under a
false theory ; or as it is urged by some writers, the extravagant
use of the lancet, in which Bouillaud and others have indulged,
may produce consequences, thus dwelt on, as parts of the disease
under discussion.
   Treatment.  The  earliest and  most prominent indication in
the treatment  of acute rheumatism, is obviously the reduction of
vascular excitement, morbidly great, both  locally and generally.
Our most ready means of effecting this  is venaesection, which is
almost universally advised and resorted to.   Under all ordinary
circumstances, you will not  hesitate to employ the lancet effi-
ciently ;  taking away, at once, a sufficient  quantity of blood to
make a decided impression upon the pulse  and circulatory sys-
tem universally.   About the inflamed joints too, you will place a
proper number of leeches, or apply the cups  in the neighborhood.
It may be proper to  repeat this sort  of depletion in robust sub-
jects  and highly inflammatory attacks, but there is a point of
time at which you must  begin  to exert a degree of caution in
regard to it;  when the transition occurs into the sub-acute con-
dition, so called, the fever  assuming a character rather irritative
than  merely  symptomatic, and the constitution falls into an ex-
citable condition, readily associated with increasing debility, both
sensorial and  vascular.   The lancet will now become dangerous,
even in the most  skilful  hands, and utterly  destructive when
employed by  the inattentive and  reckless.   For myself, I prefer
to  regard venaesection chiefly as subservient  or preparatory to
the administration  of diaphoretics and  opiates.   These will not
produce their best effects until depletion has been premised, and
the febrile force and  frequency of the pulse have been brought
down.  Beyond this, the lancet is likely to  do mischief.  I have
known chronic rheumatism result directly from this ultra venae-
section ; and I am confident that you will find  practitioners con-
versant with internal or metastatic rheumatism, in an exact ratio 
RHEUMATISM.
493
 with the exclusiveness of their dependence upon "free bleedings."
 Hence the vehement and though indiscriminate, not unfounded,
 invectives against this practice, to  be found in the works of so
 many modern and ancient  writers.   Lieutaud warns us against
 "opening a vein more than three or four times at most, as pro-
 ductive of tedious protraction of the disease."  Heberden doubts
 the benefit of large or repeated bleedings, and tells us that "one
 of the worst  rheumatisms which he remembers, immediately
 succeeded a most profuse and exhausting epistaxis." "Very pro-
 fuse bleedings," says Cullen, "occasion  a slow recovery, and if
 not absolutely effectual, are ready to produce a chronic rheuma-
 tism."   Some modern pathologists  look upon rheumatic irrita-
 tions as neuropathic  rather than properly inflammatory; and no
 one denies the presence of an element of this character, as at least
 modifying the nature of the case, if it be not the most promi-
 nent of its characteristics.  Now, there  is no method  by which
 we can so surely develope or enhance this  nervous element as
 by venaesection; thus increasing the sufferings of the patient,
 impairing his constitution  and  protracting  or  rendering perma-
 nent his  infirmities.  The result of the whole  warmly con-
 ducted dispute  then, concerning the employment of the lancet
 in acute rheumatism is,  that you are to use freely, but  not abuse
 the remedy ;  and that you are to be guided  in its application by
 the received rules that govern the resort to it in other forms of
 disease,  but with something of added caution.
   The next step in our treatment is the exhibition of cathartics.
 Some physicians have not hesitated to denounce  altogether the
 use of purgatives here, as unsuited and  even injurious, by the
 necessity which they occasion  of motion which  is painful to
 the patient, and by the centripetal tendency  which they give to
 the fluids, by their action on the internal surfaces.   On the lat
 ter point, I have already expressed my opinion.  I have seen no
 such ill effect as is here  threatened,  and am not fearful of its
 occurrence.  Experience abundantly proves that their good effect
 as depletory, and perhaps in some measure as revulsive, (for
 even revulsion is not so  unsafe as it has  been pronounced, in  so
 tenacious and violent  an  arthritic affection,)  far more than com-
pensates for the inconvenience to which the patient is put.  Much
has been said  of the preference  due to certain articles of the
      vol. n.—42 
494
RHEUMATISM.
class over others ; and Parr, speaking out the prejudice of many
practitioners, declares pointedly against the neutral salts as
unfit.  In my hands,  they have succeeded well, however, either
alone or combined with rhubarb and some aromatic.
  Diaphoretics, I have already hinted, constitute the chief reme-
dies in rheumatism;  yet they  require  to  be properly chosen,
and carefully adapted to time and circumstances.  Sweating has
been long regarded as the  natural solution of a rheumatic at-
tack, but it is not every cutaneous discharge which is thus criti-
cal  and salutary.  Spontaneous  sweats often  appear,  which do
the patient no good.   These are usually partial, and transient or
intermitting.  We can force such by the heat of the bed clothes,
as is often done domestically, and by hot drinks and  hot appli-
cations to the surface, which the patient submits to the more
readily, as he is usually liable to a recurrence of  occasional
chilliness.   Rutherford asserts,  that under these circumstances
no sweat  flows  from  the pained  part,  which  continues rigid,
harsh and dry.
  Those sweats only are salutary,  which come on gradually
and diffusively, with a diminution of the hardness and constric-
tion of the surface, the pulse becoming fuller, softer,  slower, or
less abrupt and frequent.  We may commence early the diapho-
retic plan of treatment, by  combining our sudorifics with the
cathartics already advised.   Thus, to the common  compound
cathartic powder of jalap with  sulph: potass, we may add the
tart: antimon:, or prescribe a solution of sal epsom in  infus: rad:
senek:  or serp.   When these have acted sufficiently upon the
bowels, the purgative may be left out, and the antimonial will then
deserve our  chief reliance.   It may be given in such dose as the
stomach will tolerate, and either in solid or fluid  form.  James'
powder is much used in England, and as a substitute for it, the
pulv: antimon:  of the shops, here.  Perhaps the common tartar
emetic is more  worthy  of  our  confidence than either.  They
may be given alone, or combined with nit: potass:,  seneka, ser-
pentaria, etc.   Opium, which is one of the best of our sudorifics,
possesses besides, the singular and inestimable advantage of ad-
ministering immediate relief to the intolerable sufferings of the
patient.   It may be added to the antimonials, or conjoined with
ipecac:, as in Dover's powder, a happy formula, which strikingly 
RHEUMATISM.
495
 exemplifies the advantage of a resort to  the combined operation
 of energetic medicaments.  It should be given in as large doses
 as can be borne.  Its inventor, we are told, prescribed not  less
 than thirty to forty grains, repeated every few hours.  We can
 seldom venture beyond fifteen or twenty, twice or thrice in the
 night, when chiefly I exhibit it.   I have long used opium freely,
 and with such benefit and success, that  I will not take up your
 time with the discussion of the speculative objections which some
 theorists still continue to urge against it.  Abundant  authority
 in its favor, can be brought, both from the writers of Europe  and
 our own country.   Of the former, Cazevave,  and of the latter,
 Holmes and Bigelow,  Webb  and Mauran may be specified to
 you.  Some other diaphoretics are  proposed, and may find a
 place in  the  management of protracted  and tenacious cases.
 Camphor is one of these ; it is seldom ordered alone, but usually
 in combination with opium.   So also we  may say of the  spt:
 nit: dulc:, which in full dose, is a good  adjuvant to  our other
 stimulant diaphoretics.   The acet: amnion:,  is also mentioned
 under this head.  Sulphur may often be exhibited with  advan-
 tage, in tenacious rheumatisms of transitive or sub-acute charac-
 ter.  The doses should act in the slightest degree  as laxative,
 not more than once or twice in the twenty-four  hours.  It de-
 termines to the surface, which it keeps moist and warm, and per-
 haps, is of use too, as in  intermittents, by its  tonic and anti-pe-
 riodic properties.
   At this juncture, the einchona has been much used and highly
 eulogized, and in advocacy of its very decided utility  in rheu-
 matism, we have the very respectable names of Morton, Fother-
 gill, Fordyce and Haygarth.   The sulph:  quinine is,  perhaps,
 the best form, and it may be united, pro re nata,  with  eamphor
 or opium, or some of the  salts of morphine, or with serpentaria
 or the carb: ammon.
   Mercurials are employed by many  reputable physicians, both
 in this country and in Europe.  I do  not perceive their adapta-
 tion to the case, and have  never been in the habit  of depending
 upon them.  Hall and Craigie both declare, that they prescribe
frequently and  with great benefit, the combination of calomel
and opium.  I do not doubt  their facts,  but  ascribe the good
done, almost exclusively to the  opium administered.   Guiac  is 
496
RHEUMATISM.
with many, a favorite medicine, in all rheumatisms; it  does not
seem to me suited, at all, to the early stages of entonic or febrile
cases, but will often prove serviceable in the sub-acute or local
affections, such as lumbago, sciatica, or cephalalgia.  The tinc-
ture is to be chosen, and should be given in full dose, from one
drachm to half an ounce, so as, like sulphur, to prove gently ecco-
protic.  Under similar circumstances,  colchicum is alike bene-
ficial, though this remedy seems to have a much  wider extent
of adaptation, and may be used early, and  even in the acute
cases.   It will act as emetic and purgative,  in large  doses, and
I think, somewhat as narcotic also.  Yeratrine is its active prin-
ciple, probably.   The new remedies, aconitine, delphine, etc., are
all employed here, but I have not had any satisfactory  experience
with them.
  Local Treatment of the joint affected.  While thus bestowing
our principal attention upon the general  management of the dis-
ease, we are by no  means to neglect the local remedies adapted
for the relief of the inflammation  seated in the limbs  or other
parts.   Of the application of cold, I have  only to observe, that
however strongly it may seem to be indicated, by the heat, pain
and swelling, and redness, its effect here is equivocal and unsafe.
The patient seems  instinctively indeed, to desire  warmth and
protection, and if there are any metastatic propensities connected
with the nature of  this inflammation,  this is surely the way to
arouse them most promptly.  I cannot, therefore, recommend it
to you, although it is  said to be in  successful  use among the
Russians and  our  own  aborigines,  and  other semi-barbarous
tribes.
  Of topical bloodletting,  I have already spoken ;  if not indis-
pensable, it is almost uniformly palliative.  Leeches or cups may
be used.  Stupes and fomentations, and soft, warm poultices, and    (
local vapor baths, are all  comforting and  soothing; and after
the painful  sensibility of the surface in  the neighborhood is
somewhat reduced by these means, a vesicatory will  be found a
very impressive and beneficial revulsive, which may  be repeated
from time to time,  if circumstances require.  Prof. Mitchell, of
Philadelphia, has discovered  that counter-irritants of this sort,
are frequently  more serviceable when applied to the  spine, than
directly over the part.  He  selects that portion of the column 
RHEUMATISM.
497
 whence issue the nerves that supply the seat of the inflamma-
 tion.  The suggestion is a valuable one, and deserves your at-
 tention.
   Concerning the various internal seats of rheumatism, whether
 originally misplaced or retrocedent and  metastatic,  it is  neces-
 sary to make a few remarks.  A majority of pathologists regard
 the rheumatic affections  of the heart,  the  diaphragm, etc., as
 being truly inflammatory, and, like original phlegmasiae, occupy-
 ing the same localities, demanding the most  prompt  and vehe-
 ment depletion.   Others look upon them as neuralgic, or neuro-
 pathic, or of specific character, and propose corresponding modes
 of treatment.  All agree upon counter-irritants, as being imme-
 diately necessary.  Some administer mercurials freely;  others
 depend upon colchicum;  opium has its advocates,  and I think
 exhibits a preponderance of testimony in its favor; it must be
 given in large dose.  My experience, I have said, is happily very
 limited, as I trust yours may be, in these terrible attacks.  One
 of the patients whom I spoke of formerly, was bled again  and
 again, and otherwise depleted, and  in every way  subjected to
 counter-irritation.  She sunk soon, and  her  sufferings were in-
 describable.   The other took colchicum, guiac and opium,  and
 his chest was blistered for many  months, and afterwards kept
 irritated by tartar emetic, etc. The result, though postponed a long
 while, was unfavorable.  If so unfortunate as to encounter a case
 of rheumatic carditis, phrenitis, diaphragmitis or gastro-enteritis,
 I should be guided by the condition of the patient.   If the pulse
 were full and strong,  I  would bleed him  to  the  relief of the
 symptoms or to syncope.   I would  immerse him in  the  warm
 bath, and relax his skin and general system with  some one of
 the antimonials.   I would  then  endeavor with full doses of
 opium to  procure for him quiet and repose.   If. on the contrary,
 his pulse  were feeble, his  visage livid, and his muscular strength
 sinking, I would exhibit opium largely, with camphor, alcohol,
 and other diffusible stimulants.  In  both cases, I would apply
 mustard, and afterwards epispastics, near the seat of pain.  For
 these, if the case become protracted, I would  substitute issues
 and setons, and prescribe mercurials to an alterative extent, with
iodine, occasionally using colchicum, digitalis,  and opium pro
re  nata, as narcotics, diaphoretics and diuretics.
       42* 
498
CHRONIC RHEUMATISM.
   We go on next to treat of Chronic Rheumatism.  I have
always doubted, whether in their  extreme limits, the several
forms of disease included under the generic title of rheumatism,
have any thing in common; it is certain, nevertheless, that in
their intermediate shades, we find it often difficult to draw such
lines of distinction, as shall  clearly  separate them.  Perhaps, to
follow up a suggestion more than once alluded to,  if we con-
sider the malady as composed  of different elements of which
neuropathy and true inflammation are the chief, at one end of
the scale, the inflammatory,  and at the other, the neuralgic, shall
be found prominent;  yet  the  organic changes of the latter, or
chronic affection, prove that there is, sufficiently energetic in its
mischievous results, a morbid  action in the vessels,  as well as
derangement seated in the nervous filaments  of the tissue as-
sailed.  Cullen gives us a delineation, which he intends both as
descriptive and diagnostic, and I am not  sure that it  would be
easy to offer you a better: "When  the pains are  still ready to
shift their place;  when they are especially severe in the night
time ; when they are attended with  some degree of pyrexia, and
with some  swelling, and  especially with some redness  of the
joints, the disease is to be considered as partaking of the nature
of acute rheumatism.   But when there is no degree  of pyrexia
remaining; when the pained joints are without redness; when
they are cold and stiff;  when they cannot easily be made to
sweat, or when, while a warm sweat is brought out on the rest
of the body, it is cold and clammy on the pained joints; and
when especially the pains are increased by cold, and relieved by
heat applied to  them, the case  is  to be  considered as purely
chronic rheumatism."
  As you would infer from the above paragraph, chronic rheu-
matism is most frequently the  consequence of the acute form
unsuccessfully managed; but it may occur originally.   Its causes
are the same, however, as of the other variety, modified in their
influence, we scarce know how; cold and moisture, especially
when combined, as in damp  beds, wet  clothes,  wet feet, etc.
The predisposition seems to be created by any considerable de-
gree of bodily fatigue, or previous exhaustion and debility.  A
physician of my acquaintance rode many miles to visit a patient.
He arrived late on a warm summer night, and having prescribed, 
chronic rheumatism.
499
 lay down imprudently under an open window and fell asleep.
 After some hours he awoke to find himself altogether incapable
 of motion, and though in the very prime of life, and  enjoying,
 until then, excellent health, remained to the day  of his  death,
 four years after, in a state of  most deplorable helplessness, with-
 out fever or any other token of constitutional disorder.
   It is usual that a limb, or only one joint may be  attacked, or
 a few of the joints at once.  They show, at first,  no change of
 shape or color, but after a while, the muscles which move them
 emaciate and wither away; all the tissues seem to decay, with
 loss of symmetry;  and in the smaller joints and membranes, as
 the fingers and toes, hands and feet, there are irregular enlarge-
 ments, with a white, dull, waxen appearance, very peculiar and
 characteristic.
   Two of the seats of chronic rheumatism have  been thought
 worthy of special name and notice.  Lumbago is  a word which
 you will often meet with in your books, and  hear.   It denotes
 an affection of the dorso-lumbar region, occasioning  great stiff-
 ness, and pain on motion; the body  being  sometimes rig-icily
 upright, sometimes kept in a half bent position.   The muscles
 of the back and loins,  and  perhaps  the spinal  ligaments, are
 here  affected.  Sciatica  or "hip  gout," is a similar affection of
 the hip or gluteal region,  deep seated in  the parts about the
 joint, and often spreading down the thigh, with great lameness.
 At first, there is inflammation only of the aponeurosis  of the
 gluteal muscles and part of the tensor vaginae femoris ; but after-
 wards, it attacks the sciatic  nerve, thus presenting a most an-
 noying complication of neuralgia with rheumatism.   Both lum-
 bago and sciatica are most  frequent in old people,  and are, in a
 majority of instances, of a chronic form; though  I  have seen
 them assume,  as well, the acute and sub acute character.
  Treatment.   Chronic rheumatism not only does not require,
 but will not bear the measures of energetic depletion recited to
 you, as fulfilling the indications presented in  the  acute form of
 the disease.   Yet, I have known bloodletting carried to an enor-
 mous extent;  the physician I spoke  of, was  immediately bled
to the amount of forty ounces, with evident aggravation  of all
the symptoms present.  Generally speaking,  this  obscure and
tenacious affection seems unconnected, if not incompatible with 
500
CHRONIC RHEUMATISM.
 the actively phlogistic diathesis, the sanguineous temperament.
 Even local bleeding by cups and leeches, will fail to do any ser-
 vice, unless in cases which partake more or less of a transitive
 character—an  acute or sub-acute modification.  Perhaps this
 mixed condition is more often met with  in lumbago  than any
 other variety of rheumatic affection, and in the  early stages of
 sciatica.
   There are few maladies on our long and dark catalogue, in
 which the indications are  more obscure, or the practice  more
 empirical or less successful.  Experience  has,  on the whole,
 dictated a preference of medicines and formulae which combine
 the narcotic and diaphoretic and  stimulant  properties ;  and it is
 by a persevering, yet prudent and judicious use of such pre-
 scriptions,  that we are entitled to expect to render most service
 to our patients.   The guiac,  of which the vol:  tinct: is the pre-
 paration generally chosen, has been long,  and I think, not unde-
 servedly celebrated here.   It must be given in as full doses as
 the stomach and bowels  will bear,  without disorder.  From its
 known  influence over arthritis, you will lay special stress upon
 it, whenever you have any reason  to  suspect the presence of
 gouty predispositions.  The  colchicum is  adapted  to a similar
 class of cases, and often exhibits very impressive influences. I
 frequently  combine the two,  adding a proper amount of tinct:
 opii:,  to prevent nausea or  catharsis.   Of colchicum, the books
 record numerous  and greatly exaggerated  eulogies.  Williams
 speaks of it as "a happy desideratum, a mild, yet powerful medi-
cine ; capable of substituting calmness, tranquillity and  balmy
 sleep, in the place  of pain, weariness  and  sleepless  nights; a
 renovation of long lost limbs  and comparatively  robust health,
 in lieu of feebleness and emaciation."
  Prussic acid has been  employed  with advantage  in  chronic
 rheumatism.   Dr. Coates, of the Penns: Hosp:  reports  "two se-
 vere cases,  in which this agent was eminently serviceable, and
 in combination with subsidiary means, effected permanent cures."
  The phytolacca decandra, pokeberry, has been loudly extolled.
 I have seen it a good deal  used in  domestic and hospital prac-
 tice ; but the brandy in which the berries were infused, appeared
 to me the most pleasant and  energetic  portion of the  tincture.
Savin has been a  favorite  remedy of Prof. Chapman.  It seems 
CHRONIC RHEUMATISM.
501
to be best adapted to old cases, and such as would have been
styled by Lieutaud "frigid  rheumatisms."  It must be given in
large dose, from gs. xv to 3i, three or four times a day, and with
some perseverance.   Cubebs  are  also prescribed, and all  the
other varieties of  pepper.  Turpentine and each of the volatile
and essential oils, have had  their advocates.  Cantharides in
tincture, are said to be of obvious advantage, especially if pressed
to the production of some irritation, probably revulsive,  of  the
urinary apparatus.
  Sulphur is, I think, more  uniformly beneficial.  How it acts,
is difficult to say.  Its dose should not be large enough to purge
the patient; and it may be combined  usefully,  with several of
the stimulant diaphoretics,  as camphor, aether,  ammonia and
opium.   Of late,  it has been used externally upon the surface-
as for psora and other cutaneous  affections, in  the mode com-
monly  spoken of as sulphureous fumigation.  Very  little inge-
nuity is requisite for the construction  of an  apparatus for  this
purpose; the principal difficulty to be surmounted,  lies  in  the
absolute necessity, that the sulphurous acid gas generated by the
process of combustion, shall be so closely confined  that none
shall escape to enter the lungs of the patient.  Gales, in Paris,
Del Carro, of Vienna, and a long list of respectable names might
be adduced, in favor of this process.  The effects of this  sul-
phurous vapor bath,  are of a stimulant character, and require,
to develope themselves, not more  than fifteen  minutes to half
an hour.  There is first a stinging or prickling  over the naked
body; the face flushes slightly; the pulse rises  in force and  fre-
quency ; a full, free sweat breaks out, and the patient becomes
somewhat  vertiginous, languid and  exhausted.   In many in-
stances, cures have been effected  by a few repetitions of such
fumigations.  Phosphorus, aether,  and several other  substances,
which yield, on combustion, stimulating gases or airs, have  also
been applied in a similar way. They possess, so far as I know,
no superiority over sulphur, and when thus volatilized, besides
being irrespirable, remain liable to combustion, and are thus highly
dangerous.  In the use of some one of them, a gentleman of  this
city was severely burnt. Warm and  hot baths  have  long been
popular remedies for chronic rheumatism, and the natural have
been preferred to the  artificial always.   Whether  this be owing
to the fact that such  thermal waters,  almost of course, contain 
502
CHRONIC RHEUMATISM.
some peculiar ingredients, or that the heat of the bath  is more
uniformly kept up at a high point, I will not say; nor am I pre-
pared to pronounce decisively  upon  the  popular  opinion, that
springs, like those of the Virginia Valley, in our own country,
impregnated with sulphuretted hydrogen,  are  more beneficial
than the simpler and purer waters, both as baths and as  taken
internally, in abundance.   Even cold bathing,  especially with
sea  water, has  had  its advocates.  I should be  unwilling  to
apply cold to the entire body of most of the subjects of chronic
rheumatism, that have come under my care;  but I have, more
than once, seen decided benefit from the forcible affusion of cold
water upon  the affected part—the spout  bath.  It  will  not be
easy to diagnosticate  the cases to which it is adapted; but I have
known no injury follow its experimental employment.
   The  disturbed and impaired state of the constitution, with
which this most tormenting disease is apt to associate itself, has
led to the persevering use of tonics and alteratives.   Cinchona,
in many of  its forms  of preparation, and in combination with
camphor, ammonia and serpentaria, has been  thought servicea-
ble.   The sulph: quinine  is  the best mode, after all,  of admin-
istering it.  The infus: and  extract of sarsaparilla are largely
employed, but I  have no confidence in  the article.  As com-
bined with  mezereon, guiac:, sassafras, etc.  in the  Lisbon diet
drink, it has obtained an  undeserved reputation  from the un-
doubted good properties of the stimulating diaphoretics with
which it  is associated.
   Arsenic has been thought a serviceable tonic in old cases ; and
in the broken down constitutions of malaria districts, will often
prove itself  a valuable adjustant.  Mercury, the subject of such
warm dispute among writers on rheumatism, has not seemed to
me  well  adapted to  simple, unmixed cases, whether acute or
chronic.  In union with opium, I occasionally prescribe it, when
I suspect  any complication  with derangement of the digestive
system. You will often have reason to doubt whether there may
not be  some constitutional modification  impressed  by previous
venereal contamination of the system.  Here, you may resort  to
the mere: corros: sub:  introduced slowly and by very small doses,
or (which is perhaps  better) to the dent iodide of mercury and
potassium. Iodine indeed, both simply and in several of its com-
binations, has been gradually gaining the  favorable notice of the 
CHRONIC RHEUMATISM.
503
profession.   The formula of which I have spoken, and  the
iodides of iron and of potassium are preferred.  They all seem
to deserve a persevering trial.
  The local applications  for the relief of chronic rheumatismy
are exceedingly numerous and diversified.  On the principle of
counter-irritation, a great  variety of acrids have been suggested,
and there has been  warm contention as to  which among them
deserves most confidence.  Croton oil, mustard, and turpentine ;
tartarized antimony, veratrine, and iodine  in ointment and strong
tincture, have been fully  experimented with.  I prefer the can-
tharides to  them all, and put on repeated  blisters at intervals.
Granville's  ammoniated liniment is sometimes effectual, when
the vesicatory is unsuited.  If the part is much swollen or dis-
torted, firm pressure  with a roller bandage, as tight  as can be
borne, will  be  found useful.   I  have seen good done, in waxen
emaciation  and distortion of the wrist and fingers, by the splint,
carved to fit, and worn along the arm and hand, as  in cases of
paralysis from lead.   Balfour  recommends  percussion over the
painful and withered joints ;  it  may be done in various modes,
the best perhaps being by a hard stuffed  ball, or one of gum
elastic on a handle.
  Strong friction on the part, is a very impressive and beneficial
mode of treatment.  The hand perhaps  is the best instrument;
next, a flesh brush, sufficiently hard.  Its utility may sometimes
be aided by the  interposition of volatile oils and other irritants.
Extraordinary cures of stiff and disabled  limbs and joints, aban-
doned and neglected  by professional  men, are, to  their  great
shame and mortification,  every day made by coarse and ignorant
manipulators, simply by  virtue  of energetic and long continued
rubbing, handling  and shampooing the part.  The case of the
celebrated Chenevix is much in point here.  Having heard of the
cure of a noted  race  horse, crippled by rheumatism, under the
hands of a trainer  who sweated him daily by forcibly exercising
him, the great chemist put himself through a similar process,
with very happy results,  limping his two or three miles out and
back daily, under an immense mass of clothing, and heavy blan-
kets, until his powers of  motion were quite  restored.
  Electricity and galvanism are agents of a nature not to have
been overlooked in the management of such cases as we are now
discussing. 'On a  former occasion, I hinted my belief that there 
504
CHRONIC RHEUMATISM.
 is a marked difference in the modes of therapeutical influence ex-
 erted by these fluids, identical  as they are considered by che-
 mists.   In lumbago and sciatica, I have, if I am not deceived, seen
 most good effect from smart shocks passed from the Leyden jar
 across the loins or through the hip, or sparks drawn  in a stream
 from the parts, the body being saturated with the fluid and insu-
 lated.  In general rheumatic affection of  the smaller joints and
 of the limbs, a preference appears to me, on the other hand, due
 to the employment of the galvanic trough or pile, or  the electro-
 magnetic apparatus, lately invented and easily manageable.
   Applications of this kind, to  be at all hopeful or available, re-
 quire frequent repetition, constant employment and resolute per-
 severance ;  without  which we shall never  indeed relieve  a
 chronic  rheumatism.
   Last,  though, perhaps, not  least on this long list of  remedial
 measures, is acupuncture—the introduction of a needle of steel
 into the parts pained and suffering.   This instrument has long
 been in  use among the Easterns, the nations of India,  the Japan-
 ese and  others, for a very great variety of  diseases. Since Euro-
 pean and American physicians have  become acquainted with it,
 many attempts have been made to ascertain its modus operandi,
 and to define the conditions that  promise  benefit from it.  It is
 generally regarded as acting  by some modification of the elec-
 trical energies ; it is considered as properly adapted only to the
 management of rheumatism and tetanus, and local pains of a neu-
 ralgic or neuropathic character.  I need hardly describe the in-
 strument or its mode or insertion.   It  has  been considered inap-
 propriate to acute and inflammatory attacks. Perhaps, when there
 is much  fever present, the local  pains, in such cases, will not be
 likely to be  relieved; yet in the  locally acute and sub-acute, as
 well as  the  purely chronic, 1 have  seen it  promptly effectual.
 Berlioz of Paris,  remarks that "vague and wandering rheuma-
 tism sometimes  attacks  the respiratory muscles ; the patient is
 obliged to remain  motionless ; deep inspiration is almost impos-
 sible ; acupuncture dissipates at once this distress, and restores
 to the muscles their full liberty of action. In one or two minutes,
 a patient, whose sufferings drew tears from him, exclaims, that
 he is quite cured."
  Mr. Scott,  who introduced the operation from India  into Eng-
land,  was  assailed with  severe  rheumatic pain in  the  loins, 
CHRONIC RHEUMATISM.
505
which for three  days, was so violent as to render respiration al-
most impossible.  No fever or  general  derangement being pre-
sent, acupuncture was  resorted to.  The needle  was passed, by
his friend Mr. Jukes, into the muscle opposite the second lumbar
vertebra.   "As soon as it had penetrated to the depth of an inch,
a sensation arose, apparently from its  point, which Mr. S. des-
cribed as resembling that produced by the  passage of the elec-
trical aura.  Three other  needles were inserted into different
parts of the muscles of the back and  loins, and in the space of
three to five minutes, the pain  subsiding gradually, ceased alto-
gether ; the patient rose, dressed  himself and left the house in
good health."
   I have seen many failures of such experiments, but, have also
witnessed  several  most surprising and  gratifying  instances of
successful acupuncture ;  in one of which the needle permanent-
ly relieved a (quasi) rheumatic pain in the wrist, which had
afflicted and disabled the patient, according to his previous state-
ment, for three years.
   The general management of the Rheumatic is a matter of no
little importance. He must be clothed comfortably, rather warmly
perhaps;  guarded against  all exposure to sudden  atmospheric
changes, and protected from chilly night air,  dews, rain and irre-
gular draughts of air.
   His diet must be nourishing, and if his system fall into an
atonic state, somewhat stimulating also.  He should wear flan-
nel next the skin, and the emaciated limbs and joints should be
enveloped  in folds of soft flannel.  Cold is  always  injurious in
chronic rheumatism.  Let the sufferer,  then, if it  be  in  his
power, seek an equable climate, a genial sky.   Our seasons are
too variable, and subject to vicissitudes too sudden  and violent.
But let him enjoy as much  as  possible the  open air, and  take
every mode of exercise, active and passive, that  it is within his
power to endure.  He must shun despondence, idleness, languor
and inactivity.  With unshaken fortitude and steady resolution,
he must  do and suffer all that has the tendency  to preserve
what may remain of the original vigor and energy of his sys-
tem.  We  can scarcely  hope to inspire with new powers of
motion the joints and muscles of an enfeebled body and a shat-
tered constitution.
      vol. ii.—43 
506
&OUT,
                      CHAPTER LIII.

                            GOUT.

   This disease, denominated by Cullen, Podagra, from its most
 usual location in the foot, and, by Parr  and others, Arthritis, a
 term which implies inflammation of a joint, is among the most
 obscure and  least  understood  of the  infinite number which
 crowd the lists of our  several systems  of nosology.  Every
 point in its character, history, pathology and treatment, has been
 and still continues to be warmly contested, and it  is with much
 difficulty that anything like a clear, connected and consistent
 statement concerning it is to be made out.  I shall not occupy
 your time, nor  fatigue your patience, with  a repetition of the
 several opinions which have been advanced upon  the various
 points in debate, but shall proceed to give you, briefly, the views
 which I myself entertain of the  matter after attentive observa-
 tion of such facts as have come under my own notice, and care-
 ful examination of all the documents upon  the subject within
 my reach.
   Gout deserves to be considered in two separate and distinct
 forms, and in this respect  resembles, and may  be compared to
 scrofula.  Like  scrofula,  it constitutes a peculiar  diathesis or
 morbid state of constitution, a condition of Avhich  the  whole
 frame partakes in every part, and upon which depends the pre-
 disposition to  its  several  developments.  These make up  the
 diseased appearances to which the name of gout is applied, and
by their difference in location, give the various names by which
 the several forms of gout  have  been,  and  are  distinguished.
 Nothing is better ascertained, than that the gouty  diathesis or
predisposition is capable of being transmitted hereditarily.  That
 it is thus transmitted  is matter of common remark, and  in  re-
ference to the usual  source  or origin of  gout, furnishes one of
 the best examples of the fulfilment of the scriptural threat,  "that
 the sins of the fathers shall  be visited upon the children,  even
 to the third and fourth generation."  The peculiarity of morbid
 conformation thus communicated, is often so  full and so  com- 
GOUT.
507
pletely developed in the offspring of a gouty ancestry, that regu-
lar paroxysms have been met with in young  children, who are
entirely exempt as yet from the  influence of any of the circum-
stances to be hereafter enumerated as exciting causes.
   That climate has no little effect in promoting these gouty ten-
dencies, we may fairly infer, I think, from the fact that the dis-
ease is so much more prevalent in Great Britain than elsewhere.
It has been attempted to explain  this circumstance, by a refer-
ence to the habits of full  living, in which the British nation are
known to indulge.  But our countrymen make use of as large a
quantity of food  as they.  The French drink more wine;  and
the Germans and other northern nations of Europe more ardent
spirits ; and yet the  British Islands are pre-eminently noted for
the number of  arthritic as well  as scrofulous cases;  the former
being met  with in the higher ranks of society—from the King
and his prime minister  to the fox-hunting knights of the shire;
and the latter among the lower classes in crowded cities, and in
manufactoring  towns and villages.  Indeed  we shall be led, by
a perusal of the English  writings upon gout, to the belief that
our professional brethren of that country are, in a peculiar de-
gree, martyrs to this painful disorder; as most of them take oc-
casion to acknowledge, in feeling  terms, not only a scientific,
but also a  personal acquaintance with the subject of which they
are treating ; and this renders their opposite and contradictory
testimonies particularly embarrassing to an impartial and unini-
tiated inquirer  after truth.
   Among  the circumstances which tend to originate a predispo-
sition to gout, I must not omit to record, as doubtless the principal,
all such  habits  of full living and indolence as produce a pletho-
ric state  of the  system.   Plethora, the fruitful parent of so many
evils, perhaps the very corner stone of the arthritic diathesis, is a
state or condition of  the vessels with which this  diathesis is very
generally,  if not invariably connected. Indulgence and excess of
all kinds lead to this result, whether in the pleasures of the ta-
ble, in the use of wine, of ardent spirits or malt liquors.
   The exciting Causes of gout are almost infinitely numerous—
the predisposition in arthritic constitutions being often so strong
as to be capable of being developed by the  slightest variation
from the ordinary routine of habits, and  sometimes  developing 
508
GOUT.
itself spontaneously—the actual  disease being, I believe, trans-
missible hereditarily, as  well as the diathesis or  constitutional
tendency.
  Caldwell, in his notes to Cullen's First Lines, declares that he
had seen a regular paroxysm in a boy of six  years old, whose
ancestors  for several generations  had been subject to it.   We
have  mentioned, on  authority equally good, a child not more
than eight months of age  subject  to regular paroxysms.  The
most common of the causes which  bring  on  a fit of the gout
are—intemperance of any kind; debauchery; a full meal of
stimulating food; nay, a single glass  of wine, or the smallest
quantity of any article which disagrees with the stomach, whether
from a dyspeptic or debilitated state of the organ, or from idio-
syncrasy.  It is occasioned likewise by fatigue, by a deprivation
of the usual indulgence in sleep, and very  often by uncommon
degrees of exertion of the intellectual faculties. A strain or twist
of the ankle or any part of the foot, or a blow received upon it,
will sometimes serve to bring on gouty inflammation of the joint
so hurt.   In no  instance is the necessity for a pre-existent dispo-
sition to any particular form of morbid affection  so  evident as
here.  No possible application or combination of exciting causes
can produce a paroxysm of gout, unless the constitution has been
previously prepared  to receive the peculiar morbid impression
through which it is developed.
   History.  I shall follow the division of gout into Entonic
and Atonic ; the first implying a  paroxysm of local inflamma-
tion of the arthritic  character, united  for the most part with a
greater or less degree of fever or vascular excitement: the second
consisting more in general disorder of the system, and  especially
connected with  derangement of  the digestive functions, uncer-
tain in its nature or symptoms, but invariable in its occurrence;
and without fever or obvious inflammation.   Gout is farther di-
vided into Regular and Irregular.   It is regular when we have
an inflammatory affection of some joint  or joints.  When this
inflammatory affection of any part of a limb subsides suddenly,
and the morbid action  appears to be  translated to some of the
internal organs, it  is denominated Retrocedent gout.   Another
form of irregular gout is termed  Misplaced,  when  in a gouty 
GOUT,
509
 constitution such  inflammation attacks the internal organ, with-
 out previous pain or inflamed state of any joint or limb.
   The Pathology of gout is involved in great obscurity, which
 from the functional nature of the disease, seems likely to be per-
 manent.   It has been for hundreds  of years an object of parti-
 cular attention with the profession, whose  reiterated efforts have
 hitherto  failed to  elucidate most of the contested points in its
 history.  In ancient days, the predisposition or diathesis was
 supposed to consist in the presence of a peculiar morbific matter
 in the system, which required to be  eliminated, and which was
 thrown off or attempted to be thrown off by the restorative ener-
 gies of nature, exerted  in the formation of a regular paroxysm.
 Cullen,  who  succeeded  in  driving  this hypothesis of morbid
 matter from the field, has given us a substitute very little better,
 in which the supposed vis medicatrix naturae still holds the place
 of primary influential  agency in the production of the disease.
 For the sake  of illustrating the  observation  made long ago on
 the  absurdity of the common references  to the offices of this
 imagined restorative energy of nature, I will introduce here, in
 his own words, his explanation of the pathology of gout.   "In
 some persons," he  says, "there is a certain vigorous and pletho-
 ric state of the system, which at a certain period of life, is  liable
 to a loss of tone  in the  extremities.  This is in some measure
 communicated to  the whole system, but appears more especially
 in the functions of the  stomach.   When this loss of tone occurs,
 while the energy of the  brain still retains its vigor, the vis me-
 dicatrix naturae is excited to restore the tone of the parts, and ac-
 complishes it by exciting an inflammatory affection  in some parts
 of the extremities.  When this  has subsisted  for  some  days,
 the tone of the extremities and of the whole system is restored,
 and  the patient returns  to his ordinary state of health,"
   I need  not remark here, I am persuaded,  upon the inextricable
 confusion of words and ideas, which runs through  the whole of
 this  unintelligible  paragraph.   The value,  however, of Cullen's
 practical observations, is by no means diminished by the un-
 founded nature of his speculations;  and he has not failed to
 notice, what I  must not  omit to press  upon  your particular atten-
tion, viz:  the special connection which seems to  exist between
      43* 
510
GOUT.
the gouty diathesis, and some derangement of the digestive func-
tions ;  and upon this acknowledged connection, has been based
the doctrine at present prevailing, and warmly advocated in this
country by Professors Chapman and Caldwell, that gout actually
consists in a certain deranged  state  of the alimentary canal.
This they infer from the facts "that the stomach is the internal
part that is most frequently, and often  considerably affected by
the gout;  that the paroxysms of this disease are commonly pre-
ceded by an affection of the stomach;  and that the symptoms
of irregular gout are, for the most part,  affections of  the same
organ."—(Cullen.)  These facts, however,  though impressive
and undoubted, do not by any  means warrant the deduction
thus drawn from them.   Gout, it may be admitted, is connected
in the  majority  of instances, with certain peculiar, and often
permanent forms of digestive disorder or derangement; but it
does not essentially consist in this disorder; they are  rather to
be  viewed, (as in  scrofula,) as coincidental  effects of the same
morbid cause acting upon the constitution generally.   The sud-
denness  of the  onset  of the paroxysm, and its occasionally
equally rapid disappearance or subsidence, seem to me altogether
incompatible with  the opinion of their being dependent on, and
symptomatic of chronic gastric  disorder.  Here we should be
under the necessity of supposing  the effect to be independent of
its assumed cause.   Besides this, nothing is better known than
the existence of gout in men who enjoy otherwise,  the most
perfect health.  This is a circumstance so remarkable, that ar-
thritic patients have been considered objects of envy; and Heber-
den complains, that in his time there seemed to be much more
anxiety prevailing  to obtain an attack of this fashionable disease,
than was shown even by the  sufferers, to get rid  of it.  But
from the universal sympathies of  that all important  organ—the
stomach, we should surely be led to expect,  not only a liability
to pain and swelling of a limb,  but a general languor and de-
bility, both of body and mind;  and such, indeed,  we find to  be
essential consequences of all the known and acknowledged forms
of gastric disorder, whether structural or functional.  From the
absence, then, of these  symptoms in  many cases, we have, I
think, a right to infer  the independence of gout upon  gastric 
GOUT.
511
derangement, although they may be in numerous other instances
coincident, and apparently connected.
   A paroxysm of entonic regular gout, begins most commonly
with a pain and swelling of the first joint of the great toe.  The
skin at the part, is very red, very smooth, and the vessels ap-
pear distended.  There is more or less  fever attendant,  with
general uneasiness, heat, and some  oppression at the stomach.
Both Parr and Good, who were fellow sufferers under this dis-
order, describe the kind of pain as distinct and peculiar.
   With all the intense vascular and nervous excitement in the
part, "it is numbed, heavy, and incapable of action; so  that  if
the pain could be for a moment forgot, the foot would be found
to feel like a paralytic one, and though the muscles which raise
the leg are not affected, they drag it along with much difficulty."
It was owing, I suppose, to this combination of sensations, that
Dr. Oliver, of Bath, was induced to consider  gout as  partaking
of the nature, both of rheumatism and palsy.  The duration  of
the inflammatory action in the part  which it first attacks, varies
from twenty-four hours to three or four days, but before it has
quite ceased, often seems to  be removed to  another toe,  or  to
extend itself to the ankle or knee.   The  first fit  seldom,  how-
ever, lasts more than a week or ten days; the  symptoms then
go off entirely, leaving the patient in excellent health and per-
fect comfort.   They recur again, it may be, not until a year has
elapsed, but afterwards  become more frequent;  until, perhaps,
they are almost permanent, or attended with  no  remission, ex-
cept two or three  of the warmer months, and now  seem to in-
clude under their tyrannical dominion, almost every portion  of
the frame.  I have seen the tip of the nose affected with intense
gouty inflammation, in a subject  of hereditary gout.  The at-
tacks of an old gout are less painful, but of a longer continu-
ance, and attended with a greater and  more lasting weakness.
  Among the worst consequences of the repetition of the arthri-
tic paroxysm, or of the full  and complete development of the
gouty diathesis in the vessels, is the deposition  of earthy con-
cretions in the  joints  of the  toes,  fingers, etc.   These  concre-
tions are called chalk stones, and are said to be composed of the
lithates or urates,  and phosphates of lime, resembling very much 
512
GOUT.
the several  varieties  of urinary  calculi.   Dr.  Wollaston, in a
paper published in the  Phil: Trans: 1797, describes  them as
consisting of the urate of soda.   It is not easy to account for
these extensive depositions in the joints of old martyrs  to gout.
A singular case is given in the books, in which  almost every
part, except the hollow  viscera,  was a mass of chalk;  yet the
urinary organs were not diseased.  The author attempts hence
to disprove the supposed general  connection of gout with  uri-
nary concretion, which has been inferred from the identity of
these masses in composition with those found in gouty joints.
   Atonic gout is described as the result of the arthritic diathesis,
affecting infirm or debilitated constitutions, in which the attack is
not determined to, or fixed in any particular part; no local inflam-
mation is perceptible; but we have general uneasiness, restlessness
and distress, with annoying disorder of the digestive functions, loss
of appetite, nausea, sour eructations, sometimes vomiting, flatu-
lence, constipation, etc.   In the mean while, the true nature of the
case may be shown by the occurrence of slight and  fugitive pains,
in which consists the  "flying gout," of some of  the older writers.
This state of things, if not relieved, may terminate in gradual sub-
sidence—in a regular paroxysm, the arthritic inflammation fix-
ing  itself in some  limb—being determined to some  internal
organ, it may occasion misplaced gout, or may slowly wear out
the powers of the constitution,  producing  general dropsy  and
entire exhaustion of the  patient.   The  retrocedent and mis-
placed forms of irregular gout, have been  incidentally spoken
of,  and indeed, the peculiarities are sufficiently indicated by the
denominations applied.   The former is   preceded by a regular
paroxysmal affection of one or  more of the  joints  ordinarily
attacked, which suddenly subsiding,  the patient is seized with
violent disorder of  some of the  internal viscera—the brain;
stomach, or intestines.  Gout is said to be misplaced, when these
internal disturbances occur in a gouty constitution unpreceded
by any of the  accustomed local inflammations.   It may thus
assail the  brain with vertigo,  apoplexy  and paralysis; or the
bladder, when there is micturition, or painful and  frequent de-
sire to pass water, with or without strangury, and attended by
an acrid discharge of mucus from the urethra.  Directed upon
the lungs, it gives rise to the symptoms of pneumonic inflamma- 
GOUT.
513
 tion, in high intensity, and  sometimes  a  species of dyspnoea,
 with great pain, but apparently unconnected with fever or in-
 flammation.
   The heart also, is  liable to these attacks; being oppressed,
 debilitated, with  intermission of action and  palpitation; some-
 times with intense pain, at others  with  sobbing, gasping,  syn
 cope and instant  death.   But misplaced gout  most frequently
 seizes on the stomach, which organ becomes sensible of the
 severest suffering.  A burning heat, or  a  feeling, at times, of
 great coldness, with weight and oppression, are connected  with
 sudden prostration and sinking of the powers of the patient, con-
 stituting one of the most serious and alarming states of disease
 which we can be called on to remedy.
   The Diagnosis of gout  is perfectly easy, as regards  all other
 diseases, with the exception  of rheumatism, and  even here,  I
 have seldom met with any cases in  which  the distinction was
 difficult.   The peculiar appearance  of the inflamed part, in the
 gouty patient—a singularly smooth  and  tense state of the  skin,
 with a glossy shining glow, and a deep cherry redness; the fact,
 that in the first fit gout almost invariably  attacks the  smaller
 joints, as the toes or fingers, which are seldom or never the ex-
 clusive seats of rheumatism—and  it is  in the first paroxysm
 alone, that we shall ever be likely to confound  gout with rheu-
 matism, as by the repetition of the attacks with their peculiari-
 ties, we become soon aware of the  existence and influence of
 the  arthritic  diathesis; the  suddenness, too, with  which the
 gouty pain and swelling come on and assume an excess of in-
 tensity, rarely reached by rheumatism, in its greatest violence and
 longest duration—these will serve us as distinguishing marks.
   We shall  also be assisted by referring to the difference of the
 causes which produce the  two affections,  and to the almost  con-
 trasted habits of body and  circumstances of constitution, in
 which they are severally most likely to supervene.
   Treatment.  Until  of late  years,  the majority of the  most
 respectable names of our profession were  enlisted among the ad-
 vocates for an inefficient and  temporizing method of managing
 patients affected with gout, which scarcely  merits to  be  spoken
of as medical treatment.   Gout was  regarded, as you have  been
told, by the older writers,  as consisting in the presence of a pe- 
514
GOUT.
culiar morbific matter necessary to be occasionally elimenated,
and thrown off by some outlet.
  Cullen modified this notion  so as to do away with the refer-
ence to the supposed morbific matter in the system, but attribu-
ted the paroxysm in a similar way to the  restorative effects of
the vis medicatrix naturae.   In both systems of pathology, the
occurrence of paroxysms was considered to be  necessary, and
though their repetitions might be regarded as evils, yet they
were  lesser evils than those  they were intended by nature to
remove or to remedy.  No wonder then, that during prevalence
of either of these modes of belief, gout was looked upon, in some
measure, as a sacred malady, and  the poor arthritic, with little
sympathy for his imagined beneficial sufferings, left to the exclu-
sive remedial efficacy of "patience and flannel," the proverbial
applications in podagra.   Clearer views of the nature of disease,
have since  given more  professional courage;  and we are  not
afraid, at the present day, to apply to our treatment of gout the
same  general principles which  govern us in our management of
other affections ;  making due allowance,  as in every case we are
bound to do, for the particular modifications in the nature and
circumstances of the morbid action, which  may be ascertained
by experience and observation.
  The Treatment, is fairly divided into the paroxysmal and the
preventive,  or such as  may be necessary during  the intervals
of the attacks.  On the first accession of the  fit, if the case is
recent, and the patient young and robust,  venaesection should be
promptly  resorted to.  The propriety of this practice has been
much disputed; but I think I am justified in saying, that the
result, of the discussion is  decidedly in favour of the lancet, in
the above circumstances.   Dr. Parr, who seems unwilling, how-
ever,  to countenance it, declares that he knew a judicious prac-
titioner, who, on the first appearance of a paroxsym, was in the
habit of taking a large quantity of blood from the arm; or, if
possible, nearer to the part affected. He was of a strong, robust
constitution, and had followed  this plan for many years, without
inconvenience.   I would by no means, however, expect to derive
advantage from blood letting in the habitual gout of  old arthri-
tics ;  or when the constitution of the patient seemed debilitated,
or impaired. 
GOUT.
51$
    The employment of purgatives has met with nearly as much
  opposition as venaesection;  an opposition founded on the same
  views, of the impropriety of interfering with the supposed salu-
  tary operations of nature, and the danger of substituting worse
  symptoms  than those of the paroxysm.  At the present dayr
  however, there  are few physicians who would hesitate to purge'
  actively and freely; and the practice is  both rational and suc-
  cessful.  We thus remove irritation from the alimentary canal,
  which is almost always  disordered, and reduce the vascular ex-
  citement so commonly, I might say universally, present.  I have
  never seen any  the least  ill effects from this practice; but, on the
  other hand, have  repeatedly witnessed after it an almost imme-
  diate diminution of the  severe pain, a solution of fever, and, in
  some instances, an evident subduction of the paroxysm.  The
  common  cathartic  powder, composed of  a combination of jalap
  with the  sulphate of potash, is  well  suited to  the case.   Some
  practitioners are fond of the mixture of  epsom salt with mag-
  nesia.  To either of these formulae an aromatic  may be added
  with advantage: as the essential oil of mint, or of anniseed.
   Emetics are sometimes prescribed in the gouty paroxysm • and
  may be used without fear, and  with  benefit, whenever a disor-
 dered and irritable stomach, with vomiting of foul porraceous
 matters, call for a cleansing out of this important organ.   I have
 chosen to employ,  in preference, the ipecacuanha.
   The excessive pain uniformly attendant on a fit of the gout,
 early led to the adoption of opiate, or anodyne remedies;  but
 whether from any dread of their consequences, or from experi-
 mental proof of their inapplicability, I cannot say;  they are now,
 however,  rarely used.  We are told of an arthritic,  who kept a
 regular diary for 40 years of the length of his paroxysms,  and
 their intervals ;  he noted  that from the time he  commenced the
 free  use of opium, the former were shorter and milder; the latter
 were more prolonged.   I  do not  consider  opium adapted to re-
 gular entonic gout  in an early attack; it will almost  invariably
 fail to remove, or even lessen  pain  from inflammation, until the
 vascular excitement is reduced.  When  the disease becomes
 fixed, however,  and the  paroxysms have recurred  frequently
with a tenacious  periodicity, the exhibition of opium,  in some of
its forms, is not only free from objection, but proves our best 
516
GOUT.
and most efficient palliative, if indeed it does not absolutely sub.
due the vehement pain of the attack.
  1 scarcely know whether to arrange under the head of narco-
tics, or purgatives, or emetics, the celebrated specifics whose em-
ployment is even now so fashionable :  I allude to the eau medi-
cinale d'Husson, and the tincture of colchicum.   These are dis-
tinctly asserted, by the writers who have treated of the matter,
to be identically the same ; although the composition of the for-
mer has been most studiously kept a profound secret.  The ef-
fects of the two are  so precisely similar,  as to give  sufficient
countenance to  the notion of  their identity.   The former  was
long since  invented by a French officer ; the latter was brought
into notice principally  by Sir Everard  Home, whose papers you
will find in the Philosophical Transactions.  They both produce
vomiting and  purging, with depression  of the pulse, and great
languor ; which symptoms are attended  with rapid  diminution
of the local suffering.   It is  asserted, however, by the advocates
for their specific or antidotal efficacy, that the  arthritic pain and
inflammation are often entirely subdued, without any evacuations
of any kind being produced  by the proper dose of the medicines;
this is  affirmed  particularly of the French  preparation.  The
dose of each is about 60 drops to zi; the  tinctura colchici being,
perhaps, the least energetic of the two.  A more recent specific,
known from  the name of its discoverer as  " Wilson's Tincture,"
has seemed to me still more  effectual than either of the above.
It appears to resemble them closely in its  modus operandi, and
has very seldom failed in the numerous experiments I have seen
made with it.   Veratrine is suggested as probably the chief in-
gredient in this  nostrum ; a conjecture which has derived sup-
port from some attempts to imitate its effect with the tinct: veratr.
  The local management of the inflamed limb, or joint, next de-
mands our attention; and on  entering on this subject, we are
obliged to tread upon the unextinguished cinders of angry de-
bate.  Shall we apply to the pained and swollen part the  usual
local remedies for inflammation, or is this resort forbidden by
any peculiarity inherent in the nature of the  case before us?
Arthritic  inflammation differs  specially  from all others; it does
not terminate in any species of effusion,  or in suppuration, or in
 gangrene.  There is not on record, so far as I am aware, a sin- 
GOUT.
517
 gle  instance,  in  which  any of these  consequences followed a
 gouty inflammation, however intense, or long  continued.  The
 vessels which have been subjected frequently  to this species of
 morbid action, show its eccentric and characteristic tendency by
 their aptitude to deposit the chalky  concretions formerly  de-
 scribed, which clog the joints, prevent their motion, and finally
 occasion obstinate and troublesome ulcers.   Now it is rational to
 suppose, that a form of inflammation so peculiar and distinct, as
 the  arthritic thus shows itself to be, should demand certain  pe-
 culiarities of management; we do not treat pustular inflamma-
 tion with poultices, nor anthrax  with lead water.  It is agreed
 on all hands, I believe, that leeches are a safe and proper applica-
 tion to the gouty joint.   Large numbers should be put on to  oc-
 casion any  prompt effect.  Blistering has its  advocates:  yet I
 must say, that I have not seen it exert much immediate influ-
 ence upon the case.   In a patient, in whom the arthritic inflam-
 mation affected the ankle and knee, as well as the foot, I have
 known blisters prove evidently serviceable  when applied to the
 knee; they only added to the irritation  when  put on the lower
 seats of the attacks.
   We now reach debateable ground, and enter upon the conside-
 ration of a measure forcible and  impressive, calculated in the
 utmost degree to shock the prejudices of the advocates  for the
 ancient and  established  expectant  practice, of  "patience and
 flannel."  Dr. Kinglake,  confident  in the belief that  gout  is
 principally, and in its own nature, a  local affection, thought it
 but fair and proper to assail it with all such local means  as were
 adapted to  reduce the inflammation,  which was its principal
 symptom, and ventured boldly to plunge the limb into cold water.
   The doctrine upon which he proceeded, is undoubtedly erro-
 neous, whatever may be thought of the practice which he de-
 duced  from it.  It is  certain that the  relief from pain and in-
 flammation which follows the cold bath is  prompt and obvious.
 The  remedy, therefore, attracted as it  deserved, much attention,
 and public opinion concerning it has been, since its introduction,
 in a fluctuating state.  It was not a difficult matter to prove the
incorrectness  of Dr. Kinglake's  pathology  of gout, and the im-
propriety of a practice built upon false  principles was readily
inferred.  The numerous facts however, which were brought for-
      vol. ii.—44 
518
GOUT,
ward in  favor  of the  plan, both by patients and  physicians, it
was impossible to overlook or gainsay.
  As a further confirmation of the truth of the  declaration of
the wise man, "that there is  nothing  new under  the sun," the
use of cold  water in gout was traced  back to Vander Heyden
and Camerarius, who flourished a century before, and Dr. King-
lake was thus deprived of all claims to originality.  Next we have
the affirmation of several respectable authorities, that the use of
the bath, although it did not fail  to effect the removal of the
local sufferings, yet was  followed by the terrible consequence of
metastatic affections of more important parts—the patients dying
of retrocedent or  misplaced gout.   It was  observed too, that
many gouty persons,  while in the  habit of using  the cold bath
with apparently complete success, died of apoplexy, palsy, etc.,
as was declared by Cullen to be the fact with those who resorted
to the  use of the  Portland  powder, to  be hereafter  mentioned.
Nay, Dr. Parry, whose name stands high among the first patho-
logists of his day, declares positively, when treating of metasta-
ses  of disease, that in two cases he knew "immersion of a gouty
foot in cold  water, which  produced instant  relief of the pain,
and a  proportional abatement of the  inflammation, to be in a
few hours followed  by hemiplegia."   On the other hand, testi-
mony of equal weight and point is  by  no means wanting,  to es-
tablish the safety  as well as the efficacy of the refrigerating plan.
It is not  necessary to  adduce any other than that of Good and
of Harvey.   Dr.  Heberden  tells us that Harvey, "upon the first
appearance of gouty pains in his foot, would instantly put them
off  by plunging his leg into a pail of cold water."   Good,  being
attacked with gout for the  first time,  in  his forty-seventh year,
"bore with patience and submission under the ordinary manage-
ment, the pain  and inflammation,  which  continued to increase
for three days ; he then unrolled the flannel in which the limb
was wrapped, and immersed  it in cold water four or five times
in succession."  The application, he says, was peculiarly refresh-
ing ;  the fiery heat and pain, and  all the inflammatory symp-
toms instantly diminishing.  He continued the same practice for
five or six years  afterwards, with the same benefit, and without
experiencing from it the least inconvenience or injury.  I shall
be  glad to see the safety of this plan established; but I confess 
GOUT.
519
that I have not ventured to resort to it in any case, being deter-
red by the dread of the evil  effects  recorded  by Dr. Parry, in
whom I have always placed much confidence.   I must therefore
leave you to determine for yourselves ; having  laid before you,
as fairly as I was able, the present state of the controvesy upon
this matter.
   A  number of other local applications, supposed to be less equi-
vocal in their ultimate effects, have been proposed, as cloths dip-
ped in tepid water, light poultices, oily and opiate frictions, most
or all of which I have seen tried without any effect; nor should
I omit to mention here the singular, and as it has been punning-
ly called, "striking mode" of treatment proposed by Dr.  Balfour.
I allude to the gentle percussion and compression of the inflamed
part.   I have  never seen a  patient  who  was willing to let me
touch his gouty joints, except in the most cautious and tender
manner, and have therefore been unable to experiment with this
method.
   The intervals between the paroxysms of gout are at first long
and afford us much opportunity of doing  service to the patient.
The Prophylactic treatment, properly so called,  will come under
our consideration  by  and bye; at  present we go  on to speak
of the particular remedies which have been found to promote
the immediate object in view, viz: the  prevention of the recur-
rence of these fits, or if we cannot  effect  thus much, the post-
ponement of their access, and the consequent diminution both of
their frequency and intensity.  For  it is  well  ascertained, that
each gouty paroxysm tends strongly  to increase the force of  the
diathesis, and to lay a foundation for a quicker repetition, and an
augmented severity of the attacks.  And this consideration alone
should make both  the patient and his  physician willing to risk
something,  in order to remove or put a stop to a forming parox-
ysm—an intention altogether incompatible with the ancient  no-
tions on the subject, but consonant both to reason and sound pa-
thology.  It may be perhaps considered somewhat singular, that
the remedies which have been recommended as possessing effica-
cy in  putting an end  to the paroxysm or  allaying its severity,
have no influence whatever as preventive of its access ; thus  the
tincture of colchicum and l'eau  medicinale, so celebrated  for
their  anti-arthritic virtues, are of no use here.  The general con- 
520
GOUT.
nection of gout with  gastric disorder, has led to the adoption
of several modes of treatment directed  towards  the stomach;
and the correctness of the expectation is clear and obvious. The
alkaline salts have been much employed to neutralize the pre-
vailing acidity, and of these magnesia deserves the preference
from  its superior laxative  powers;  much advantage being de-
rived from an occasional cathartic operation on the bowels. The
various tonics have  been  tried  in  succession;  but very little
stress is laid upon any except the class of bitters.
  A compound of several of these, entitled "the Portland pow-
der," from the secret recipe for making it being  bought  by one
of the  dukes of Portland,  rose into very high  estimation at one
time  in England.  Cullen,  however, who had  some peculiar
notions concerning the effects of the bitters, set himself  against
it, and contributed much to the  downfall of  its  reputation by
declaring that "many persons who had been relieved by it from
the ordinary symptoms of gout, had been attacked with apoplex-
ies, asthmas,  and dropsies,  which proved fatal."   I cannot help
agreeing here with Heberden, who  affirms that the Portland
powder lost its reputation  partly by  having all  the natural ill
effects of the  gout attributed  to  it, among which he specifies
apoplexy and  palsy.   And  I am unable to trace  the connection
between the cause and effect suggested by Cullen.  The  loss of
the tone of the stomach, which is occasioned  by persisting too
long in the use of bitters or raking too large doses of them, has
been spoken of, but I do not believe them to be possessed of the
malignant properties insinuated here.
  It seems to have been generally allowed, that this compound
of bitters did actually exhibit not a little anti-arthritic influence.
Heberden declares, further, that  its  disgrace was not owing to
its  doing too little, but to its doing too much ;  as the dread of
being cured of the gout was, at that time, much greater than the
dread of having it.   I consider it, hence, as not unlikely, that in
the rotations of medical opinion, this medicine  may again rise
into notice, and perhaps deservedly.   The best of all the formu-
lae, however, with which I have any experience as being useful
in  subduing or  controlling the gouty diathesis, is  the guiac.
The vol: tinct: is preferable; the addition of the ammonia seems
to  promote its  efficacy.   Its good  effects are in great measure 
GOUT.
521
 attributable, no doubt, to its powerful stimulant and diaphoretic
 operation ;  but, besides this, it seems to  me to possess a specific
 and peculiar action.
   Having thus gone  through, in some detail, the  management
 of regular entonic gout, it comes next in order to speak  of the
 atonic form of the disease.   I confess I am unable  to point out.
 with certainty, any means of distinguishing  clearly  when the
 general sufferings formerly  enumerated as being present in at-
 tacks of this sort are really attributable to gout.   We must be
 guided by our knowledge of the patient's constitution, his habits
 and the answer to  the question whether or  not he  has  previ-
 ously suffered  by a definite attack of gout.   We have always
 here a low, depressed state of the  system,  and  the resort to
 stimulants of  the most active and energetic  character  is abso-
 lutely indispensable.    Of  these,  the camphorated julap, with
 ammonia, aether, brandy warm or made more stimulating with
 spices, are among the best means of supporting the system, while
 we proceed, without delay, to procure a free  evacuation of the
 bowels.  Rhubarb,  with ginger, capsicum, mint,  or some other
 aromatic, is  perhaps to be preferred, and should be assisted by
 the  prompt  and stimulating  enemata, such as the  turpentine
 emulsion.   In the meantime, the extremities  should  be bathed
 in warm  water, and  if any of the limbs  or  joints  should be
 visited by slight or flying  gouty affections, the  morbid action
 should be invited to fix itself there by the application of a sinap-
 ism, of a  blister, or of the  actual cautery, as by moxibustion.
   Irregular gout, in both its forms, retrocedent and misplaced, may
 assume either  the entonic  or atonic  character.   If the entonic
 gouty affection fix itself upon any internal organ, the brain, the
 lungs, the stomach,  I am totally at a loss to see why we should
 not treat the case precisely as we should a similar inflammatory
 or congestive affection of the same parts from other causes;  and,
 indeed, I find this opinion announced by the accurate  and  judi-
 cious Heberden,  although somewhat cautiously.—"Wherever
 there is a doubt," he says, "whether the attack  be gouty, or what
 is called inflammatory, then blisters, and other remedies suitable
 to both these cases, should be used till the doubt can be  cleared
up by a little  delay ;  but if  the danger be too urgent to admit
of this, it will  be far  more hazardous to neglect bleeding in an
      44* 
522
GOUT.
inflammatory distemper, than to take away blood in the gout."
And, again—"If the lungs be  strongly affected, bleeding will
often be unavoidable and necessary, although we be sure that it
is  a gouty affection."   The same observations will  apply  at
least with equal force to the  brain and the stomach, organs of
equal delicacy and importance.
  On the other hand, if the attack  should assume the atonic
form, as  it most usually does,  especially when  the stomach  is
affected, we are called upon for the most  instant and  unremit-
ting use of the local, and diffusible stimuli.   The  pain and
oppression under which the patient labors  are severe and alarm-
ing in the highest  degree, and require for  their relief unshrink-
ing boldness  and  steady assiduity in the exhibition of all the
means within  our reach.   Laudanum must be given with aether
and the vol: alkali;  camphor and the musk julap are highly
extolled.  Hot brandy must be drunk internally, and applied
externally to the pit of the stomach and  abdomen.  The skin
must be  stimulated by embrocations with  hot  spirits, cayenne
pepper and turpentine, and  the misplaced  or retrocedent  gout
invited to the extremities, its ancient and  proper domain, by the
application of mustard, vesicatories, or, if time and circumstan-
ces urge, the actual cautery by moxa, cones of carded cotton, or
by the heated iron.  In short, nothing must  be omitted, whether
of internal or  external administration, which may tend  to arouse
the prostrate energies of the  system and excite  the torpid sensi-
bilities of our patients.   The blow struck is indeed violent, but
the influence and agency of the morbid cause are often transient,
and if successfully opposed for a short time,  will  cease to oppress
the vital powers.  A corresponding decision and readiness are
demanded on our parts, without  which  nothing can  be done,
and nothing  effectual will probably be even attempted.
   The Prophylactic management of gouty patients is the more
 hopefully instituted, and the more successfully carried out, in
 proportion to the clear and definite knowledge which we possess
 of the causes that  tend to  produce the disease.  These causes
 have been already enumerated ; among them are full living,
 intemperance in eating and drinking, indolence,  habits of unduly
 protracted study  or inordinate intellectual exertion,  excess in
 the indulgence of the passions.   With the  bane thus set plainly 
GOUT.
523
before us, we can be at no loss to discover the effectual antidote;
the true difficulty lies, unfortunately, in its application.
  Temperance—moral, mental, and physical;  a plain and regu-
lated diet, and vigorous exercise, or, I should rather say, labor—
hard labor in the open air:  these  few injunctions  comprehend
all that it  is necessary for the arthritic to submit to.
  Milk has been preferred by many practitioners as an exclusive
diet; but  it disagrees with  some, and is disgusting to  others.
Indeed, it  has always appeared to me unreasonable to fix, in this
way, upon any individual article, when we can obtain our object
as well by allowing, within a certain range, that variety without
which appetite palls, and digestion, which in the order of nature
"waits on appetite," is of course impaired, or  at  least goes on
languidly.  It is  by no means desirable, that  the system of the
patient should be  reduced in  tone, or  brought down  below a
normal  point.
  The Plethora forming so  considerable a part of the  predispo-
sition to arthritis, as of so many other  diseases, does not consist
in the actual amount or quantity of fluids within the vessels,
but in the disproportion between their fulness  or state of disten-
tion, and their tenacity, vital elasticity, and capacity of re-action
upon their contents.   Repeated bleedings, we  know, reduce the
latter as rapidly and more permanently than they diminish the
mass of fluids and the force of their circulation ;  and  the  same
I think is true also of diet reduced below the proper  standard,
as when  made exclusively vegetable,  or perhaps in  any way
exclusive.
   To prove the wisdom of the Scotch physician's advice to a
gouty patient, rich, luxurious and indolent, "to live on sixpence
a day, and work for it!" we have on record numerous instances
in which  such persons  who had  formerly lived high, being
reduced to want by adverse fortune, "have exchanged/' in the
quaint phrase of Lieutaud,  "their gout for poverty."   This au-
thor tells us of "a certain nobleman,  who  being about sixty
years of age, given up  to every kind of debauchery,  and now
tormented with gout, so that he could, neither stand on his feet,
nor take hold of any  thing with his hands, resolved to abandon
his depraved  manner of life.  Discarding,  therefore,  his  plea-
sures and desires, he allowed  himself nothing but  pheasants 
524
GOUT,
boiled, with no condiment, bread and water, as his only aliment.
While thus endeavoring to follow a  life of virtue, and make
amends for his  wickedness by even  a late repentance, he not
only received," says Lieutaud,  "a foretaste of eternal  salvation,
but gradually repelled his now inveterate and knotty gout, and,
without thinking, entirely eradicated it."  This is only one out
of a thousand similar authentic histories that might  be recited
to you from our  older books, to precisely the same purport.
  I cannot but  reflect with astonishment upon  the negligent
manner in  which the physical education of the children of gouty
families is conducted.  Although the  force, the certainty, and
the tenacity  of the arthritic predisposition is familiarly ktiown
to all concerned, by the experience of several successive genera-
tions  of afflicted descendants  from a luxurious ancestry; and
although the influence of the  ordinary habits and mode of life
in developing the disease is matter of every day remark, yet
race after  race tread wilfully  or  blindly  the same downward
path, and are  content to transmit, with added foulness, the con-
taminated stream,  to their children and to their children's chil-
dren.   While we wonder at and  pity this infatuation, let us en-
deavor to  remove  it.   Let us open the eyes of fond parents to
the evils which they are thus entailing  upon their offspring ; let
us  do all  in our  power to check the  spreading degeneracy.
The physical, as  well  as the   intellectual  condition  of man, is
fully deserving our best care ;  and indeed, any exclusive efforts
directed for the improvement of either separately, must necessa-
rily be attended with very partial success.
  The present state of society  in our own beloved country, is
well adapted to promote our laudable exertions.  We possess, in
sufficient abundance,  all the elements of civilization and refine-
ment ;  while our population is not yet dense enough,  and our
wealth is too equally diffused, to allow of the introduction of the
extremes of luxury and effeminacy.
  Our sons should be  universally trained  to temperance and to
labour.  Their frames thus hardened  by honorable  toil—their
muscles  strung  by exercise—and  their  intellectual  powers
strengthened by the spirit  of freedom and ambition,  they will
render perpetual the existence of a nation uniting  the wisdom and
vigour of manhood, with the buoyancy and freshness of youth. 
CUTANEOUS DISEASES.                525
                     CHAPTER  LV.
                            4
          DISEASES OF THE EXCERNENT SYSTEM.

  The  Diseases of the Excernent  System will be readily in-
ferred, from a moment's reflection upon the importance of the
functions with which  they interfere, to  be  highly interesting.
The office of excretion scarcely seems to be the exclusive busi-
ness of any other organ than the  kidneys.   The lungs and the
skin are thus occupied constantly, it is true, but both of  them
are engaged, too, in effecting other purposes than the mere depu-
ration of the  blood.  As  this  is, however, the chief function of
the skin, I arrange here the maladies that have their seat in the
cutaneous integument.  The  lungs and  their ailments  have
already  received a fair  share of our notice.  Respiration is  by
no means proved to be a simple separation of effete matter, but
implies re-composition  as well as decomposition—admission of
oxygen  as well as elimination of carbon—a  mingling of more
with less highly vitalized  fluids, and an  ultimate assimilation
and animalization  of the chylous products of  digestion.  The
liver and large intestines have, with more reason, been arranged
under our present head, but we must not assume that we yet
know all that is to be known of the  uses of the bile, or that it is
proved to consist altogether of effete materials.   As to the lower
intestines, they are, doubtless, principally receptacles for the un-
assimilable portions of the   ingesta, and  hardly deserve  to be
regarded in  any other light.  It  is  not  easy to set apart any
maladies to which  they are exclusively subject; continuous as
they are in structure, and in functional action separated only by
an  undefined line, they partake of  the disorders  of the upper
portions of the tube.   Of the affections of the  kidney and  the
morbid  conditions of the urine, and of the  bladder and  tubes
which retain and convey that fluid,  I am hereafter to speak; at
present,  we shall  proceed to consider the more  frequent and
familiar  diseases of the Cutaneous integument—a long and va-
ried list, the classification, arrangement and description of which,
have given very great trouble to the nice  pathologist.   Indeed, 
526
CUTANEOUS DISEASES.
so numerous and diversified and complicated  are  they, that a
very large proportion oi' them can hardly be recognized or pour-
trayed without the aid of the engraver and the colorist.
  The Skin is liable, of course, to inflammation from an infinite
number of causes, each of which exerts a controlling  or  modi-
fying power, and determines the  nature and appearance of the
resulting  changes.   Thus,  heat  and cold,  and  irritants of all
imaginable variety, animal,  vegetable and chemical, give rise to
definite effects.   We attribute certain others to the peculiarities
of the structure assailed, and others still, to  the specific  nature
of the constitutional disturbances with  which they are associa-
ted.  Some cutaneous inflammations are merely local—some are
essentially pyrectic, involving the whole system  at once—some
that are non-febrile, spread slowly their influence throughout
the organism—some are acute, others chronic—some are diffuse,
others circumscribed—some are irregular in  aspect, others very
distinctly figured, nay, even symmetrically uniform.
  You  are familiar with many of the  terms in  use to  denote
these diverse appearances—squamous, vesicular, papular, pustu-
lar, phlegmonous,  erythematous,  punctuate, etc.,  in which  the
learning of the several writers on  these topics has delighted to
display itself by the coinage of  significant words  chiefly from
Greek and Latin sources.   I shall not go over  any enumeration
of them at present, but reminding you of the paramount object,
which I have ever kept in view,  of practical usefulness, I pro-
pose to discuss briefly a few  of this  large class of maladies;
such as being most common in the region of country in which
we live, will be most often met with in your future professional
practice.
  Of these, the most important  are the Eruptive  Fevers—the
Exanthemata  proper.  Their general history  presents striking
characteristics, which  distinguish them from  all the ordinary
diseases of the skin.   1. They are  essentially-pyrectic—that is,
the whole system participates in the morbid condition affecting
the cutaneous surface,  and fever attends, with  marked determi-
nations both to the mucous membranes and to  the nervous
centres, the disorders of which, are  incorrectly, I think, regarded
by most pathologists  as  sympathetic ;  they seem to me to be
uniform and essential  portions of the history of exanthematous 
CUTANEOUS DISEASES.
527
disease.   2. With the exception of erysipelas, which, it is gene-
rally agreed, should nevertheless be  placed among  them, they
are  self-limiting, a phrase which  I  have already carefully de-
fined.  They come to an end, subside and disappear, at a given
period.  3. They are contagious—perhaps with the same excep-
tion noted above, though that, as  I  shall show by and  bye, is
somewhat doubtful.  Each case becomes a generating  centre,
and, under favoring circumstances, a cause of successive attacks
in those exposed to the presence and action of the contagion
generated.  4. They leave the system, in greater or less degree,
indisposed to, or insusceptible, of a second invasion of the same
nature.  In some, the protection thus given, seems  perfect and
complete; in  others, the immunity is far  less absolute.  Here,
again, we must again  except erysipelas, which  rather tends to
increase, by once affecting  the  subject, his liability  to be again
attacked;  urticaria also,  and perhaps some of the  varicelloid
affections,  seem to be capable of repeated intrusions.
  Another interesting class of cutaneous inflammations is com-
posed of those which  are connected specifically  with   certain
inquinations of the  humors, and obvious  deteriorations of the
constitution.   Such are the scrofulous, the gouty, the venereal,
all of which  require,  of course, to be  treated of under those
heads.   I am not sure whether  the herpetic should  be  classed
among them,  but I  am persuaded that it may very properly be
made the title or designation of  an extensive series of affections.
At times, indeed, the whole system seems to be  brought under
its influence.   It is one of the few eruptive disorders that as-
sume both the diffuse and figured  forms.   The first is common
and very troublesome, constituting the most annoying variety of
pruritus, both of the vagina  and  the anus, spreading over the
lips and the eyelids, and dipping into the roots of the hair and
beard,  where  it fixes  itself most  tenaciously.   In  ring-worm,
arfd in shingles, it takes on a circumscribed character and re-
tains a defined figure,  and, in the latter case, is always, as far as
I have seen, pyrectic.
  Some of the worst varieties of this class, are  to us mere pa-
thological curiosities, as being met with only within particular
geographical  limits remote from us;  such are yaws, sivvens,
pellagra.  Yaws are confined, as far as is clearly known, to the 
528                CUTANEOUS DISEASES.
West Indies, and to the black race ;  si wens does not  make its
appearance except in Scotland ;  and pellagra is found no where
but in Lombardy.   There are many analogous affections which
prevail particularly in one locality rather than in others, but are
not so exclusive as  those just named—for example, the swelled
leg of Barbadoes, bucnemia, which derives its  appellation from
its  more frequent  occurrence in one of the Caribbean islands
than elsewhere, yet  may be  met with in any country.  I have
seen a few cases here, two of them in one family.       »
  The skin is not always  inflamed  in the same portion of its
tissue or structure.   When external and entirely superficial, the
inflammation  is called erythema; it may affect the inner or
lower surface when it constitutes—in  the language of some
pathologists, phlegmon.   The results of all these modes will of
course vary.   Some merely separate the cuticle which flakes off;
this happens in measles and scarlatina, and is called desquama-
tion. Small  red points  form as in nettle rash, it is not well
understood how.   Pimples are elevated as in acne; these may
contain  a minute quantity of serum, which readily  dries  and
rubs away—or may elevate the cuticle with a vesicle containing
what is very commonly called "lymph."  You  must  not be
misled  by the improper use of the word here.  The effusion
from a blister—that which forms in a burnt or scalded or fretted
part—that contained in the blebs or bulla of pemphigus or pom-
pholyx, seem to me by no means to partake of  the characters of
the fluid so styled in physiological writings.  It is serum only,
differing little, if at all, from the sub-cutaneous effusion in  ana-
 sarca, or the abdominal fluid in ascites.   It is readily substituted
 by pus, when the  vesicle  becomes a pustule, as we see  in nu-
 merous examples of all  the  conditions I have mentioned, and
 as happens every day in variola and varioloid, and in vaccine,
 when  the pellucid lymph, as we  term it, of  the  seventh and
 eighth days, is changed into pus on the twelfth and  thirteenth,
 and hardens subsequently by exsiccation (?)  into a scab.  In
 some cases, the whole substance of the skin seems inflamed ; in
 others, again, the morbid action seems  confined  to the  conical
 eminences denominated papillae, which swell and grow red  from
 the distention of their minute vessels.  The former  include all
 the tubercular inflammations, as they are styled by Willau and 
*>
CUTANEOUS DISEASES.
529
 Bateman, elephantiasis, leprosy, bucnemia, etc.; the latter state
 is shown in strophulus, lichen, and prurigo.   In some, the affec-
 ted structure is destroyed; as in small-pox, which consists in a
 circular  or  annular inflammation of the chorion  or true skin,
 enclosed within a red ring or zone, which Craigie describes as
 being  formed by the outer corial surface, highly vascular  and
 elevated.  This he  calls "the phlyctidine," a mode of cutaneous
 inflammation  which, he says, may also be produced artificially
 with tartar emetic.  But, however closely  the eruption  from
 tartar emetic may resemble that from small-pox, and the resem-
 blance is very exact, I have never  known it produce pitting
 like the latter.
   We  must not  omit to  notice the frequent  concurrence of
 cutaneous eruption with  gastric disorder,  sometimes  in  the
 unquestionable relation of cause and effect, but more frequently
 as coincident  effects of a common cause, and  occasionally as
 mere unconnected concomitants.
   There are certain persons who cannot indulge  in particular
 articles of diet without suffering some such eruption, which has
 hence  obtained vulgarly the name of "surfeit."   In some, the
 mushroom produces this effect;  in others, the eating of pungent
 stimulants, as  pepper,  mustard, and the like;   and in great
 numbers, the use  of shell-fish as food.   An  erysipelatous swel-
 ling and redness, in which weals arise like the mark of a blow
 or of a stripe with  a whip-lash, from gastric disturbance, is not
 very rare among children, and even occurs among adults.
  In all  the  exanthemata there is notable disorder  of  the
 general system, the  cutaneous inflammation  being only one of
 the elements of the  almost universal  disturbance of the or^an-
 ism.  From  this  uniform  and indissoluble  connection  of  the
 several processes in  the history of these maladies, has arisen the
 belief in  the metastatic nature of the affections of the several
 tissues.  The word  eruption took its origin from, and is expres-
 sive of,  this idea;  the phrases "repelled eruption" and "striking-
 in" convey a reference to the same doctrine.    It is undoubtedly
 true, that, in  this class of diseases, there  is exhibited a sort  of
 necessity  for the  development of their characteristic inflamma-
 tion on the surface at a well known, regular and duly appointed
period.  If it does not then show itself, there will  take place in
     vol. n.—45                           , 
530
CUTANEOUS DISEASES.
*
       its stead a series of annoying and  often dangerous symptoms.
       If, showing itself, it does not persist for the ordinary and regular
       time, or go through  its usual progress, and, more  especially, if
       it suddenly disappear or subside, it is  said  "to be repelled" or
       "to strike in ;"  and long experience has pronounced the subject
*      to be in serious  danger from congestion or inflammatory irrita-
       tion of  some internal organ on  the one hand, or, on the other,
       from exhaustion or irremediable prostration.
         Nay,  it is not in the eruptive fevers  alone,  that this contrasted
       association is observed to take place.   We cannot easily account
       for or explain the fact,  but we must not refuse the testimony
       which goes to prove, that, in the most chronic  and local affec-
       tions of the skin, it is not always safe suddenly to dry up the
       habitual exudation, if there be any. or to put an end to the irri-
       tation and inflammation.  A thousand instances are on record
       which  go to  show the danger of such abrupt change.  The
       gastric  disease which  so long  tormented, and was  ultimately
       fatal to  the great Napoleon,  is ascribed to  the  hasty drying up
       of a long persistent  itch or  dartre, acquired at Toulon in  the
       very beginning of his  brilliant  career.  Delirium and mania,
       coughs  and dyspnoea, and  palpitation, are  said not seldom to
       have arisen from the same source.
         I am  not satisfied  with any of the pathological views of this
       obscure subject.  That, in   many cases of  cutaneous disease,
       whether febrile or non-febrile—whether confined to the external
       surface, or spread over the mucous membranes within, there is
       a peculiar alteration, contamination, deterioration of the fluids of
       the  body, the blood especially,  cannot, I  think, be reasonably
       doubted.  But I cannot go with the  ancient physicians, who
       were led by the facts I have above alluded to, into the belief,
       that in all  these instances  there is a requisite extrication and
       elimination of some morbific matter, whose  retention would be
       injurious to the animal economy.  We must allow, that in  no
       other example was this  ancient  doctrine so plausible  as when
       applied in reasoning upon the phenomena of the eruptive fevers.
       There  is, however, something  peculiar and individual in the
       history of each of these.  Rubeola, be the cuticular appearances
       what they may, is not itself without a quasi-catarrhal affection
       of the respiratory tract of mucous membrane.  Scarlatina essen- 
CUTANEOUS DISEASES.
531
 tially implies  an inflammatory irritation—specific doubtless  in
 its nature—of the  gastro-intestinal and  the  urinary surfaces ;
 and small-pox involves an analogous  condition of both the di-
 gestive and respiratory apparatus.
   Now, if  at the proper  and  precise  stage of the progress  of
 each of these, and of all similar disorders, the natural and ordi-
 nary share  of morbid action fail to occur, or is in any manner pre-
 vented from finding its place upon  the cutaneous  integument, a
 contrasted  or reversed determination,  or  quasi-revulsion  must
 happen, assailing, with* undue force, the tissues usually implica-
 ted, or perhaps involving  some which  bear no part in  the  com-
 mon course of the  disease;  and this  irregularity is apt to be
 productive  of serious and  even fatal evil.   I am  not sure  whe-
 ther the reasonings adapted to the above cases, will apply to the
 purely local and chronic eruptions.  These  certainly present
 difficulties  of another kind.  If psora  depend, for example,  as
 is generally admitted, on  the presence and irritation of a parti-
 cular insect, the acarus psorae, it is impossible to perceive any
 reason for the supervention of the evil results alleged to  have
 followed when an abrupt  cure had been effected.
   The view which I  have taken of the relation  between the
 cutaneous affections in the eruptive fevers, and the internal de-
 terminations with which  they are associated,  seems to derive
 confirmation from  the well known facts—1st. That they differ
 much among themselves as to the degree of relief that follows
 the "breaking out" of the  eruption.   Thus, in measles, urticaria
 and miliary fever, the gastric and  general uneasiness subside
 very notably when the skin becomes covered ; this  relief  is
 much less notable in  scarlatina, and is not observed  at all in
 erysipelas.   2. That, in some of them,  at least, the more exten-
 sive and abundant  the eruption, the more intense will be the
 visceral and organic disturbance.   In small-pox,  which divides
 itself, you know, into distinct and  confluent, the danger of the
 patient is very regularly proportioned to the amount of eruption.
 So, I think  it is in erysipelas, and so, generally though not uni-
 formly, in scarlatina.   But, the very reverse ought to be true,  if
 the cutaneous inflammation were  revulsive or metastatic.
  Concerning the  Pathological nature  of this class of diseases,
there has been much dispute.   While  one  set of writers seem 
532
CUTANEOUS DISEASES.
 disposed to regard them as mere cutaneous  phlegmasias, others
 maintain, and with more apparent reason, that the affection of the
 integument is by no means of  a simply inflammatory character.
 Among the other differences  by which they are separated from
 each other, these are not the least notable. In erysipelas, the skin
 presents the clearest proofs of being violently inflamed ; it gives
 the sensation of heat and soreness, and is  tender to the touch.
 In scarlatina, the heat is much higher, and more pungent to the
 feeling of another, though it is by no means so much  com-
 plained of on the part of the patient himself;  there is  for less
 soreness, and very little tenderness on pressure and friction. In
 many cases from the beginning, and in  all when it has begun to
 decline, it is exceedingly itchy, and rubbing and scratching are
 not only well borne, but eagerly sought for.   In measles, there
 is little either of heat, soreness or tenderness, and I am some-
 what doubtful whether the skin can  be, with any propriety.
 said to be inflamed at all, in the ordinary meaning of the word.
 In small-pox, the inflammation  is often destructive, leaving deep
 seams and scars.  Some of the  local and chronic may be inflam-
 matory, or not so, according to circumstances.   Acne may be a
 mere punctuate elevation, an  obstruction, as some affirm, of the
 minute sebaceous follicles, or may become a severe and tenacious
 inflammation, acne  rosacea.   Herpes, in  many of its varieties,
 defies all cooling  and  sedative applications;  but the peculiar
 itching and burning which it inflicts, are readily palliated or put
 an end to by the stronger local  irritants and  even sharp acrid
 applications, as  citrine  ointment, acetic acid,  tinct: of  cantha-
 rides.
  It would, perhaps, be difficult to  assign a satisfactory reason
 why we have not included under the general head of the Exan-
 thema, certain febrile disorders  not usually enumerated here,
 typhus and typhoid  fevers,  for instance,  and pestis—plague.
 The most minute and  scientific treatises  on  these, assert  the
uniformity of  the eruptive affections with  which they are at-
tended, and yet there is a prevailing unwillingness to  remove
 them from the  order of Idiopathic fevers.   This is, doubtless,
owing to the obviously less importance  of the  eruption  in such
examples.  It is a mere  concomitant, as was formerly remarked.
It does not seem to connect itself with  the  symptoms that pre- 
CUTANEOUS DISEASES.
533
  cede or follow it either diagnostically or  as  a prognostic—cer-
  tainly not in the relation of cause  to which  any of the results
  are ascribable.  Perhaps, I ought to modify,  in regard to pestis,
  the assertion just made as to the diagnostic import of the erup-
  tion, the buboes and  plague spots, which, as some authors tell
  us, serve to denote the invasion of the terrible disease where it
  would not otherwise be suspected.  Other writers, however, lay
  less stress upon it, and it would, indeed, be strange if a charac-
  teristic like this should so often escape attention, as would seem
  to be the fact.
    Typhus  and typhoid attacks are readily enough recognizable
  by their general phenomena, as when occurring in negroes who
  cannot exhibit  at all  the rose colored spots, and in whom it is
  even difficult to detect petechiae.
    Farther,  the exanthemata differ very much in relation to the
  actual  importance  of  the  cutaneous affection considered  as a
  portion of the disease.   This difference I am disposed to regard
  as associated with, if  not absolutely dependent upon, the evi-
  dently inflammatory nature of the  eruption  in certain cases.
  Thus the patient does not appear to be in  any greater danger in
  measles, when the eruption has been most vivid and  abundant,
  than when the efflorescence has been most partial,  least marked
  by redness and least prominent.  Scarlatina holds a middle place
  here, and I  cannot profess myself indifferent or careless about a
  case in which the skin is specially covered with the characteris-
 tic redness.   But in erysipelas we may generally measure the
 degree of risk incurred by the violence and intensity and  by the
 diffused extension of the cutaneous inflammation; and  so also in
 small pox, which is always mild in proportion to its distinctness,
 and kills by its confluence.
   How then do the exanthemata prove fatal ?  Obviously in va-
 rious  modes, and by no means  uniformly alike.  Some patients
 die in what  we call  the eruptive stage of the attack, probably
 from congestion  oppressing some [vital organ—the  brain or the
 heart, and this is a mode  which evidently may be common to
 them all.  Some die in a stage farther advanced, from undue in-
 tensity of the  inflammatory determinations to internal organs
 associated with them; in measles from pulmonitis; in scarlatina
anginosa, from tonsilitis and laryngitis ;  in erysipelas from phre-
      45* 
534
CUTANEOUS DISEASES.
nitis and memingitis.  Lastly, some die in a condition, not no-
ticed definitely, so far as I am aware, by any author; produced
by the unintermitting and protracted impediment to the perform-
ance of the essentially vital functions of the external integument
of the body.   Take for example, the instance of small pox.  In
this loathsome disease, when confluent, the offices performed by
the skin in the animal  economy are all for a longer or shorter
period, suspended by the state into which its tissues fall from the
commencement;  thickened, tuberculated, vesiculated, pustulated,
undergoing destruction by suppuration, and as some say, by par-
tial  sloughing, its transpiration,  exudation, absorption—all its
functions must stop.  Large portions of  it are thus lost too, and
must be replaced by what we call  new skin;  eschars in fact, in-
capable, as I have maintained,  of  carrying on the natural and
normal actions of original tissues any where, certainly unfit for
a time at least, in the present case.  Let us reflect how difficult
it must  be for the other organs of  depuration—the lungs and
the kidneys—themselves profoundly diseased, much deranged in
action and impaired in capacity, to supply its place in these ex-
igencies of the  system;  and we  shall  wonder  rather that so
many recover, than  that the actual proportion of deaths should
occur under so many causes of mortality.  Some die of dropsy,
the  urinary organs  yielding, as so often in scarlatina ; perhaps
oppressed and irritated by the extra demands  made upon  them
as I have just suggested, in the performance of their excretory or
depurative  office, on account of the incapable condition of the
skin.   The  pulmonic engorgement and the hepatic affections
which are  occasionally fatal,  may arise from a similar source
and grow out of the same contingencies.
   In studying the diseases of the skin,  I would propose to avoid
 the entanglement likely to follow  too close a dependence upon or
 observance of the conventional and arbitrary modes of arrange-
 ment and classification, so common  among the authors who
 treat  professedly of the subject.   I would consider, 1. the seat:
 2. the nature as far as  it can be ascertained; 3.  the  cause; 4.
 the complication or association with the affections of the system,
 and its parts—of each separately and in order.
    1.  Of the seat.  "The cutaneous envelope is composed of four
 layers; the epidermis, rete mucosum, corpus papillare, and cori- 
CUTANEOUS DISEASES.
535
 urn."   "Cutaneous inflammation may be seated, in the cuticular
 surface of the corium ; 2. in the papillae or minute elevations of
 the corium ; 3. in the substance of the  corium ; 4. at the inner
 or cellular surface of  the corium."
  2. The nature of the eruption.   Hypercemia is an undoubted
 element in all, and the same may perhaps  be predicated of in-
 flammation ;  but  if so, the  term must  be employed with some
 allowances, demanded by the modifications  in nature as well as
 in the  degrees of prominence and intensity evident in different
 cases.  The  seat  of  the  affection  will also  perhaps modify its
 nature.  Some affect the  bulb of the hair of the head and face,
 and produce ulceration or baldness ; some give rise to desquama-
 tion ;  some to effusions of  serum or  lymph or purulent matter,
 which may be contained in papulae, vesicles or pustules;  or
 thrown off, drying in  scales  or scabs.   A large number of these
 eruptions fix themselves in preference upon  the skin of the face,
 on  account, as is  supposed, of the greater  fulness and force of
 vascular action in that portion of the  surface.
  3. The causes of cutaneous affections  undoubtedly give di-
 rection in the great majority to the  whole course of the disease.
 Specific contagion is the source  of  many among them;  as is
 proved definitely by the fact of inoculation.  So widely does this
 principle  extend, that  I am inclined to regard them all as capa-
 ble  of thus transmitting themselves, provided only there be some
 definite and uniform  secretion  or effused  fluid produced by the
 morbid action of the vessels of the part affected.  All the exan-
 themata are contagious—erysipelas alone excepted, if  this be an
 exception, a point to be hereafter discussed—and contagious not
 only by their palpable secretions, but by their impalpable ema-
 nations.  A  delicate  nostril can  detect, I think, a peculiar and
 characteristic odor as belonging to the effluvia which  exhale
 from the subjects of all the febrile affections  of the skin, and in-
 deed many others.
  Of the  chronic cutaneous  diseases—the  non febrile—there are
 several which are conveyed by mere contact.   Itch for example,
 is promptly propagated in this way, and the fact is singular  in
 some of its relations.   All the symptoms are ascribed as I before
 told you, to the presence and irritation of the animalcule,  acarus
psorae.  Now it is difficult—as experimenters say—to dislodge 
536
CUTANEOUS DISEASES.
this minute insect from the  cell which he is reported to inhabit
in the vicinity of the itch-vesicle; so  difficult  that  we cannot
imagine, in all the infinitely numerous instances of the commu-
nication of the disease by a hasty touch, the escape or removal
of this very domestic creature from one person to another.  The
secretion from the vesicle, the formation of which is attributed to
his presence—must therefore itself too be a means  of extending
the disease, properly contagious ;  it must  be capable of acting
upon  a sound and unbroken cuticle ; it must be exceedingly te-
nacious of its contagious property, retaining it after complete and
long desiccation, as is proved by the frequent infection from sleep
ing in beds used, or wearing clothes, gloves, and the like, formerly
worn  by a patient.
  Herpes, I doubt not, is communicable by inoculation, as in
the use of the same comb and brush, so common in families and
boarding schools; sycosis and mentagra, as  well as  herpes, are
frequently caught in barber's shops, by the employment promis-
cuously of the implements of shaving and hair-dressing.  It is
my uniform custom to insulate, as completely as I can, every
case of cutaneous disease; and by strictly  enjoining abundant
ablution, frequent changes of dress, and  all other modes  of the
observation of nice cleanliness, to prevent all accumulation or
concentration of the materials of contagion and infection.
  Numerous agents, by  their chemical or otherwise irritating
qualities, give rise to particular and well known  inflammation,
when applied to  the  skin.  The cashew nut, the rhus vernix,
and rhus radicans "poison"  those who  handle them.  Tartar
emetic, ipecacuanha, croton oil, capsicum, mustard,  turpentine,
and many others, give rise, each to its own distinguishable mode
of inflammation.   Soot collected in the loose folds of the  scro-
tum,  excites cancer  scroti  in chimney sweeps.   Fermenting
dough produces  eczema—baker's  itch, in the hands of those
who work it without frequent and careful washing;  and  so in
many other of the arts of civilized life, the  manipulators suffer
from the materials they employ.
  Some of the maladies we are discussing, depend upon obscure
modes of causation, connected with geographical, or geological,
or climatic contingencies. Thus the pellagra of Lombardy, the
sivvens of Scotland,  the  radesyge of Norway, and the yaws of 
CUTANEOUS DISEASES.
537
the West Indies, are confined altogether or  almost exclusively,
to the localities and people designated.   The  most minute in-
vestigation into the circumstances which surround the subjects
of these diseases, has failed to elucidate  the peculiarity of con-
dition to which we may ascribe their origin.   I set  aside, after
mature consideration, all the attempts that  have  been  made to
trace these, or indeed, any other cutaneous disorders, to the food
on which their subjects are accustomed to subsist.   It is clearly
established, that for the production of any one of them, the con-
currence of several elements in their influence on the body is
absolutely requisite.  Scabies has been  attributed  to the use of
oatmeal as the diet of the Scotch, and pellagra to the  maize of
the Lombards ;  but psora is found every where among the poor
and uncleanly, however they may live, whether upon animal or
vegetable sustenance, and  maize has for centuries  formed the
principal support of many American tribes, among whom pel-
lagra is unknown.
   1 ought to notice here, however, as apparent exceptions,  per-
haps, to the rule above laid down, the unquestionable  influence
of alcoholic drinks, in the production of certain forms  of cuta-
neous inflammation, fixing almost exclusively upon the face;
the rosy pimples, "whelks and bubukles," which adorn the Bar-
dolphian visage, and which, thanks to the glorious  progress of
the temperance reform, are now becoming comparatively so rare
among the civilized nations.  With  this exception, it may be
affirmed, that so powerfully available are the  assimilative energies
of the human constitution, that no diet in use among men, how-
ever it may be adapted to deteriorate the general  health, seems
capable of impressing any specific changes upon the  skin, proba-
bly not upon any of the tissues.  Scurvy itself, so long ascribed
to the mere diet of sailors, is  never generated  among  the trap-
pers or Indians  of the West, or the  Esquimaux,  subsisting as
they are often forced to do, upon an exclusively salt or animal
diet;  provided they are not straitened - for  a proper amount of
nutriment, or otherwise subjected to concurrent influences, mor-
bid and depressing.
  4. The complications or associations uniting cutaneous mala-
dies with other disorders of the system.   Some of these are, per-
haps, to be looked upon as coincidences only, while others again, 
538                CUTANEOUS DISEASES.

stand connected in the relation of cause and  effect.  The first,
and perhaps the most striking result of the present inquiry, will
be a  great surprise at the very limited number of diseases which
are purely and exclusively  local affections  of the skin, even
among  the  chronic and non-febrile.   Next, we shall find an
extreme difficulty, as has been shown already, in detecting the
nature of the connection in many cases; these then I would
designate rather as simple coincidences, than as being in any
known  or definable manner dependent one upon the other, any
more than the several  symptoms of vascular, nervous and vis-
ceral disorder, which concur to give the history of any idiopathic
fever, are connected.   In the eruptive  fevers, with hardly an
exception, the tokens of general  or febrile derangement precede
the efflorescence on the surface;  nor do they seem to observe
any essential proportion in degree or violence, to the amount or
intensity of cutaneous inflammation that is to follow.
   In some of the exanthemata, if not in all, the whole mass of
blood seems imbued with new and  peculiar properties.  Scarla-
tina  and measles, may be conveyed by sanguineous inoculation,
and small pox attacks  the foetus in utero.  In vaccine, and in
erysipelas, this change in the condition of the circulating fluid
does not seem to take place, or  rather has  not been proved by
experiment.  Nay, in syphilis, in which the inquination  of all
the humors seems to be as complete and permanent, as it is tran-
sient in the examples given  above, we have not any foundation
for the belief that the blood either of the veins or  the arteries,
or of the diseased portions  of skin, is capable  of transmitting
the infection, which can  only be communicated  by  the virus
secreted from a primary  ulcer; the exudations from secondary
ulcers are denied by the majority to possess this poisonous power.
   These discrepancies go to show that every one of these affec-
tions must be studied  apart, must be individualized.  Classifica-
tion, which aids so efficiently the botanist and the mineralogist,
may tend, unless corrected by prudent caution, to  mislead us in
our  pathological inquiries.
   With these few and brief  observations upon the general sub-
ject of  cutaneous diseases, I pass on to the consideration  of the
most important and familiar of the  classes into which they have
been divided, the  exanthemata, namely, or eruptive  fevers; 
CUTANEOUS DISEASES.
539
under which head, I shall treat of rubeola or measles, erysipelas,
scarlatina, vaccine, variola, and  dengue.  If the  foregoing  re-
marks are desultory, rather than arranged according to the scien-
tific niceties in which  these topics have been enveloped, I will
remind  you that this is  partly owing  to the real  difficulty
attending the acceptance of any of the arbitrary views proposed
for our guidance, and  partly to the  limit  of time  which forces
me to the most practical course of discussion, however abrupt
it may occasionally appear.
  I insert here for convenient reference  and comparison, two
tables of cutaneous diseases ; the first taken from Dunglison, the
second from  Craigie—authors  whom you may always  consult
with advantage, and whose works are entitled to a place in  all
your libraries.
  Dr.  Dunglison, in his  " Practice of  Medicine,"  separates
"eruptive fevers" from "diseases of the skin."  He admits "eight
divisions of cutaneous diseases,  according to their elementary
characters."
   I. The Exanthematous, which he regards as "partaking rather
     of the  nature of hyperaemia  than  of positive inflamma-
     tion."  Erythema.
  II. The Vesicular, characterized by small acuminated collec-
     tions of fluid beneath the cuticle, including—1. Herpes.   2.
     Eczema.  3. Scabies or Psora.
  III. The Bullar, from bulla, a bleb—a  blister or elevation of
     cuticle by serum, including—1. Rupia.  2. Anthracion.
  IV. The Pustular: by small collections of purulent matter in the
     cutis vera, or under  the  cuticle,  including—1. Ecthyma.
     2. Impetigo.  3. Acne.  4. Mentagra.  5. Porrigo.
   V. The Papular: by simple prominences; no effusion ;  furfura-
     ceous desquamation ; including—1. Lichen.  2. Prurigo.
  VI. The Squamous : by red spots or patches, followed by scales
     or lamellae of cuticle, including—1. Lepra. 2. Psoriasis. 3.
     Pityriasis.   4. Ichthyosis.
 VII. The Tuberculous: by solid primary tumors tending to sup-
     puration, or destructive  ulceration,  including—1. Lupus.
     2. Elephantiasis Graecorum. 3. Frambaesia. 4. Molluscum
VIII. Maculce, discolored states of the skin, including—1. Len-
     tigo.   2. Chloasma.  3. Naevi. 
540
CUTANEOUS DISEASES.
  IX. Syphilides.
  Of eruptive fevers he recognizes four varieties, which he de-
scribes  under the first four  heads given  above; "taking the
elementary form  of the eruption  as the basis  of the classifi-
cation."
  I.  The Exanthematous, including—1. Measles, true and false.
     2. Scarlet Fever.  3. Nettle-rash.   4. Erysipelas.
 II.  The Vesicular, including—1. Miliaria.   2. Chicken-pox.
III.  The Bullar,       "      1. Pemphigus—Pompholyx.
IV. The Pustular,     "      1. Small-pox.  2.  Cow-pox.  3.
     Glanders.
  Dr. Craigie "regards it as most expedient to arrange the cuta-
neous inflammations, according to the part of the skin in which
they are specially seated, according to the  mode  in  which the
inflammatory action proceeds, and according to the effects which
it produces, in the following order:
  "Diffuse or Spreading Inflammation.  I. Cutaneous inflam-
mations seated in  the outer  surface of the corion, and generally
spreading along it.—Measles—Rubeola.  Nettle-rash—Urticaria.
Rash Fever, Scarlet Fever—Scarlatina.   Common Rash—Ery-
thema.  Rose Rash—Roseola.
  "Effusive Inflammation.  II. Cutaneous inflammation seated
in the outer surface of the corion, producing a fluid which ele-
vates and detaches the cuticle.—Rose, St. Anthony's Fire—Ery-
sipelas.   Bleb Fever, Bullose Fever—Pemphigus, Febris Bullosa.
Simple Blebs—Pompholyx."
  "Punctuate Papular Inflammation.   III. Cutaneous inflamma-
tions commencing  in  circumscribed or definite  points of the
corion, producing minute eminences.—Gum, Gown, Red Gum,
Tooth Gum-—Strophulus.  Sun Rash,  Prickly Heat—Lichen.
Itchy Rash—Prurigo."
  "Punctuate Desquamating Inflammation.  IV. Cutaneous in-
flammation of the outer surface of the corion, more or  less cir-
cumscribed, affecting its  secreting power, and  producing exfo-
liation of the cuticle.  Scaly Leprosy—Lepra.   Scaly Tetter-
Psoriasis.   Dandriff—Pityriasis.   Fish-skin  Disease—Ichthy-
osis."
  Punctuate Vesicular Inflammation.  V. Cutaneous  inflamma-
tions originally affecting the outer surface of the corion, circum- 
CUTANEOUS DISEASES.
541
scribed, definite or punctuate, producing  effusion of fluid, first
pellucid, afterwards slightly  opaque,  with elevation  of cuticle,
with or without further affection  of the corial  tissue.—Miliary
Rash—Miliaria.  Chicken Pox—Varicella.  Shingles, Vesicular
Ring Worm or Fret—Herpes.   Cow Pox Vesicle—Vaccinia.
Heat Spots or Red Fret—Eczema.   Limpet-shell Vesicle  or
Scab—Rupia."
  "Punctuate Phlegmonous or Pustular Inflammation.  VI. Cu-
taneous inflammations originally affecting  the  outer  surface of
the corion, afterwards its substance, and producing matter more
or less distinct.—Small Pox—Variola.  Malignant Pustule, Per-
sian Fire—Carbunculus—Anthrax.  Itch—Scabies.   Moist or
Running Tetter—Impetigo.   Great  Pox—Ecthema.  Scall  or
Pustular Ring Worm—Porrigo."
  "Punctuate Chronic Phlegmonous Inflammation.  VII.  Cuta-
neous inflammations originating in the substance of the corion,
sometimes at the bulbs of the hair, and terminating in partial or
imperfect suppuration, with formation of scales, crusts, etc., and
more or less destruction of the corial tissue.—Boil—Phyma, Fur-
unculus.   Whelk—Acne.   Scalp or  Chin  Whelk—Sycosis.
Canker—Lupus,  Noli  me tangere.  White Scall—Vitiligo.—
Yaws—Framboesia, Rubula.   Sivvens—Sibbenia."
  "Punctuate Phlegmono—Tubercular Inflammation—Chronic.
VIII. Cutaneous inflammations, chronic, attended with general af-
fection of the fibro-mucous tissues.—Arabian Leprosy—Elephan-
tiasis.  Arctoic Leprosy, Radesyge—Lepra Norwegia.  Wart—
Verruca.   Lombard Evil—Pellagra.  Soft Tubercle—Mollus-
cum.  Crim Evil—Lepra Taurica.   Scherlievo,  Falcadina—
Lepra Pedemontana.  Austrian Itch or Scab,  Mai  di Rosa—
Lepra Asturiensis."
vol. n.—46 
542
SMALL POX.
                     CHAPTER LVI.

      VARIOLA.--SMALL POX.--VARIOLOID AFFECTIONS.

  Small-pox is a well known febrile disease.  Cullen arranges
it among the exanthemata, and characterizes it as inflammatory
and contagious.   Baron and Willan contend that it was known
to the ancients ; but we have no  intelligible notice of it in his-
tory,  before  the  sixth century,  and  certainly no  professional
recognition or description earlier than that of Rhazes, who wrote
about the beginning of the tenth.
  It appears to have been universally  confounded with measles
until the time of Sydenham,  who first clearly separated  them;
from him also, we derive the division  of Variola, so familiar ever
since, into two forms—discreta et confluens—the distinct and con-
fluent.  We should be careful to understand these terms,  how-
ever, as referring to differences merely in grade or intensity;
and by no means implying any diversity of specific character.
  The history of small pox may  be comprised under successive
heads or stages, of which there are commonly admitted—1. The
stage  of incubation.  2.  That  of maturation.  3. That of de-
cline.   The first includes all the phenomena that occur, between
the period of  exposure and the time when the eruption  shows
itself.   It is not necessary to discuss here, the possibility of any
other causative agent than contagion,  to which we attribute un-
hesitatingly the exclusive production  of small pox.  When the
contagious matter is introduced into a wound purposely made;
we speak of the subject as inoculated; this process shall  be de-
scribed by and bye; at present, we shall consider the circum-
stances of atmospheric infection, when the patient is said to take
the disease "in the natural way."  The  latent period after effi-
cient exposure, is differently stated by different authorities, who
agree very generally in placing it somewhere between seven and
twenty-one days.  You will be struck here with the analogy of
the malarious latent period, which those most familiar with  it
set down as of the same extent.   The average date of attacks,  is
calculated by some as fixed at the ninth,  by others, at the four- 
SMALL pox.
543
teenth day.  During this stage of incubation proper, the patient
may or may not retain his usual health.   Gregory alone, insists
that it is always a condition  of more or less malaise, discomfort,
disorder, depression
   The actual invasion, like  that of other fevers, is certainly, in
the majority, sudden and unexpected.  The patient  is seized
with a sense of chilliness, a  shivering, or formed rigor, followed
by heat, pains in the head, back and limbs, gastric  oppression,
and nausea, going on occasionally to retching and vomiting.
To these symptoms are soon added soreness of the throat, with
difficulty of swallowing,  and the spitting of a tough,  offensive
mucus;  and not unfrequently, dyspnoea,  cough and pain in the
thorax.
   In young children, the access of this annoying malady is often
marked  by convulsions—quasi epileptic—of greater or less se-
verity, alternating with drowsiness or coma.
   2. On the third or fourth day, the eruption makes its appear-
ance, and the second  stage commences.  Pimples are first  ob-
served on the forehead and over the face; next, on the neck and
arms, whence they spread to the trunk and over the lower limbs.
These papulae assume, in a day or two, the vesicular form,  be-
ing distended with a thin serous fluid; while the febrile disor-
der above described,  subsides,  and in ordinarily  mild cases of
distinct  small pox,  goes off  entirely.   It has been disputed
whether there is any  development of successive papulae.  I will
not venture to deny the occurrence of occasional  exceptions  in
very slight attacks, but the rule has been, according to  my own
experience  and observation, that  additional eruption presents
itself in  steady progress for three or four days.
   The papulae are not thrown  together or scattered promiscu-
ously ; but collected into groups, assuming, perhaps somewhat
vaguely, a crescentic  or semi-circular form.  They enlarge  in
diameter, and are surrounded by a halo or florid  areola; on or
about the sixth day, their apices become flattened, or even  de-
pressed in the  centre; and the fluid  contents  grow yellowish
and purulent.  About the eighth day,  the marginal ring begins
to grow pale; the central depression disappears;  and the pus-
tule, now hemispherical in shape, is much thinned at the sum-
mit, and easily broken.  The suppuration of the vesicles, how- 
544
SMALL POX.
ever, is not universal;  many of them, especially on the limbs,
subside, their serous contents  being  absorbed,  leaving a hard,
dry, brown spot on the  cuticle.   The pustules are fullest, as
well as most abundant on the face, which is  diffusely swollen
with heat and itching; the eyes, indeed,  are  frequently closed
entirely for a day or two, by the swelling of the lids.
  Variolous pustulation is not confined exclusively to  the skin.
It extends over the adnata, and may even attack the surface of
the cornea.  The base of the tongue  and the throat, the larynx,
not unfrequently, and the trachea,  sometimes, are thus assailed.
The patient is hoarse; coughs  much ; the tonsils and salivary
glands are engorged and enlarged,  with  great  difficulty of de-
glutition, and constant excretion of tough and  offensive  mucus
from the mouth and fauces.
  3. Maturation being now completed, the third stage of desic-
cation or decline, arrives.  On  the tenth or eleventh day,  the
swelling of the face goes down; the inflammation, both pustu-
lar  and diffusively cutaneous, abates rapidly ; the pustules hav-
ing partly discharged their contents, especially those on the face.
which are for the most  part likely to burst, dry away, shrivel
and scab over, forming  crusts.   The general or constitutional
disturbances have subsided, pari  passu with the cutaneous irri-
tation ; and from  the  seventeenth to the  twentieth days,  the
crusts drop away,  leaving a new surface of skin  of  a reddish
brown color, with here and there "pits"  or slight depressions.
The case may thus terminate without farther danger or incon-
venience ; and such is the history of a mild attack of Distinct
small pox, variola discreta.
  In Confluent small pox, we go on to remark, the eruptive fever
is  almost uniformly  violent  and severe; and attended with
urgent internal suffering from  congestion, or  inflammatory  de-
termination to the respiratory and digestive organs and surfaces.
The eruption comes out at once, more hastily and thickly crowd-
ed from the first, and in its  progress coalescing over the face,
and often over many other parts.   The countenance is deformed
by  the degree of swelling, and the skin intensely inflamed.   Not
only suppuration,  but very frequently extensive ulceration takes
place, and the sloughing spoken of by Hunter, occurs, producing
deep  pits, scars, seams, blindness and deformity. 
SMALL POX.
545
   The febrile symptoms do not subside when the eruption breaks
 forth;  there is merely a slight remission, sometimes hardly per-
 ceptible.   Becoming again violent about the seventh  or eighth
 day, this "secondary fever," as it is termed, continues  without
 abatement, during all the remaining course of the disease.   The
 tongue and mouth are often dry; the pulse is frequent, and for
 a while tense and chorded, but soon yields and  is feeble;  the
 breathing is  difficult;  drowsiness comes on, increasing into
 coma;  and the patient sinks exhausted with intolerable sufferings.
   The Prognosis is favorable in distinct  small pox; in the con-
 fluent form it is the reverse.   Bad  cases may be known from
 the first,  by an imperfect eruption, the  vesicles rising very little,
 being rather livid than florid, and filling,  or as  the phrase,  is,
 maturating badly.   If at any time the  pustules flatten, and the
 skin becomes pale or livid, the danger is great,  especially if the
 pulse and strength fail,  and the mind is  observed to wander.
 The occurrence of any  urgent internal determination is to  be
 dreaded,  whether to the brain, as shown by delirium, coma, etc.,
 or to the respiratory organs, with pain in the side or chest, cough
 and dyspnoea.
   The sequelae of small pox are often very serious.  Deformity
 and blindness, as I have said, or a persistent opthalmia, a chronic
 diarrhoea, anasarca, occasionally follow it.  The voice is in some
 permanently changed, and rendered disagreeable, by injury done
 to the soft palate.  Scrofula is said to be excited to severe and
 rapid development, and the predisposition to pulmonary disease
 generally, but more especially tubercular or scrofulous phthisis.
  Autopsy.   The  variolous eruption  is found not only on the
 skin, the vascular network or rete mucosum being the seat of the
 pustules,  but extends to the mucous tissue lining the mouth, fau-
 ces, pharynx, trachea, larynx, and upon the conjunctiva.  The
structure  and  formation of the pustule in these positions, is not
 well made out.
  Craigie, in  his  "Elements of Pathological Anatomy" and his
 "Practice of Physic," has given us a minute account  of all the
observations made by himself and others, of the structure and
changes of the cutaneous pustule of small pox ; of which detail
I offer you the following abstract.  The primary points of in-
flammation__phyctidia—commence at the cuticular surface, and
      46* 
546
SMALL POX.
 spread at the same time  by radiation along the surface and by
 penetration downwards.  Each point thus surrounds itself with
 a hard,  red. elevated circle.  A fluid is  secreted within, and on
 cutting open the phyctidium on the eighth or ninth day, we find
 opaque, thick, purulent matter in its centre, which may be re-
 moved, exhibiting the true skin hollow, cupped, red, rough, vil-
 lous,—not  ulcerated,—and without a  slough.   :fThe  external
 covering and the foundation of the whole phyctidium is formed
 by epidermis, and within its cavity and especially in its margins
 where they spring from the skin, is found a thick substance of a
 consistence  almost mucous, but which  when  scraped  off with
 the knife, which is easily done, forms a granulated pulpy mass."
 This is pronounced by Craigie, definitely, to be a new and cha-
 racteristic product: it is what Hunter speaks of as "the variolous
 slough."
   Although it has been asserted  that such pustules have been
 found in the stomach  and intestines, both Craigie and  Gregory
 assert that they never  exist there ;  nor  upon the genito-urinary
 mucous tissue.   But  the gastro-enteric  mucous membrane is
 often seen in a state of extensive and vehement inflammation.
   In many  subjects the brain and its membranes are found dark
 with vascular congestion.  In others the lungs are engorged and
 hepatized, and the pleura inflamed.
   Treatment.  During the eruptive fever of small pox, if we
 are aware of the nature of the case, there is little temptation to
 interfere, when the attack is mild.   I know not that there is any
 risk or evil, in the ordinary management of fever of equal inten-
 sity applied here.   If at  the time of access there are exhibited
determinations to the head, lungs, stomach, etc.,  violent and se-
vere, the lancet may be used, and its effect aided by mild purga-
tives.  The mercurials are supposed to exert here a pecular effi-
 cacy, but of this I am not satisfied.  Great  gastric oppression,
 with  foul tongue and fetid breath, require an emetic, especially if
the retching be insufficient, and fail to empty the stomach of its
 crude contents and morbid secretions.  Mild emesis can  scarcely
 do harm, and is serviceable besides, by favoring a centrifugal de-
 termination of the fluids.  It often relieves the infantile convul-
 sions which precede the eruption.
   The purgatives which I have advised to be used with modera- 
SMALL POX.
547
tion during the eruptive fever, must be abstained from when the
papulae are forming upon the skin ; after this, the bowels should
be kept free by laxative enemata.
  The use of the warm bath, should be one of our earliest mea-
sures in the management of negroes and of whites of the lower
class.  It is beneficial to children attacked with convulsions, who
may be relieved with the lancet cautiously employed, if the pulse
be full and hard  and the face flushed; and on the other hand, if
pale and feeble, may be tranquilized with small doses of the tine:
op: camph.  The apartment of the sick should be well aired, and
perfectly  clean.  He should lie on a firm mattrass, and  if able,
sit up occasionally.  The cool regimen, so vastly preferable to
the heating system  anciently in vogue, must not, however, be
carried to  an extreme.  It will, if urged, do harm, when the  pul-
monary symptoms are prominent.  Nor do our negroes, in gene-
ral, bear it well, unless much modified.
  Light mucilaginous drinks should form the only nourishment.
The sore  throat should  be gargled often with tepid water, and
the inflamed eyes washed from time to time with milk and other
mild collyria, and carefully protected from light and other irri-
tants.
  To prevent the pitting, so much  feared, many expedients are
proposed.   I have not confidence in any one of them.   The re-
sort to them in confluent and really severe cases is trifling, and in
distinct small pox there  is little deformity left.
  The larger pustules and confluent masses of pustules  may be
punctured with a lancet, and the matter gently pressed out. Some
supposing light and air to be the causes of ulceration and slough-
ing, keep  the apartment as dark  as possible, and cover the face
with gold beaters skin or masks of various kinds, while others
have  advised the  application of nit: argenti  to  the  still  ima-
ture vesicles, to prevent their farther progress and complete pus-
tulation.
  In the  secondary fever, most advantage is derived from the
mildly stimulating diaphoretics, as the infus: rad: serp: with slight
additions of aether, camphor, or ammonia.  I employ opium un-
hesitatingly and freely, when it is required to relieve the cough,
dyspnoea,  restlessness, and other sufferings of the patient. It  does
not seem contra-indicated by any circumstances but those which 
543
SMALL POX.
show a tendency to  coma.  I prescribe Dover's  powder or the
camphorated tincture.
  In  protracted cases,  when the  strength yields, cinchona is of
much  service.  The  infusion  may be combined with other re-
medies. Extensive crusts are rubbed off occasionally by the mo-
tions of the patient in bed, leaving painful  sores.  These must
be dusted with  cinchona or finely powdered chalk, the pressure
of the body frequently changed by the attendants, and extreme
cleanliness inculcated.
  If the "striking in" of the eruption, as the phrase is, occur,
the pustules flatten and become indistinct, with failing pulse, and
cold and livid surface, it  is necessary to stimulate promptly and
energetically, both by internal and external means.
  The treatment  of the convalescent requires much attention.
He is covered  with a new and highly susceptible  integument,
and is specially liable to the ill effects of exposure and  alterna-
tions, from which he must be guarded strictly by proper clothing.
His diet  should,  for  a long time, be plain and unstimulating,
though nutritious.
  Variolous contagion is both palpable and impalpable.  It may
be communicated palpably by contact with  the diseased person
or with fomites, and by inoculation, or the direct insertion of
small pox matter  into  a wound.   It is also capable of diffusing
itself impalpably through the atmosphere.   At what stage of the
case a sick  body becomes thus a focus of contagion, is not clearly
known—perhaps  from the sixth or seventh day, when a peculiar
odor or effluvium begins to be given off.
  The latent period, the interval between infection and invasion,
is also doubtful; it  is usually rated at from nine to fourteen
days.  The effects of inoculation show themselves earlier—about
the fourth day.
  Small pox attacks' the same person but once-—a rule clear and
positive, though not without exceptions.  This exemption gave
great importance  to the practice  of inoculation, which enabled
the subject to select his own time and circumstances for  suffer-
ing the disease.  It is difficult to account for the immense differ-
ence  in violence  and mortality between the casual and inocula-
ted small pox. 
SMALL POX.
549
  Variola is liable to many modifications in history and charac-
ter, some of which  have been pointed  out  and separated in
common language by special  denominations, while the strong
similarity which they present to each other and to the common
stock of all, is indicated in the use  of a word  now become
familiar every  where, Varioloid.
  All  the  old writers  speak of irregular forms  of small pox.
Sydenham  is particular  in detailing the varieties which the dis-
ease offered, in the several  years  of its epidemic occurrence
under  his  own notice.   Lieutaud speaks of a "spurious small
pox," occasionally taken for  the  legitimate.  Parr tells us that
"the varieties of small pox are numerous."  Others tell us of
water-pock, of wind-pock, stone-pock, etc. in almost  unnum-
bered  diversity.  It was only among the English, and not by
them until  the time of Heberden,  that varicella  (chicken pox)
was distinguished  from small pox—that is, by the profession;
nurses and common people had noted and named  these varieties
at least half a century before.  Morton, of the time of Syden-
ham, speaks of it as  mild small pox.  His  cotemporary must
so have regarded it, if he  met with  it at all.  And though  He-
berden, Willan, Rayer and Mcintosh talk very positively  of the
distinctions between the two, yet other writers have  not been
able to mark them so clearly.  Thomson, for instance, maintains
varicella, in all its varieties, to be  a modified small pox, and
while  Willan  recognizes it only as presented in the serous or
vesiculous  form, Rayer acknowledges that it occasionally as-
sumes a pustulous condition.   With regard to the grade,  which
is made the source of distinction between distinct and confluent
small pox,  it should be remembered, that Ring has given us a
case of confluent chicken pox, and that Mcintosh has recorded
two fatal cases, one in a child, the other in an adult.  Heberden
speaks of a malignant sort of chicken pox, in which  "the con-
tinuance of the pain and fever, after  the eruption, and the degree
of both these, though there be not above twenty pustules, are, as
far  as I have  seen,  what never happens in the small  pox.5'
Chicken pox has been known to pit the skin, and distinct small
pox often fails to do  this.  If we receive  the diagnosis of  Mcin-
tosh and others, who discern chicken  pox by the  succession of
crops and  pustules, what shall we  say to Heberden's acknow- 
550
SMALL POX.
ledgment of his having seen four cases of its unequivocal occur-
rence in small pox ?   These are  "the  only instances,"  he says,
and  his language is  striking,  "which have  happened to me,
something like what is often talked of—a. second crop.
  It seems to me that the above observations,  in  making which
I have referred in preference  to the old writers,  exhibit plainly
enough the difficulty of distinguishing small pox from its kindred
affections, if  their actual identity be not established.  The term
varioloid is a new one, first used by Thomson, in his "Account
of the Varioloid epidemic," which  prevailed  at  Edinburgh, in
1S11.   Cross gives an excellent history of a  similar epidemic,
(which, however, he terms small pox,) as occurring at Norwich.
The same pestilence, it is asserted, raged about the same time in
France,  Italy, and Germany, from which last  source it was
brought into  America in 1818, making its first invasion in  Balti-
more,  (Md.)  and Lancaster,  (Penn.)   It  was first noticed  in
Charleston in January, 1S24.
  Varioloid has been assumed to  differ essentially from variola,
(small pox,)  because first—it  affects  persons known  to  have
previously  passed through attacks  of  regular small pox;  se-
condly, it affects persons previously vaccinated;  and thirdly, it
presents certain peculiarities of history and  character, which
serve as distinguishing  marks.
  The  first of these  alleged  reasons is obviously of no  force.
It was  long  since observed, that small pox sometimes failed to
destroy the liability to its own recurrence, and instances of  its re-
petition are to be found in all the old writers.  "Petrus Borellus,"
says Heberden, "records the case of  a woman  who had  this dis-
temper seven times, and catching it  again, died of the eighth
attack."  Dr. Oppert, of Berlin, relates the case of a girl, who, at
six years of age,  had confluent small pox.  Seventeen  years
after, she was again attacked, and died of  the disease.   A simi-
lar case is authentically stated to have occurred in this city.  If
it is  replied, that  these cases are too few in number to affect the
general rule,  that small pox invades the constitution but once,
we readily acknowledge the correctness  of the assertion, and
proceed to apply the inference to the  case before us.  During
the prevalence of the epidemic  of 1823-24, in Philadelphia,
(call it varioloid or small pox,)  but  sixteen persons  are reported, 
SMALL POX.
551
by Drs. Bell and Mitchell, as attacked with it, who had  previ-
ously small pox.  A  similar list may be made out of cases of
the same kind  occurring here, while the  pestilence  prevailed
among us, so limited in  number, however, as to prove most
conclusively, that variola  protects, at  least  in a certain degree,
from varioloid disease.
  With regard to the second point mentioned above, it is only
necessary to observe, that no  well informed physician  of the
present day, retains  any confidence  in  the absolute preventive
power of vaccine against the invasion of small pox, however
much he may be disposed to confide in its unfailing  modifying
influence.  But of this,  more hereafter.
   Thirdly, the  principal peculiarities which are supposed to
characterize the varioloid, and to offer specific marks  by which
we may discern it, are, so far as we have  been able to collect,
the following:
   First, the eruption comes forth in successive crops.
   Secondly, the pocks  or pustules, when formed, are conoidal,
without a central depression.
   Thirdly, they are vesicular, not multicellular, as small pox is.
   Fourthly, they are smaller than the variolous.
   Fifthly, they contain  lymph and not purulent matter.
   Sixthly, they dry and fall off without pitting.
   Seventhly, their progress and maturation are unattended with
secondary fever.
   To all these we would rejoin, that the  circumstances above
described are by no means regular or connected in their occur-
rence ; and that if they were, they would not imply sufficient
distinctness to constitute a separate form of disease.   For,
   First,  in the  small pox, the  eruption is sometimes incomplete
at  first, the pustules appearing to thicken as the disease pro-
gresses ;  and it is well known to all nurses, to be easy to in-
crease, locally,  the number of pocks,  by exposure of part of the
body to long continued heat, as  by lying on it, wrapping it, or
exposing it to the heat of a fire.
   Secondly, thirdly, and fourthly, the size and configuration of
the pustules, vary much in the most clearly defined cases of
small pox.  Upon the same individual, some will be seen large,
and others small—some conoidal, and others depressed in the 
552
SMALL POX.
  centre.   The internal construction of the pustules will be found
  to differ in  a corresponding  manner;  the conoidal are vesicu-
  lar—those which present the depression  in the  centre are, like
  the vaccine, multicellular—that is, divided into  many separate
  cells  or spaces.   If I  have  not greatly deceived myself on
  many occasions, I  have further  noted  that  the pock changed
  its appearance in this regard during its progress ; at first vesicu-
  lar  and conoidal,  it exhibited afterwards a depression  at the
 apex, becoming flattened and  multicellular.  But upon this, as
 it is by no  means  important to the argument,  I shall lay no
 further  stress, content if I can draw the attention of the pro-
 fession to it by the remark.
   Fifthly, as to the assertion, so often repeated,  that it is  cha-
 racteristic of the varioloid vesicle to contain lymph or serum
 and not  pus or matter, as the common phrase is,  I affirm, on the
 other  hand, that true small pox virus is  limpid and colorless.
 The most experienced inoculators, as for example, Parr and the
 two Suttons, always preferred clear transparent lymph.   It is in
 the latter stages of  the pock, after common inflammation super-
 venes upon that which is specific  and  peculiar, that we  find
 purulent matter;  and the  few cases of  varioloid or  modified
 small pox, which run on into this stage, exhibit just as distinctly
 the  formation of pus.  If  the inflammation of the skin be stop-
 ped  at an early stage, we  prevent  this; and such, as I shall
 hereafter show, is the most important  of  the train  of effects
 attributed to the vaccine.
  Sixthly, John Hunter  has somewhere  declared, that in each
 pock of the variolous eruption, a slough of the cutis vera takes
 place, answering in dimensions to  the size and form of the pus-
 tules.  This sloughing forms the pit or depression left by small
 pox, and the circumstance is assumed by him and others—Ring,
for example, and Dr. Adams—to be peculiar to and diagnostic
of small  pox, and to depend, not upon the intensity of the in-
flammation, but on  its specific nature.  Thus, they propose to
separate Varicella or chicken pox, from variola or small pox.
It is easy, however, to demonstrate the fallaciousness of this test,
supported as it is by the authority of such high names.  A pit
is not made  by every small pox pustule.   In distinct small pox,
and in inoculated persons, there is frequently left no mark or 
SMALL POX.
553
 trace  of  the  location  of  a pock.   Goethe,  when  a child at
 Frankfort, was attacked  by small pox there—long ill—but had
 the good fortune to escape without being disfigured.  Mary,
 Queen of Scots, so  remarkable for her exquisitely fascinating
 beauty, had the small pox in her early childhood—but,  says
 Bell, "it must have  been of a particularly gentle  kind, having
 left behind no visible  trace."   Nor can  it be  doubted,  that
 the chicken  pox and  the (so called) varioloid,  occasionally,
 though seldom, produce similar sloughs or depressions, and so
 leave  marks  on the faces of  those who have gone through an
 attack.
   Seventhly,  secondary fever is often wanting in the mild cases
 of distinct small  pox, and very rarely occurs in the inoculated.
 Dr. Parr,  indeed, mentions  the absence of  it as a peculiar  cha-
 racter of inoculated  small  pox. It is clear, then, that no infer-
 ence can be drawn from its absence, of a nature  favorable to our
 opponents. It arises,  like the secretion of pus, from the irritation
 of the cutaneous surface, and is proportioned in degree to that
 irritation.   It  is, therefore,  met with now and then, both in vari-
 cella and varioloid.
   I believe varioloid to be identical in  nature with small pox,
 because they are promiscuously capable of producing each other.
 The modifications which  have been noted and discussed, I at-
 tribute, in a vast majority of the instances presenting themselves
 at the present  day, to the influence of vaccine, of which I shall
 speak presently.  In others, (for they are confessedly irregular,)
 to certain indefinable and varied peculiarities of constitution, or
 habit, or condition of body in the affected subject.
   Under this  head of varioloid, I  unhesitatingly coincide with
 Dr. Thomson  in comprising  Varicella, (chicken pox.)  This
 gentleman entered upon the course  of observations, upon  the
 Edinburgh epidemic, made by him  with  so much  care  and
 nicety, a thorough believer in  the opinions of Heberden and
 Willan, with regard to the separate and independent nature of
 chicken pox.   His candor,  however, did not long permit him to
 remain the advocate of this view  of the matter.  "During the
 epidemic, I had occasion,"  he says, "to  observe  natural  small
pox,  modified  small pox, and  the disease  which  I had been
      vol. n.—47 
554
SMALL POX.
accustomed to regard as chicken pox, co-existing in the same
situations, and appearing  in  their progress to produce one ano-
ther.  In three families in particular, situated at a considerable
distance ffom one another, and between which, except through
their medical attendants, no sort of intercourse had existed, my
attention was strongly excited by observing chicken pox arise in
unvaccinated children, from  the contagion of malignant small
pox.  The occurrence of this event, in circumstances  which
left no room for doubt, because there appeared to be no possible
source of fallacy in the observation, led me to conceive that all
the various appearances of the epidemic, in the different classes
of persons whom it attacked, might be produced by the opera-
tion of one and the same contagion."
  Phenomena precisely similar have occurred  under my own
observation, in the several invasions of this eruptive disease, call
it what you will.   Such of my patients as had not been previ-
ously vaccinated, or had not had the  small pox, exhibited for the
most part the regular symptoms of variola, as it is  found des-
cribed in the  books and recognized by  the best  authorities.
Those, on the other hand,  who had been protected by either of
the above  means, had  the disease  modified variously,  and in
different  degrees  of mildness—some of them scarcely, others
not at all, distinguishable  from varicella.   That the same conta-
gion  is capable of producing  these  several  forms of variolous
disease, whether regular or in any manner modified, is not only
proved by their occurring thus together spontaneously, or in the
natural way, but  has been  definitely established  by repeated
inoculation with the matter of the modified vesicle, varioloid or
varicelloid, in which  regular well-marked  small pox was the
result of the insertion of the  virus.  Among such examples, the
case of Dr. Hennen's son,  of Edinburgh, is most worthy of being
detailed.  This boy, from whatever source infected, was seized
with  an eruptive disease, concerning which Dr. Thomson thus
explicitly expresses  himself:—"If I had been requested to point
out the case, which seemed to me to correspond  most accurately
with the descriptions of  chicken pox, I  should certainly have
fixed upon the eruption of Dr. Hennen's boy."  It was the cir-
cumstance of Dr. Hennen's  viewing the disease  in his son, as a 
SMALL POX.
555
well-marked example of chicken  pox, that led him to think of
instituting  the experiments which produced  such interesting
results.   These results may be stated briefly, as follows:—In
four children inoculated from the above case, the disease was
mild, and of short duration—varioloid or varicelloid ;  in two, it
exhibited the  appearance  of small pox.  In  three men, who
caught the infection from sleeping in the same rooms with these
inoculated children, the disease was "uncommonly severe"—not
to be distinguished from small pox;  and in a fourth, under the
same  circumstances,  "the  mildest variety  ever described,  of
chicken pox."
   Upon these grounds, then, I cannot help reprobating  the intro-
duction of  a new term, the application  of which is  not only
unnecessary, but calculated to confuse and lead into error.  The
modifications which have been assumed to constitute a separate
disease, dignified with the  specific appellation of varioloid, are
each and all of them to be  found  described by the old writers,
under various  names.  Thus we  have from  Dr. Huxham, "an
Account of an  anomalous form of Small Pox at Plymouth, in
1741."  Thus we meet among the old writers with the phrases,
horn-pock, stone-pock, water-pock, wind-pock, crystalline-pock,
swine-pock, sheep-pock, chicken-pock, and numerous others,  by
which they intended to point out the undefined, but not uncom-
mon varieties, which the  variolous eruption occasionally as-
sumed.   I have already remarked, that chicken  pox was fami-
liarly recognized  as  one  of these varieties  until the time of
Heberden,  who separated  it  under  the  name of Varicella  or
Variola  pusilla, in which he was followed by Willan.  I now
add, that Dr. Bateman, closely as he was attached to Dr. Willan's
views in  general, found reason to  doubt their correctness in this
particular, as appears from an extract of a letter, written by him
to Dr. Howitz, of  Copenhagen, in which  he says, "I  am much
inclined to  concur with you  in  the  supposition, that chicken
pox is, in fact, modified small pox."
  These varieties and irregularities formerly noted of  variolous
disease, arose from peculiarities of constitution probably, in some
instances; in others, from local or general condition  of atmos-
phere, habits, manners, etc., and  perhaps in most, from causes
entirely unknown and unassignable. 
556
VACCINIA.
  To all these is now added, a more general  and an  uniform
disturbing cause—the  influence, namely,  of the  vaccine;  and
hence, at the present day, these variations  and  modifications are
more regular, and better defined than they were of old, as well
as infinitely  more frequent.
                      CHAPTER LVII.

                         VACCINIA.

   Vaccinia, the vaccine,  derives its  origin  from the cow,
 (vacca.)  It was first  made known to the medical profession in
 1798, by the justly celebrated  Dr. Jenner, whom we rank, un-
 hesitatingly,  among the greatest benefactors of the human race.
 The history  of vaccine is an exemplification of the acuteness of
 the remark of Southey, in his Omniana, "that most things are
 known before  they are discovered."  Prela,  physician  to the
 Pope in 1825, contends, plausibly, from passages in  Pliny and
 Celsus, that the  vaccine was known to the ancients, under the
 name of boa.  It had  been long  observed, in  Gloucestershire
 and  Dorsetshire, two  of the  dairy counties of England, that
 their cows were occasionally affected with a species of ulcera-
 tion about the udder, which communicated to the hands of the
 milkers a pustular eruption.   The occurrence of this  eruption
 was  noticed  to  have  conferred [upon  such persons  a security
 against the casual infection of small pox, and such  was the
 "general opinion," says Parr, "that the inoculator, who attempted
 to convey the small pox  to one who had been thus previously
 affected with vaccine, was ridiculed."  There was  no difficulty
 in following up so plain a hint, and the artificial communication
 of this  disease, as a preventive of variola, was  tried first by a
 farmer of that country, and  afterwards by Dr. Jenner, with the
 most satisfactory results.  The early writings of the latter  on
this subject were received with scorn, and his  papers refused
publication among the Philosophical Transactions.   It, how- 
VACCINIA.
557
ever, forced its way into notice ;  the value of the discovery was,
after vehement  and  angry debate, established on the most  au-
thentic basis, and the zeal of  its promulgator amply rewarded
by the British parliament.   Since that time the vaccine has been
extended all over the globe, and all nations of mankind have
exulted in the benefits thus bestowed upon them.  It was first
introduced into this  city by our highly esteemed historian and
practitioner, Dr. David Ramsay.  To  the present  time it  has
enjoyed the undoubting confidence of the profession, with scarce-
ly a solitary exception, and  at once superseded, and almost en-
tirely suppressed, the practice  of inoculation.
   Vaccination is performed by introducing, under the cuticle, a
small portion of lymph,  taken from a vesicle about the eighth,
ninth or tenth day, while yet  the fluid distending the vesicle is
transparent and colorless.   The puncture remains unchanged
until the third or fourth day, when slight elevation  and inflam-
mation are perceptible, which  increase slowly.  About the sixth,
it assumes a regular circular form, with a depression in  the cen-
tre.  The vesicle is completely developed on the eighth or ninth
day, and attains the average  diameter of one-third of an inch.
An areola now surrounds it of an intensely florid red color, and
some  febrile excitement of the system is perceptible, with stiff-
ness, pain, and slight swelling under the  arm, if the vaccination
be performed about the usual spot, above the elbow. The diam-
ter of the areola differs from one to two inches.  It is attended
with a degree of roughness, hardness and intumescence of  the
skin over which it spreads—circumstances which denote its ex-
istence  and extent in the black.  The vesicle is multicellular,
that is, composed internally of  numerous  spaces or little cells,
which communicate  freely with each other.   The  fluid within
these cells  begins to dry away  on  the eleventh or  twelfth day,
having  previously lost  its transparency, and  become  milk or
straw colored ; the areola at the same time declines, and gradu-
ally disappears.  About the twenty-sixth day, a hard round scab
of mahogany color,  smooth on the outside and remarkably hol-
lowed in the centre, falls  off, leaving a permanent cicatrix or
scar  of peculiar and characteristic aspect—its surface being
marked with  minute pits or depressions, similar  to those on  the
head of a thimble, "denoting,"  probably, "the  number of cells of
      47* 
558
VACCINIA.
which the  vesicle had been  composed."  It has been observed
that, in variolous inoculation, the vesicle forming at the point of
insertion has been attended by the eruption of others in different
parts of the body ;  but as respects vaccine, it is a fact of very
rare occurrence.  Two such instances, however, have been com-
municated  to me authentically.
  I shall not attempt to describe any of the numerous deviations
from the above history, which are to be met with in the irregu-
larly diversified forms of what are called  "spurious  vesicles."
Suffice it to say, that any striking or obvious  departure from the
ordinary phenomena, in the progress of a vaccine pustule, should
make us cautious of confiding a patient to its protective influence.
Vaccine, like every other disease, may undergo certain  modifica-
tions from  the condition of the  recipient, an infinite majority of
which are slight and unessential, not affecting its character and
influence,nor impairing its genuineness.  Others there  are, how-
ever, though few in number, which  change the nature of  the
specific action, either locally, or in its effect upon the system, and
thus render it "spurious."  Of  the local modifying causes,  the
principal and most common  is the mechanical irritation of  the
vaccinated  spot, (as by rubbing,) by which a common inflamma-
tion is substituted for the specific, and a common sore produced.
Erysipelatous inflammation  may also supervene and interfere
with the formation of a regular vaccine pustule.  Vaccine may,
perhaps, be affected by or combine with some forms of constitu-
tional  disease, and thus take on  a hybrid state.  All cutaneous
affections disturb the regularity  of its progress, if they do  not
hinder the  success of the operation, and no physician vaccinates
as willingly  from a pustule on  the arm of  a patient known to
labor under  scrofula,  herpes or lues venerea, etc.,  as from a
healthy subject.  There is a lurking doubt in the mind of every
one, however scornfully he may regard the humoral pathology,
whether he may or not, by vaccinating from such  a case, com-
municate a mongrel  disease.
   I am disposed to lay some  stress upon the  progress of matura-
tion of the vesicle, although this  may be  slightly hastened or
impeded, without detracting from the value of the pustule. Thus
the temperature of the season, if high, may occasion it to antici-
pate twenty-four or thirty-six hours perhaps; and severe cold on 
VACCINIA.
559
the contrary, by checking the cutaneous circulation, may retard
it in an equal degree.  The debility or robustness of the subject,
may give rise to like results.
  The pustule should be prominent and clearly defined, and the
areola distinct and vivid.  There should attend some febrile dis-
turbance of the general system.  The appearance of the scar, as
above described, I consider as of much importance.  We should
re-vaccinate when this peculiar appearance is wanting, and when
the scar is smooth and resembles that of a burn.
  I do not find the  observation made by any writer, but I have
certainly noticed the occurrence of a doubtful or spurious vesicle
to cause much difficulty in procuring, subsequently, the satisfac-
tory results of vaccination in the production of a regular or ge-
nuine pustule.
  Vaccination is, of course, best and most successfully perform-
ed with fluid lymph, taken  immediately from the vesicle, but
this simple  mode of communication is  not  always  possible.
When required to be transported  to  a distance, or kept for any
length of time, it may be preserved by various methods.  The
fluid is caught on a small  plate of glass, which is  pressed closely
against another of similar size and shape, and the edges waxed
to prevent the access of air. We receive it on the points of quills,
likewise protected from the air by envelopes.   Cotton  thread is
dipped in it, and laid aside with equal care.  But in the scab we
have the most convenient  means of preserving  and transporting
this invaluable agent.  It has been kept for years, and found ca-
pable  of commmunicating the genuine disease, just as  when  re-
cent.  It may be protected from the contact of air and moisture
by immersion in softened wax  and spermaceti.   It is scarcely
necessary to remark, that  the  first scab alone possesses the spe-
cific vaccine character; if  this falls off, or is rubbed off too early,
another may succeed it, but possesses none of its  useful pro-
perties.
  It is difficult in this latitude, to  preserve any form of vaccine
matter, (even the scab not excepted,) through one of our summers.
The heat and moisture of our climate, in the warm months, oc-
casion it to undergo a deterioration or decomposition, which ren-
ders it unfit for use—at  least, such has been the uniform result
of numerous experiments, made with  the  greatest  nicety and
care.  If we  fail in  transmitting the vaccine from one subject to 
560                      VACCINIA.
another, in continuous succession, through the summer and au-
tumn, we find ourselves  under the necessity of obtaining a new
supply from our more fortunate brethren elsewhere.
   Some have strenuously argued the  propriety of recurring oc-
casionally to the udder of the cow, the  original source of vac-
cine, to ensure its genuineness, and renew it from time to time;
but it may now be  looked on as settled,  that its primary and
essential characteristics are unchanged and unimpaired by any
imaginable number of transitions. Nay more, it is  obviously
improved  by thus passing through the human  system ; it is so
modified as to have become a milder malady,  though  not less
effectual in its influence on the constitution.  A person inocula-
ted directly from the cow, always suffers more, much more it is
said, than one who receives the infection from a human vesicle,
and as far as has been ascertained, with no  corresponding ad-
vantage to compensate.
   Among the animals which have been  found capable of receiv-
ing and communicating the vaccine,  are the horse, the  ass, the
camel, the buffalo, the goat, the sheep, and the baboon.
   It has been doubted whether variola  does or does not exert a re-
ciprocal influence upon the vaccine—whether it tends to prevent
its introduction into the system, or in any manner or degree modi-
fies it,  or disturbs its regularity when so received.   But the most
positive proof has been  obtained, of the transmission of perfect
vaccine, through constitutions previously subjected to the vario-
lous impression.   It has been in  this way brought  across the
Atlantic, by the successive  vaccination of individuals among
the passengers and crew of the  vessel, many of whom were
known to  have had the small pox.
   Much has been said of the difficulty of communicating the
disease more than once to the same  constitution.  Gregory, of
the small pox hospital, declares that "it is  impossible, or nearly
so, to  reproduce the vaccine in any thing like its  genuine form,
where the cicatrix left by a preceding  pustule is perfect, and the
result  of a perfect  vesicle."   Dr. Darrach, of Philadelphia, in
experimenting on this subject, found that the repeated insertion
of the matter in the arms of vaccinated children occasioned a
local disease, exactly similar to that produced by the first opera-
tion, with the exception that  the pustule and scab were much
diminished in size.  In none  of these  cases could  fever,  or any 
VACCINIA.
561
 other constitutional effect, be discovered.  Unprotected children
 were, with complete success, vaccinated from one of these scabs
 not larger than a line,  (one twelfth of an  inch in diameter,)
 which was the result of a fourth  insertion of the virus.
   The duration of the influence of the vaccine—the permanen-
 cy rather of the effect which it has wrought upon the system—
 has been denied by some who are staunch  believers in its tem-
 porary power to destroy the susceptibility of the body to  the
 invasion of small pox.  But the mass  of facts collected under
 this head, certainly goes to prove, that  whatever may be  the
 result of the vaccine inoculation, whatever the impressions made
 by it upon the organism, this result, these impressions, are  not
 likely to be impaired or obliterated by  any process of time, or
 any changes in the state of the system from any cause.  Of two
 hundred and fifty cases collected by Dr. Gibson, "in which small
 pox is said to have occurred after vaccination, it appears that by
 far the greater number had been vaccinated less than two years."
 In Dr. Thomson's account of similar eruptions, they  occurred
 at various intervals after vaccination, from a few days to fifteen
 years, not warranting, in any degree, the suspicion that the pow-
 er of the vaccine is weakened or exhausted by time.
   On the whole, I am nevertheless disposed to agree with the la-
 mented Forry, late editor of the New-York Journal, and author
 of the Boylston Prize Essay on the protective  powers  of vac-
 cine, that "the more you vaccinate the better ;" and with Roesch,
 would lay down the following rules on the subject:   1.  To vac-
 cinate every individual,  even those who have had the small pox.
 2. To re-vaccinate every ten or twelve years; and if at that in-
 terval the operation fails, to  repeat it annually until it  succeeds
 again.  To which, I would add a third—3.  To vaccinate and
 re-vaccinate universally, when variola becomes epidemic.
  Some of the more recent statistics of Prussia and of England,
 go to show that the trifling  inconvenience  of these re-vaccina-
 tions, is far more than compensated by  the evident advantage
 which has resulted from them.
  To ascertain the true influence of vaccine upon small pox, is
an object of the utmost  importance.  I will, therefore, briefly
and formally recapitulate the points fairly established, by a due
consideration of the facts collected on every side. 
562
VACCINIA.
   First, Vaccination is no longer to  be regarded as exhibiting
the absolute power of preventing the  access of small  pox.  In
some persons, it does seem completely to  destroy  the  suscepti-
bility to variolous contagion; in all it diminishes notably, though
in different degrees, the liability to be infected.
   Second,  The introduction of the vaccine virus into the system
in its genuine form, and in the proper manner, never fails to pro-
duce there such  changes as to modify certainly, the future influ-
ence  of the variolous  poison,  if, under any circumstances, it
should affect the constitution.
   Thirdly, The modification  thus asserted, does not appear to
consist essentially  in a diminution of the violence or duration of
the first stage, the  eruptive fever.  This, though it is in general
very slight, may be as severe as in casual small pox.
   Fourthly, Nor does it appear  to imply essentially a diminu-
tion of the quantity of eruption upon  the  skin, although  the
number of pustules is usually very  limited  in small pox, after
vaccination.
   Fifthly,  The great power of the vaccine unquestionably con-
sists in modifying  the progress of inflammation in the variolous
eruption.   Hence  the  slighter degree  of cutaneous  irritation,
which terminates in  numerous instances, without  secretion of
either lymph or pus—the less  amount of matter formed in  the
pustules (when effusion does occur,)—the sudden check given,
in a majority of cases, to the suppurative [process, after it has
commenced—the early disposition to rapid drying.  Hence  the
absence or transient duration of opthalmia, which,  with ulcera-
tion of the cornea  and  destruction  of the eye, constitutes  the
worst and most unmanageable sequela of unmodified small pox.
Hence the rare occurrence of sloughing of the cutis, and con-
sequent pitting, seaming and scarring of the skin.   It has now
become  happily, as  unusual  as it once was  common, to see a
person deformed with these marks of small pox.  Hence, lastly,
the infrequency of what is termed secondary fever, and its mild-
ness, when it does  show itself.   This is well known to be  the
most dangerous of the several stages of unmitigated small pox ;
it is tedious in duration, and leaves scarce  one constitution in a
thousand, without  inflicting severe injury and  permanent dete-
rioration.   The convalescence from  small pox is,  on this  ac- 
VACCINIA.
563
count, in the unprotected, notoriously slow.  On the other hand,
there is no convalescence more  rapid or more perfect,  than that
of a patient who has been assailed after vaccination.   He recov-
ers both perfectly and promptly.
  "Observe," says Dr. Gregory, "how strikingly opposed to (con-
trasted with) each other in this  respect, are the influences of in-
oculation and vaccination.  Inoculation lessens the quantity of
eruption but does not alter, in the slightest degree, the progress
of inflammation in that which  is thrown out.  Vaccination, on
the other hand, while it does not (necessarily) affect the quan-
tity of eruption, always influences more or less the progress of
inflammation in it."
   Sixthly, Nor can it be denied, that as far as we have a right
to draw our conclusions from the tables of mortality,  published
in reference to this question, vaccination tends much more surely
and effectually to the prevention of fatal results, than  inocula-
tion.  Thus, among the cases stated to us by Doctors Bell  and
Mitchell, as occurring in Philadelphia, in 1823-24, out of two hun-
dred and forty-eight, sixty-four had been previously vaccinated,
of whom one only died; seven had natural small pox previously,
three  of these died;  nine had been inoculated,  three  of these
died;  thirteen unknown, no  deaths.  Of those entirely unpro-
tected, (one hundred and fifty-five in number,) there died eighty-
five, more than one half—a dreadful mortality.
   It is surely impossible to set  in a stronger light the advantages
of vaccination, than is done in the above paragraph.  Results
similar to these are  given in the annual reports of the National
Institution of Great Britain, and in every other authentic  docu-
ment, without exception, to which we have access.
   In our own community, variolous and varioloid diseases have
prevailed repeatedly.  I give a  list of the deaths, extracted from
our annual bills of mortality, as follows :
   1824,    small pox,   1      swine pox, 1
   1825,       "   "   49
   1826,       "   "   29
   IQ2J        "   "            swine pox, 1
   1828, )  nQ aeaths recorded.
   1829, S
   1830,    small pox, 17      varioloid,  4.—Total,  102. 
564
RUBEOLA.
 Of whom, as far as I could ascertain, on the most diligent inqui-
 ry, but one was known  to  have been  previously  vaccinated.
 The greatest number of cases occurred in  1829-30.  Vaccina-
 tion had then been urged extensively.  The city and  suburbs
 contain a population of 40,343.  During the whole of the above
 period, cases of  small pox  were occasionally  brought into the
 harbor by vessels from infected ports.
   If we ask, how has this ancient and justly dreaded pestilence
 been deprived of its terrors, and shorn of its fatal energies, what
 shall be the impartial answer ?   Not by any change in the na-
 ture of the case, not by any loss of its inherent power over the
 human constitution, for the mortality among the unprotected is
 most appalling—greater than that of yellow fever,  or perhaps
even the plague, amounting every where, it would seem, to fully
one half.  Nor  is  it owing to such protection as  inoculation
affords, for that practice has been obsolete  among us for the last
quarter of a century.   But it is clearly attributable,  and  we do
not hesitate to ascribe it to the kindly influence of the vaccine—
the most valuable  among the generous benefits  conferred upon
their fellow men, by the cultivators of the divine art of healing.
                     CHAPTER LVIII.

              MEASLES.--RUBEOLA.--MORBILLI.

  It is not a great while since medical authorities have assigned
to measles a distinct and specific place in the long list of diseases.
The more ancient writers comprehended it under the same head
with variola, giving it the  diminutive title, morbilli.   The dif-
ferences which they  exhibit in progress, in character and in
history, are so obviously essential, and now so familiar, that we
cannot help feeling some astonishment  that they should ever
have been classed together.   There  are  not wanting, however,
certain points of resemblance, as  their contagiousness—their
occasional epidemic prevalence—and, in particular instances, the 
RUBEOLA.
565
 aspect of the earlier stages of eruptive inflammation.  Even as
 late as the seventeenth century,  physicians  puzzled themselves
 with these careless  mistakes and uncertainties.   Sennertus dis-
 cusses the question, "why the disease assumes in some constitu-
 tions, the form of small pox, and in  others, that of measles ?"
 And Diemerbroeck, in 1787, says "differunt  (morbilli,) a variolis
 accidentaliter, vel quoad magis et minus."
   Rubeola is a contagious  exanthem, consisting,  seemingly, of
 two elements—fever, of catarrhal character, with a peculiar cu-
 taneous eruption.   This combination constitutes the fully formed
 disease; but the separation of the two  is sometimes observed,
 and these departures from the ordinary history of the affection,
 have been exalted into a second  species  or  variety, by Willan
 and Good.   The regular type being known as rubeola vulgaris,
 Good styles  the variety first alluded to,  rubeola  incocta, to ex-
 press  its imperfect development; Willan,  aiming only at the
 description,  calls it  rubeola sine  catarrho.  The vulgar know it
 as "bastard measles."   That, on  the  other hand,  we  may  have
 the rubeolous fever without the eruption, is  asserted by several
 writers, and a sort  of relation or connection between the epi-
 demic  catarrhal affections, known as influenza and true measles,
 has been inferred from their frequent occurrence together and in
 rapid succession.
   The invasion of  measles is attended with the common symp-
 toms of fever—rigor or chill, followed  by heat of skin,  head-
 ache, nausea and gastric oppression, with hard and frequent pulse
 and thirst.   On the second day, the catarrhal symptoms  deve-
 lope themselves ; there is frequent sneezing, the eyes  being red,
 suffused and watery,  the  throat somewhat  sore,  with a harsh,
 rough, teasing cough.  On the third day sometimes,  but  more
 frequently on the fourth, the eruption makes its appearance; it
 is first  perceptible, I think, on the palate and roof of the mouth,
 and the forehead, spreading over the face; on the next day, it is
 visible  on the breast, and gradually covers the arms,  body and
 legs.  It is described as being formed of minute points or heads,
 less even than a millet seed, of a dusky red color, a little eleva-
ted, slightly  rough,  and arranged in patches, which are disposed
in a crescentic shape, sometimes  almost circular.  It  begins  to
fade on the face about the sixth day, and subsides in the reverse
      vol.  n.—48 
566
RUBEOLA.
order of its appearance.  We must not imagine  these  dates to
be precise and absolute; they are merely approximative.  It does
not show itself, in some instances, until the fifth or sixth day; in
one reported to me, not before the twelfth. Its common duration,
as above said, is from three to four days, fading  slowly.  Rush
saw it last, in a case in 1789, not less than nine days.   Its sub-
sidence is attended with  itching, and the  skin dries off or des-
quamates with small branny  scales.   The fever does not dimin-
ish so promptly or strikingly, on the coming out of the eruption,
as is seen in variola, but continues with little abatement, until that
subsides.   The eyes suffer much, the lids  being often swollen
and oedematous.  The inflammation is by no means confined to
the external surface; bronchitis and diarrhoea are often attendant,
and regarded by some, as accidental  complications ; by  others,
as metastatic affections;  I  am  rather disposed to consider the
respiratory and digestive mucous surfaces as  partaking with the
skin in  the specific morbid action which  constitutes the disease.
This may be greater or  less  in degree,  may be more or less
equally diffused, and may be, by whatever contingencies, deter-
mined more to one of these tissues than another.
  Measles is almost always  of the  inflammatory type,  but in
particular localities and in certain epidemic visitations, has been
known  to associate itself with fever of low or typhoid character.
This has been admitted by some writers, as a third species or
variety, and entitled rubeola  nigra—black  measles.  The erup-
tion, instead of its usual florid color, is here of a dark  red or
purplish hue.  It is described as being attended  with  some de-
gree of  languor  and debility, but as  by no  means serious or
alarming.  I have met with no examples  specifically according
with their delineations of this species.  The only instances re-
sembling it, that have  ever occurred to  me,  were of ordinary
rubeola, in which, either owing  to a typhoid predisposition in
the system, or from some other cause, a general collapse or pros-
tration of the vital powers took place, with  lividity or dark dis-
coloration of the eruption.
  The Cause of rubeola—its origin or primary source is  un-
known.  We meet occasionally with single cases, generated we
know not how—perhaps as the very first of all such cases must
have been spontaneously generated.   At present,  we only know 
RUBEOLA.
567
 it as contagious and epidemic.  Its  contagiousness  is  admitted
 universally at present, I suppose.  Our countryman, Dr.  Cald-
 well, who sometime since stood alone in  denying it, based his
 opposition to the received views, upon the fact, that  "it  is not
 communicable by inoculation, the only conclusive  test,"  as he
 maintains, "of contagion."   His premises are in every way erro-
 neous.   Neither typhus fever nor hooping cough are communi-
 cable in this way, yet it would require some hardihood to deny
 their contagiousness.  And with regard to measles, Home, Spe-
 ranza, and others, have made decisive and  successful experi-
 ments on the subject.   Home conveyed it by  introducing into
 the nostrils of a healthy person, a dossil of cotton soaked  in
 blood drawn from a cutaneous vein, at a part of the surface most
 thickly covered with eruption.  Thus excited,  the  disease was
 perfectly identical with, and fully equalled in violence the natu-
 ral attack.  Like all other contagious diseases, it frequently oc-
 curs as an epidemic, spreading widely and  rapidly.  Its  inva-
 sion in this way, usually happens in spring.
   The latent period between exposure and access,  is stated by
 Heberden to be about nine days ; by M. Hall, at ten  to fourteen ;
 by Willan, at  sixteen.   Home makes it,  after inoculation, six.
 The period of greatest contagious power, is supposed to be while
 desquamation  is going on. and to continue as long as this pro-
 cess is taking  place ; even for a  fortnight after  seeming conva-
 lescence.
   Rubeola affects the constitution but once, and  hence, perhaps
 it is, that we  see  few  cases  comparatively  in  adults.  I have
 stated the rule;  there  are  doubtless many exceptions.  Rube-
 ola without catarrh, incocta, bastard measles, is said to afford
 no protection against a second attack.  These I am  disposed to
 regard as merely local cutaneous inflammations, of  the  specific
 rubeolous character,  assailing individuals  much exposed to the
 contagion, at a period when the constitution, for whatever reason,
 is in an unfit state for the reception of the disease,  which  thus
 spreads its  force on the surface.  I have seen three adults  thus
 attacked a second time.   I have also met with  one  instance of
the repetition of true measles, in a lady, at an  interval of ten
years.  She was very ill on  both occasions.
  The general Prognosis is highly favorable; yet the malady is 
568
RUBEOLA.
by no means entirely devoid of danger.  The risk, in ordinary
cases, is proportioned to the intensity of the eruptive fever—to the
importance of the disorder of the mucous surfaces—and though
in a very indefinite way, to the amount  of cutaneous eruption.
Children are sometimes assailed with  convulsions, in the erup-
tive stage.   Adults are more liable to opthalmia, bronchitis and
diarrhoea.  These disturbances, as I have said,  I regard as spe-
cific.   If the eruption suddenly disappear, there is great reason
to dread the affection of the internal tissues and organs, which
must suffer unduly, whether  the determination of morbid ac-
tion to them,  be truly metastatic, or  only aggravated  by the
untimely withdrawal of that proportion which has been directed
safely to the skin.  The protraction of these visceral disorders,
after the disease has gone through its ordinary  duration, consti-
tutes probably, the greatest source of mortality from measles,
whose sequelae, as they are called, have thus become universally
dreaded.  Marasmus, probably from mesenteric tuberculatum in
children,  phthisis  in  the pre-disposed, chronic diarrhoea  and
chronic opthalmia, are not unfrequently  the  consequences of
severe or ill-managed attacks of rubeola.
  The Diagnosis of measles, is not generally difficult.  It has
been mistaken for urticaria, and oftener  for scarlatina;  indeed,
Morton calls the latter "confluent measles," alluding to the  cor-
responding phrase as applied to variola.  The  first  day of all
eruptive fevers, presents symptoms so  similar, as to allow of no
distinction.   On the second day  of the attack  of measles, we
can hardly fail to notice the catarrhal  irritation of the nostrils
and thorax, and the watery redness of the eyes.  These  are not
prominent in any of the kindred  exanthemata.   The cutaneous
inflammation, if examined carefully, will be found sufficiently
peculiar.  Measles runs in defined patches, circular or crescent-
shaped—scarlatina is in irregular spots or continuous.  The ru-
beolous eruption is always elevated and rough, that of scarla-
tina is softer and  smoother, and of a  velvety  feel.   A delicate
nostril is soon aware of a characteristic odour, which  belongs to
each of them, and indeed, to almost all diseases.  I cannot de-
scribe it, but am sure I can recognize many in this way.
  There is, you should be aware, a sort of hybrid affection,  par-
taking of the nature of both scarlatina and rubeola; designated by 
RUBEOLA.
669
 Dunglison as false measles, and known by various names to the
 profession and among nurses—French measles, bastard measles,
 etc.  Here you have the ulcerated or inflamed throat,  and red
 tongue of scarlatina, with the catarrhal cough  and sneezing of
 measles;  the gastric  derangement is  more  than  commonly
 urgent; the eruption is in points, and rough, like measles, but
 irregular in shape, and soft and swollen, like scarlatina.  I have
 seen examples of this kind, occasionally, all my  life, but they
 occurred in numbers, in the winter of 1842, and  the spring of
 1843.  I am informed  that they  were very numerous  at  that
 time, in Columbia, S. C, whence indeed, the first was  derived
 that I met with.   It is difficult to distinguish these cases, in
 which the preponderance of one or the other sets  of symptoms,
 will give name and character.  They are not  very serious, but
 I doubt their future protective influence.
   The Autopsy of measles presents nothing characteristic or
 uniform;  indeed, so few die during the active progress of the
 disease, that the  observations made  are  too  scanty,  to  give
 room for any definite statements on this point.  The secondary
 affections  which have proved fatal, have produced the ordinary
 lesions connected  with their idiopathic history.   Congestions
 and inflammations, cerebral, thoracic and abdominal, with their
 effusions, adhesions, ulcerations, and other  results, require no
 special delineation.  It is acknowledged, too, that  in some of the
 worst instances of mortal  impairment of constitution from the
 attack of measles,  no trace of organic  injury was discoverable.
   Of the  Treatment.   In a great majority of those assailed by
 rubeola—a self-limiting disease—which runs a given course and
 subsides after a  few days, with  small  proportional mortality, it
 would seem  reasonable to believe that very little interference on
 the part of the physician is required or indeed justifiable. Such
 is  indeed  the fact;  and nothing is demanded  of  us but a judi-
 cious supervision of the general management of most of the cases.
 A  well ventilated apartment, kept  at a temperature comfortable
 to  the feelings of the patient, and somewhat darkened to  prevent
irritation of the eyes, should be chosen for him; here he should re-
main, preserving chiefly the recumbent position, and if the season
be cool and the catarrhal symptoms annoy him much, he should
remain in  bed  favored  by the equable warmth of the covering.
      48* 
570
RUBEOLA.
He may take mucilages or the farinaceous articles as diet, with
sub-acid fruits, and use diluents freely.  If the stomach be much
oppressed with nausea and ineffectual retching, an emetic of ipe-
cac will give him relief.   If the headache be particularly severe,
a mild cathartic will probably be useful; after which, demulcents
through the day and a Dover's powder at night, or a full dose of
tinct: op: camph: will  subdue his  thoracic irritation and cough.
These measures will be aided much by the application of warm
poultices and fomentations, made variously relaxing and counter-
irritating, to the chest, to the stomach and abdomen.  You thus
perceive how little I approve of what is called "active practice,"
the use of the lancet, the drastic purgatives,  etc., in  ordinary
attacks.
  "Common measles," says  Parr, writing  in a climate colder,
moister, and better adapted to this depletion than ours, "common
measles rarely require bleeding."
  "Venisections," says the quaint old Lieutaud, "are seldom to
be repeated, unless there be danger of inflammation of the lungs,
difficulty of breathing, etc.; otherwise they are not only super-
fluous but  hurtful; notwithstanding  what  those may prate to
the contrary, who led by their own hypothesis, see nothing but
inflammation in almost all acute  diseases ;  for I have often ob-
served, not without concern of mind, that  while patients have
escaped who were committed to nature, others who were subjected
to this imprudent method, winged their way, in great numbers,
to the etherial mansions."
  I would fix  your  attention upon  the point hinted  at in the
above quotation—that the case is  not one of mere inflammation,
which we can by our remedies overcome and subdue ; there is
here a complication of specific morbid action destined to continue
for a time, which below a certain point, will be far less influenced
by our methods  of  depletion, than will the vital powers of the
patient.  I do not deny, however, that there may occur such ve-
hement determination to the thorax, such well marked pneumo-
nia or severe bronchitis,  as  shall require the lancet.   Here we
must bleed freely and promptly, taking away a sufficient amount
to make at once a decisive impression  on the system.  In such
instances too, we shall derive great advantage from a persevering
exhibition of the antimonials.  The tartar emetic is to be prefer- 
RUBEOLA.
571
red, and given in as full doses as the stomach will tolerate, com-
bining it with the tinct:  opii.
  The engorgement of the air passages in very young and aged
persons and in the infirm, known as peripneumonia notha, which
sometimes  attends both  the early and the  advanced stages of
measles, is best relieved by a prompt emetic, which will bring
away immense quantities of a thick tenacious mucus, with great
relief.  I prefer the sulphate of zinc or copper, or the mixture of
salt with mustard ; either of which will depress  and debilitate
far less than the ordinary formulae, of ipecac and antimony, and
may therefore be repeated more readily from time to time.
   It is an almost uniform  domestic custom to administer a ca-
thartic.   In subjects of common strength this is not to be objec-
ted to, and  will be found to diminish the sufferings from febrile
and catarrhal excitement on the first and second days.  The pur-
gatives selected should be unirritating, and is best combined per-
haps with some diaphoretic.  A very useful formula everywhere
prescribed in  our country, is the solution of sal: epsom in infus:
rad: serp: and when it has operated sufficiently, the infus: of ser-
pentaria may be persisted in with benefit as a sudorific. I would
advise the  cathartic  to be  abstained from, always however, on
the third or fourth day, or just at the breaking forth of the erup-
tion, in order that the  centrifugal  determination  to the surface,
proper to that period, may not be impaired  or interrupted.  At
this time I should prefer,  if I prescribed at  all, some remedy
which would promote determination to the skin, which must
now bear its part  of the morbid changes, destined to go on in a
connected series.  With these views, I mention only to disapprove
of the resort to cold affusion, proposed by Magrath, and "the
cool regimen" so  eulogized by some other practitioners.  I will
not stop here to discuss its adaptation  to small pox whence, by
an incorrect  analogy, it has been transferred hither; I will not
dwell upon the reasonable doubt whether it has been carried too
far in that malady, from a natural feeling of horror at the ancient
usages of the heating and alexipharmic system ;  but I contend
that from the very fact of the essential and  uniform presence of
the catarrhal  element, which  forms a  portion  of the history of
rubeola, it is  entirely unsuited here.
 .  In small pox too, the cutaneous  inflammation is vehement, te- 
572
RUBEOLA.
 nacious, and destined to form the most prominent part of the
 disease throughout a large share of its duration—while in mea-
 sles, it is never violent; it is transient, too, and holds both in im-
 portance  and continuance,  a very different relation to the pro-
 tracted internal and visceral affections with which it is associated;
 the pulmonary and  abdominal disorders so well known to con-
 stitute the chief dangers it is our duty to shun.  Hence, although
 I would cautiously  abstain  from all extremes, yet I would pre-
 fer the  evils of too  high temperature to the risk of chilling the
 surface and repelling the eruption.
   The  unpleasant occurrence of the "striking in" of  vulgar
 phraseology, sometimes produced by exposure to cold, sometimes
 the result of too  violent action of a cathartic, occasionally hap-
 pens  spontaneously, and  when  no  imprudence or mismanage-
 ment has been  committed.  Whether  as mere coincident effects
 of the common  cause, or as the  consequences of such  recession
 of the inflammation from the surface, we have always a train of
 urgent and troublesome symptoms betokening great danger. In
 children, convulsions  often  supervene suddenly.  I have seen
 fatal  cholera and diarrhoea  follow  in a few hours.   Extreme
 prostration and  debility, with great paleness or lividity of the
 surface, are usually the precursors of death.   Every professional
 exertion is here  necessary, and must  be made hastily  and assi-
 duously, and all our efforts will scarcely avail to save our patient
 from impending destruction.
  The hot bath, 100° fahrenheit or more, made more stimulating
 by the addition of salt or mustard; sinapisms, hot mustard poul-
 tices,  and turpentine, must be employed promptly; frictions ap-
 plied to the cold, flaccid skin ; camphor, brandy, the vol.  alkali,
 administered internally, and  in no timid doses.  The internal
 use of turpentine, in large quantity, has been advised, with or
 without tinct: opii;  and  the exhibition  of alcoholic enemata.
 Marshall Hall exhibits also the stimulant emetics, such as mus-
tard and salt.  If you succeed in arousing re-action, it must be
sustained  by cordial nourishment, wine whey spiced, arrow-
root with  brandy, and free  doses of sulph: quinine with cam-
phor ;  while epispastics  are put on  in due succession and
number.
  An opposite  condition  of  the  system is  said sometimes to 
RUBEOLA.
573
concur with this striking in or subsidence of the eruption ;  the
congestion being active, the  internal  determinations sthenic or
inflammatory.   In  such cases, a few of  which are on  record,
(vide  Mcintosh,) the  lancet  has  been used with  success,  and
topical depletion attended with benefit.  One or  two of these
have  happened in children, whose convulsions have been arres-
ted by these means, aided  by cold affusion to the head, while
the feet were kept in hot water or irritated by mustard, etc.
  I have mentioned the typhoid complication of rubeola. It  is
not an unfrequent variety  among our  black population,  and
constitutes a very serious and often  fatal form of disease.   At
the beginning  of such  attacks, the  emetic is a very generally
applicable, and often  an invaluable  remedy—indicated by the
thick,  furred tongue,  foetid breath, and  oppressive nausea.  I
prefer  the  quicker articles mentioned above—the  sulphates  of
zinc and copper, and the mustard  with salt.  By the concussion
thus communicated to the system, we remove visceral  conges-
tion, relieve vascular  oppression, and  determine well to the
surface.  This last effect must be continued  and  aided by the
steady use of the cordial and stimulating diaphoretics—aether,
camphor, ammonia, opium, and serpentaria.   The  bowels  may
be gently moved with enemata,  or,  if more be required, with
calomel or ol: ricini with turpentine.   Stimulants  and stimula-
ting nourishment are often required to be given as freely as the
stomach will bear.
  The cough,  which harrasses your  patient, will require demul-
cents  and anodynes.  Any mucilaginous infusion  may be made
the basis of your formulae, to which  you may add, as expecto-
rant, proper proportions of squill or tart:  antimon: or ipecac.  A
full dose of Dover's powder, or  some  other  opiate preparation,
should be  nightly offered, and smaller quantities  added during
the day to your cough mixture.   If  diarrhoea supervene, opium
will be your chief dependence ;  it may  be combined with the
acet: plumbi.   If contra-indicated, the cretaceous mixture, with
kino,  will be found serviceable.
  The  opthalmic irritation  which  attends  must not, in the
meanwhile, be neglected.  Cooling and sedative lotions  may  be
laid over the eyelids, and, if the inflammation  threaten to become
serious, leeches to  the lids and to the  temples, or a cup to the 
574
ERYSIPELAS.
back of the neck, or even a free bleeding may be required;  after
which, a blister between the shoulders or  behind the ears will
be useful.
  Your convalescent must not  be permitted too early to  expose
his eyes, weak and irritable as they will be, to the undue action
of light, or  to venture into the open air without the  protection
of some additional clothing.  His diet must be mild and easily
digested, and he  must be advised  to return slowly and  with
caution to his ordinary habits of living and his customary occu-
pations.
                      CHAPTER LIX.

   ERYSIPELAS—IGNIS SACER--ST. ANTHONY^ FIRE—ROSE.

   Whether  Erysipelas shall be arranged with the  Exanthe-
 mata,  is  still  an unsettled question.   Nosologists  are pretty
 nearly equally divided, but a numerical majority, perhaps, favors
 this classification.  It differs, in many particulars, from those
 which  I  have made  to accompany  it under this head.  For
 example,  it is not proved to be contagious.  The evidence on
 this point, recorded by Dr. Wells, of London,xmust not be over-
 looked ; and the opinion of Copland,  that it is  infectious,  is
 entitled to due weight.  Nevertheless, the amount of testimony,
 though it has accumulated somewhat of late,  is still insufficient
 to establish the doctrine.  It is not to be denied, that some pecu-
 liar  condition of the air  in the wards of hospitals at known
 periods, seems to predispose to erysipelatous  inflammation, and
 that the tenants of such wards are attacked in large proportion;
 but unless we can show that this condition is generated by the
 persons of the  sick, and not by the other circumstances present,
 we shall not be warranted in assuming the contagiousness  of
the disease.  The tenacity  of this condition, as confined  to a
particular  locality, is  curiously illustrated  by the fact stated in 
ERYSIPELAS.
575
Dr. Hillyar's "Narrative" of  "the peculiar tendency to erysipelas
in  the ship Caledonia  for several  years."   She was  always, he
says, "a sickly ship—a larger proportion than usual of her crews
suffering under any existing epidemic, and with erysipelas gene-
rally, as a concomitant malady."
  Some unknown contingency may spread its influences widely
enough  to deserve  consideration  as  locally epidemic, or the
development of these  agencies may be explained by combina-
tion.  Thus,  in Dr.  Wells'  examples, there was, probably, a
typhoid state of fever  conjoined with the erysipelatous eruption,
and I have more than once remarked upon the tendency of typhus,
not only  to exhibit in  itself, under favoring  circumstances, a
contagious property, but likewise  to render  communicable all
the diversified forms of disease with which it may become asso-
ciated.
  Again, erysipelas, unlike the acknowledged  exanthemata  of
which we have been treating, so far from operating any change
in the constitution which  shall forbid its attacking a second
time, seems rather to leave behind it a predisposition, greater or
less, to its own recurrence.   In some persons,  indeed, this pre-
disposition is  so  strong, that the  intervals between the attacks
are of very brief duration.   Hence it is, doubtless, that Copland
declares erysipelas to be capable of generating  a "constitutional
diathesis."  In others, a  local inflammation,  closely allied  in
character to that of true erysipelas, fixes itself with unconquera-
ble and persistent tenacity.  And again, all the other exanthe-
mata are self-limiting  in the true  sense of this word—that  is,
they come as  decidedly to a termination at or about a  given
time,as they continue  and  progress for a known period.  In this,
the proper meaning of the phrase,  erysipelas  is as indefinite as
the majority of diseases.  Its average duration may be  calcu-
lated at from six to  nine  days, but it often lasts from two to
three  weeks.    Weatherhead  observes  plausibly enough, that
"erysipelas appears to partake of the  nature both of the exan-
thems  and the sympathetic cutaneous  diseases.   It is often
ushered in by a precursory fever, and is at times infectious ;  it
is also as frequently to be traced to some idiosyncratic or sym-
pathetic affection of the primae viae."
  Writers have offered  us a number of distinctions by which 
576
ERYSIPELAS.
 they propose to separate erysipelas into as many species or varie-
 ties,  but  I am not satisfied  that there is any true ground for
 these views.  Tweedie proposes the following:—E. Verum, E.
 Phlegmonodes and E. Gangrenosum ; but the reference here is
 evidently to the results or modes  of termination of the local
 inflammations, which must depend upon a great diversity of
 uncertain and transient contingencies.
   Laycock has placed some stress, and, as it seems  to me, not
 unreasonably, upon the greater  proclivity  of the  part of the
 surface supplied by the respiratory nerve, to  be attacked by ery-
 sipelas, and the greater fixedness of the  disease in that seat.
 This refers to an old distinction which  recognized as the most
 important  and frequent of all  the forms of  the disease, Erysi-
 pelas Faciei—E. }of the face and head as  contrasted with  E.
 Erraticum or  the wandering, unsettled, comparatively unimpor-
 tant eruption upon the trunk and limbs.
   Erysipelas comes on with chilliness or rigor, alternating with
 irregular flushes, which at last prevail, and give burning heat of
 skin,  attended with headache, full,  hard, bounding pulse, redness
 of the eyes, throbbing of the temples, thirst;  there is  uneasiness
 at the stomach with  a foul, furred  tongue  and  foetid  breath;
 there are also pains in the back and  limbs, with muscular lan-
 guor.
   The  eruption  varies  in  the  time of its appearance.   Most
 usually on  the second day, some  swelling is perceptible, with
 redness of the skin of the nose or cheek or lip or ear, spreading
 gradually, but not slowly, over much of the  face and the head.
 It is  worthy  of  remark, that the  cutaneous inflammation  is
 almost always  confined strictly to one side of the face, bounded
 by  the  median line which divides  it  into  two parts.   More
 rarely it attacks simultaneously both sides.
  This inflammation, which is highly characteristic  in aspect,
and bears a very much more important relation to the constitu-
tional symptoms, than the cutaneous affection  in any of the
exanthemata, with the  single exception, perhaps, of confluent
small pox, deserves a careful description.  It is of a darkish  or
dusky, not a florid red, growing pale  on pressure, and resuming
its original hue not very rapidly—from which signs of inactive
circulation, probably, it is that Copland regards it as an asthenic 
ERYSIPELAS.
577
form of inflammation; there is evident swelling or elevation of
the surface, with a mixed sensation of soreness and  burning,
whence its  name of "fire" in several  languages; the swelling
and redness extend themselves, thus becoming diffusive, yet the
line is always well marked  which separates at the  time the
diseased  from the  healthy skin.  There is never any central
pointing as in phlegmon, nor is the elevation very notable.  Its
seat is in the whole of the skin, penetrating all  its  tissues, and
sometimes affecting the cellular substance beneath.  Erysipelas,
says Weatherhead,  "consists in an inflammatory affection of the
sub-cutaneous cellular membrane, whence proceeds the  atten-
dant anasarca—extending through the  corion to  the rete vascu-
lorum, whence the  efflorescence—and sometimes to the vessels
of the lamina albida, whence the occasional vesications."
  When  it  has  reached  the  lip, it occasionally extends  within
the mouth, attacking  the fauces, pharynx and larynx.   The
face is swollen and distorted, the eye being shut or nearly closed,
and the lid thickened and puffy with soft semi-transparent en-
largement.   Occasionally, as I said above, both sides of the face
are thus swelled, both eyes hidden, the  lips immensely thick-
ened, and the deformity hideous.  On the fourth or fifth day,
vesications  form by separation of the cuticle, which  is  raised
and contains a thin sero-albuminous effusion.  These break on
the fifth or  sixth, and their contents  ooze  out, drying away and
leaving crusts or pellicles.  In very favorable cases, there  is no
vesication;  the rough  and irregular surface subsiding, with  a
change of hue to yellowish. Both the  above forms run through
their course by the eighth or ninth day,  ending  finally  in the
desquamation  of the  old and the  formation of new cuticle.
In the  phlegmonoid variety, pus is secreted into the sub-cutane-
ous cellular tissue,  which even sloughs out occasionally.   The
fluid is of a thin consistence and unpleasant odor, often  mixed
with sanious serum.
  Erysipelas Gangrenosum, as its name imports, is distinguished
by its  peculiar malignity. The color of the part  is purplish,
small vesications form  early, and black spots are seen in the
skin, which go on sloughing with great local destruction occa-
sionally, and always with much danger to the patient.
  Erysipelas Erraticum is of frequent  occurrence.   It  is  to be
       vol. n.—49 
578
ERYSIPELAS.
 met with among children as well  as adults, and is called  by
 nurses, I know not why,  "the hives."  Red patches of various
 size and irregular shape,  having all  the  characteristic appear-
 ances of erysipelatous inflammation, break out upon many parts
 of the body and  limbs, frequently changing their place.   They
 are attended with much itching and some burning and soreness.
 There is generally no great  degree of febrile irritation;  yet, in
 some cases, the constitutional disturbance is serious.  The pro-
 gress and duration  of this variety are irregular.  Some  indivi-
 duals suffer from perpetual predisposition to it, so as very seldom
 to be free from it for any considerable length of time.
  The general disorder of the system in erysipelas  keeps pace
 with the cutaneous inflammation, and bears a notable relation
 to its extent, modified by its  form and the  locality it  occupies.
 The face and head are, in every respect, its worst seats.  There
 is apt to be delirium, at first violent  and distressing;  this gradu-
ally declines into a low despondency, with incoherent muttering,
 and  on the seventh, ninth, or  eleventh day, coma supervenes,
 with obvious prostration of the powers of life.  This is more to
 be dreaded, if the inflamed part assumes a  livid  hue  and col-
lapses suddenly, while the pulse sinks.
  The  Diagnosis of erysipelas can hardly be difficult in any
 defined example.   A speculative confusion has been suggested
 with  erythema,  but, not  to  speak  of attendant circumstances,
which, it appears to me, must prevent all chance of error, ery-
thematous inflammation is readily distinguished by the want of
thickening of the  cutis—by the unchanged surface of the cuticle,
and by the gradual shading of  the lighter colored blush lost in
the healthy skin.  Hosack defines  erysipelas to be  "a fever in
which some part of the  body is affected  with  heat, redness,
swelling and  vesications.   The tumor is  soft,  diffusive, and
irregularly circumscribed, and not accompanied with throbbing
or acute pain.   The last  mentioned circumstances distinguish
the tumor of erysipelas from that of phlegmon ; and  the pre-
sence of tumor, together with vesication, distinguishes the dis-
ease from erythema."
  The Prognosis in sporadic  erysipelas is  generally favorable;
it is much less so when  the disease is endemic or epidemic, as
when fixed  in  the wards of  a hospital or in an ill-ventilated 
ERYSIPELAS.
579
 house.  A great  many unfavorable combinations or modifica-
 tions, however, are described, which you should keep carefully
 in mind.  The most serious of these consists in the determina-
 tion to the head above alluded to.   Some  affirm this cerebral or
 meningeal congestion or irritation to be metastatic in its charac-
 ter.  I have not found it so ;  the symptoms of internal disorder
 being greatest always while the external inflammation was most
 intense, and subsiding as it declined.   The supervention of
 coma is most alarming among these cerebral disturbances, per-
 haps ;  but it  is very little less  so  to  find your patient sinking
 into a low muttering  delirium, picking in the air above him or
 on the bed clothes, with dry tongue, tremors or subsultus ten-
 dinum.
   If the fever assumes the  typhoid type, the pulse sinks and
 becomes contracted, and the eruption is  dusky, livid or  inter-
 spersed with  purple or  black  spots—the  prospect  is indeed
 gloomy.   This is a condition into  which the intemperate and
 debauched are likely  to  fall.  Indeed,  your  prognosis  must
 always be influenced by the previous habits of the individual—
 his age, constitution and circumstances, at  the time.  In the con-
 taminated air of  the wards of the large and crowded European
 hospitals, as we are informed by the best authorities, the sympto-
 matic erysipelatous inflammation that often follows the slightest
 scratch or puncture, accident or injury, proves fatal in a large
 proportion.
   The Autopsy presents little that  is characteristic.  When the
 brain has been affected, the  membranes are  reddened and  the
 vessels injected—the arachnoid has been found opaque,  and
 serous  effusions are  met with ;  but none of these appearances
 are constant.  Wells and Baillie  both tell us of instances  of
 delirium  and  coma,  where  no  cerebral  lesions whatever were
 discoverable.
  The Causes of  erysipelas, beyond the infection, contagion, or
epidemic influence  formerly discussed, are not clearly under-
 stood.   Intemperance in  the  use  of distilled  and fermented
drinks will give rise  to it, and so will gross  living on coarse
oleaginous diet; but many temperate men and delicate and  re-
fined females  are assailed by it.   Many  affirm its connection
with some vice of nutrition  or depraved  state of the organs of 
580
ERYSIPELAS.
digestion ;  but it is  very difficult to designate  this particular
condition.  It is occasionally associated with the gouty diathesis,
and attacks of regular arthritis are said to have alternated with
erysipelatous inflammation of some part of the surface.  Among
the exciting causes are enumerated a full and  stimulating meal,
more especially if of indigestible food, as of some fish and shell-
fish, exposure to sudden vicissitudes of weather, and the influ
ence  of extremes of  temperature, as when  the season is ex-
tremely hot or cold.
  Of the Treatment.   Sporadic erysipelas met with in ordinary
private practice,  not only bears, but requires, pretty active deple-
tion.   The lancet is very generally used, but a certain degree of
caution should be observed in its employment.   When the head
and face are assailed, and early delirium or coma has threatened,
we must bleed freely.  There seems to be  a  definite advantage
in pressing the venaesection to deliquium ;  indeed, some have
attributed  all the benefits of blood-letting to  the syncope in-
duced.   Thus, Martin Solon being  about to open a vein in a
delicate and timid young lady, she was so much alarmed at the
preparations made,  that she  fainted ; on her recovery, the cuta-
neous eruption had disappeared, but returning in a few hours, he
proposed again to bleed her, she again fainted, and the inflam-
mation subsided entirely.
  If the patient were of  doubtful vigor, and the pulse uncertain
in force and hardness, cups might be applied to the back of the
neck, or leeches to the temples and angles of the jaws.
  Allusion has  been made  to the  frequent connection of the
disease  with  certain  undefined derangements  of the stomach
and other digestive  organs, and hence physicians were led to the
exhibition of emetics, which  indeed are often found serviceable.
They are indicated by foulness of the tongue, with gastric op-
pression, nausea and  ineffectual retching.  I would prefer  the
tart: antimon: alone or in union with ipecacuanha.
  In the same class of cases, Cathartics are also of much  im-
portance.  The resinous and drastic are advised as most strongly
revulsive, and calculated best to derive  from the brain.   Jalap
with tart: antimon:  or the bi-tartrate  of potass: or calomel with
ipecacuanha  may be selected.  These will act  thoroughly, and
produce a general sedative and  diaphoretic effect.   The conti- 
ERYSIPELAS.
581
 nued  administration of the tartarized antimony,  in as large
 doses as the stomach will tolerate, is a practice highly eulogized
 by the best and most recent authorities.  It is said to be benefi-
 cial, not only, nor even chiefly, by its sudorific influence, but by
 its peculiar sedative or anti-phlogistic, or, as some call  it, febri-
 fuge operation.  If it act too freely on the bowels, this may be
 checked by combination with tinct: opii, or avoided by diminu-
 tion of dose.
   In epidemic erysipelas, however, and in hospital practice, we
 rarely meet with  the disease in this sthenic or inflammatory
 form;  and it is  found necessary to  modify the treatment, and
 adapt it to the varying contingencies.
   Topical depletion may be cautiously tried by cups and leeches;
 the less debilitating emetics used, such as sulph: zinci: or sulph:
 cupri; and the mercurial  cathartic, with rhubarb or magnesia,
 made to produce a moderate effect.  But even these mild depletory
 measures are often  forbidden.  In the London Hospitals from
 the time of Sir George Fordyce to the present day, we are told
 that it is commonly necessary to begin at once the exhibition of
 tonics and stimulants ; and free doses of cinchona are given from
 the commencement,  with wine and other cordials.
   Graves tells us, that  in Dublin, he is forced to resort to the
 sulph:  quinine both by the mouth and in enema, with wine and
 camphor—to which, from a notion of the usual presence of ac-
 ridity in the stomach, he adds magnesia.
   Copland advises free doses of turpentine, alternately or com-
 bined with calomel and camphor,  when coma threatens, or has
 supervened in these  bad cases ; and affirms that he has  seen be-
 nefit too  from mingling colchicum with the other remedies indi-
 cated.
   If the patient should sink  into a state of prostration, whether
 from the  gangrenous tendency of  the cutaneous inflammation,
 or the typhoid type of the fever under which he labors, we must
 have recourse to the prompt and assiduous employment of the
 highest order of diffusible stimuli.   I would rely  most confident-
 ly on  the alcoholic mixtures  with mucilage.   Some, however,
prefer the vol: alkali; indeed, one   writer  maintains that  it de-
serves to be regarded as absolutely specific here.  It is urged by
others still, that we should persist, in the meanwhile, with the
       49* 
582
ERYSIPELAS.
more permanent tonics, of which the majority consider the pre-
parations of cinchona and quina decidedly the best; while a few
contend for the special adaptation of the mineral acids.
   The treatment of the cutaneous  inflammation by local means
of relief, must  not be  neglected.  A great diversity of opinion
exists, however, as to the measures most appropriate, and I am
inclined to think that less  benefit is to be expected from any of
them than  you would anticipate from a perusal of what is said
by writers on the subject.  A long  list  has been  made out
of these local applications, affording great variety to select from.
Leeches to the inflamed skin are affirmed to diminish the sense
of burning and soreness, and lessen the tumefaction.
   To allay the severe irritation, as well  as the general restless-
ness, opium is used externally as well as internally.   The Do-
ver's powder is often beneficial after proper depletion, and I have
never hesitated to  prescribe the  alkaline  diaphoretic mixture.
To the part itself, undiluted laudanum is applied by some, while
others prefer a lotion  made  by dissolving opium in pure water.
Willan foments with  milk, bran and water, thin gruel, a decoc-
tion of elder flowers and of poppy heads. The analogy of appear-
ance with burns, has led to the envelopment of the inflamed skin
in carded  cotton, it is  said  with good effect.  Velpeau advises
the sulphate of iron to be used as a lotion, and put  on as an oint-
ment.  Chloride  of lime is  also used as a wash.   Many dislike
any unctuous applications, and direct absorbents to be sprinkled
in a dry state upon the vesications when broken, such as meal,
wheat flour, magnesia, starch, bark, etc., with a view to prevent
the sero-albuminous fluid which exudes, from trickling over the
neighboring  parts,  upon which it is supposed, without proof
however,—to exert an acrid and irritating influence.   Even if
this were true, frequent ablution with clean tepid water or with
a watery solution of opium,  or with some of the chlorides, would
be a better protective.  Bateman disapproves of powdery applica-
tions, and washes "with a cool but slightly stimulant lotion, such
as the diluted liquor ammoniae acetatis.
   Some extol the effect  of  compression, when feasible, with a
bandage or  even with  strips  of adhesive  plaster.   Copland,
Hutchinson,  Lawrence and  others, make incisions freely through
the inflamed skin into the  sub-cutaneous  cellular tissue; thus 
ERYSIPELAS.
583
depleting locally, relieving  the tension of the parts, and giving
vent to any effusions or secretions.  This plan is fully sanction-
ed by the best authorities, and should be  resorted to without he-
sitation in severe cases, unless specially  contra-indicated.  The
nitrate of silver, at first employed to prevent the spread of ery-
sipelatous  inflammation, by rubbing  it freely around  at a little
distance from its margin, is now also applied upon the inflamed
skin, and as we are told with great success.   The following pa-
ragraph incidentally appears in the "Report of the Massachusetts
State Lunatic Asylum," for 1842 :  "During the past season, ery-
sipelas, with  tendency to suppuration and  gangrene, has been
somewhat prevalent  in this  vicinity, and a few cases have oc-
curred among our  patients.  Three or four of these had exten-
sive suppuration and  were quite severe, but the free application
of nitrate  of silver arrested  the progress of inflammation.   In
three cases, in the incipient stage, the free use of the caustic, so
as to destroy the scarf-skin, entirely arrested the progress of the
inflammation, and  put an end to it  at once.
  Until of late, as  I mentioned, all  oily applications were prohi-
bited, but we have learned that  the  strong mercurial  ointment.
and even mere lard, are occasionally useful and palliative.
   With the view, I suppose, of substituting a less injurious and
perhaps more transient mode of irritation and inflammation than
the specific morbid condition already present, certain vehement
and impressive measures are  proposed.
  Undiluted  alcohol—strong ammoniacal  fluids—a  saturated
tincture of iodine, nay spts: of turpentine, are laid upon the part;
blisters are recommended by Dupuytren and Physick, and there
is abundant  testimony in their favor.  Willan, however, warns
us that "it is not safe to put them on or near the diseased surface,"
and gives us a similar warning too as to leeches.  I have found
vesicatories  serviceable, however,  as  general remedies;  that is,
as counter-irritants, to the  back of the neck or legs, when there
was urgent determination  to the brain,  and as excitants in low
and exhausted states of the system.  The actual cautery too has
found an advocate in Baron  Larrey,  who touched with the hot
iron distinct points of the erysipelatous surface, and not without
benefit.
  For my own part, satisfied that the inflammation in its simpler 
584
ERYSIPELAS.
 forms, possesses very little destructive tendency, and has an ob-
 vious disposition  to  come to a spontaneous  determination, in a
 few days at farthest,  with mere vesication and the loss of a por-
 tion of the cuticle, it is my custom to interfere very little, in or-
 dinary cases, with the part affected.   Frequent ablutions, when
 there is any oozing of serum, and, perhaps, keeping the  surface
 covered with a soft, thin cloth, wet with a watery  solution of
 opium,  constitute  most of the local treatment I advise.  But in
 erysipelas phlegmonodes  or gangrenosum, I resort  both  to in-
 cision through the inflamed skin,  and the free application of the
 lunar caustic around the margin and over the surface; with these
 I have succeeded  best, in giving relief to the suffering of which
 the patient complains so loudly, and in arresting the farther spread
 of the disease.
  I have  little doubt of the  correctness of Copland's opinion)
 as to the occasional formation of an "erysipelatous diathesis," as
 he phrases it, understanding by that term, a strong constitutional
 proclivity to renewal and repetition of attacks of this sort.  To
 prevent a frequent recurrence of them, to which some  persons
 are so subject, it will be  necessary to institute a strict examina-
 tion into the habits of the patient,  and to  lay down  such rules
for his guidance, as may serve to obviate this morbid tendency.
We can often trace the predisposition to excess in the indulgence
 of appetite, both in regard to food and drinks.  All such intem-
perance must be avoided.  Gross articles of diet, fat  and salted
meats, highly  seasoned  dishes,  pickles, cheese, shell-fish,  etc.,
must be thrown aside.   Milk, eggs, and the farinaceous prepara-
tions, constitute the best aliment for such persons.   If they are
indolent, a due amount of exercise must be enjoined upon them;
they should rise early,  and  retire early to rest, and learn as
promptly  and thoroughly as possible, the salutary lessons of
moderation and self control. 
SCARLATINA.                     585
                      CHAPTER LX.

      SCARLATINA.--SCARLET FEVER.--FEBRIS RUBRA.

  Among the eruptive fevers, scarlatina is justly considered as
holding a very prominent place.  A perusal of its recorded his-
tory, leads, I think, unavoidably, to the belief, that  within the
last quarter of a century it has been increasing notably in im-
portance, and has extended its  ravages in a remarkable manner
and degree.  I fear also, that we are bound to  acknowledge the
fact, that from causes not at all understood, and  in  defiance of
the close attention it has attracted from our profession, it has pro-
gressively become a more serious and fatal malady than formerly.
  Scarlatina is not specifically mentioned by  any writer, pre-
viously to the middle of the seventeenth century ; and when it
first attracted the notice of physicians, seems  by the names  af-
fixed to it, to have been  universally confounded  with other fa-
miliar diseases, or to have been regarded as a  mere modification
of these diseases.  By Morton, for instance, it was  styled mor-
billi confluentes, confluent measles, as bearing the  same rela-
tion to  rubeola that confluent small pox has to the distinct form
of that exanthem.
  The two appellations now commonly employed, in speaking
and writing of it, mean the same thing, and point to  the same
characteristic circumstance in its history,  the  redness, namely,
of the surface.   "Scarlatina" is an Italian word,  applied  in  its
description by the author, who speaks of  it first as appearing at
Rome;  and "scarlet fever"—"febris rubra," either as a transla-
tion, or from inevitable allusion to a very striking symptom, is
the title used by Heberden, in  his  essay upon it.  To Wither-
ing, however, who wrote much  later,  is ascribed the merit of
having drawn out its diagnostics with accuracy,  and  separated
it distinctly, from all the other  forms  of disease with  which it
had been confounded.  In marked attacks  this distinction is
clear and easy, but even now, we occasionally meet  with  cases
not easily diagnosticated.
  Scarlatina is commonly spoken of by authors, as  presenting 
 586                    SCARLATINA.

 itself under three forms—s. simplex, s.  anginosa,  s.  maligna.
 These are apparently differences merely in degree  of  violence,
 or perhaps of extension, so to speak, produced most generally, it
 is probable, by contingencies acting upon individuals, but often
 depending also upon endemic and epidemic influences.   In cer-
 tain localities, scarlatina is usually severe, and apt to be in large
 proportion fatal.   On the low alluvial banks of sluggish rivers,
 and in the neighborhood of marshes and  mill  ponds, and in
 densely populated and ill  ventilated quarters,  wherever typhus
 and typhoid affections are frequent  and obstinate, scarlet fever,
 when it invades, is likely to put on a formidable  aspect.
   So also in particular  seasons, an  epidemic scarlatina will be
 found highly malignant in the same place and among the same
 population in which a preceding epidemic has been  notoriously
 mild.  This difference, which arises often from causes so obscure,
 as to be altogether out  of our  reach, seems at other times rea-
 sonably attributable to the particular condition  of the atmos-
 phere, its moisture or dryness, the  temperature prevailing, the
 course of the winds, and so on.  We are told by Dr. Forry, that
 in Rondout and its neighborhood, on the Hudson river, where
 malignant fever prevailed in the summer of 1843, scarlet fever,
 invading at the commencement of the next winter, spread widely
 and put on a most pestilential violence.  This he ascribes, plau-
 sibly enough, to the lingering influence of that state of  the  air,
 whatever it was, which produced  the fatal fevers  of  the few
 months previous.  A similar example in our own community,
 seems to confirm these views.
  In Charleston,  whether  appearing sporadically or spreading to
 an epidemic extent, scarlet fever  has,  until quite recently, as-
 sumed a  mild and manageable form; although  we were not ab-
solutely exempt from attacks of exquisite intensity.  But in the
 autumn of 1843, and the  succeeding winter, it attained a wide
 prevalence among us, and startled us with a proportional mor-
 tality altogether unprecedented.   Yellow fever had shown itself
among us in the summer of that  year, and it is notorious, that
the largest share of deaths occurred  in the vicinity  of  districts
infected by  that  pestilence, especially upon Charleston Neck.
The deaths from  scarlatina, are recorded in the bill of mortality
for 1843, as amounting  to  twenty-eight  set down two-thirds of 
SCARLATINA.
587
 that number, in addition, for "the Neck" proper, and you have a
 list far beyond that of any former year.
   Of the Causes by which scarlatina is originally generated, we
 can take no cognizance whatever; the production of this  class
 of specific maladies, is the topic most impenetrably obscure in
 all pathology.  Of its mode  of extension,  we  know that it is
 propagated by contagion,  and is promptly disposed to spread
 epidemically.   The universal agreement upon the doctrine of its
 contagiousness, renders it unnecessary, perhaps, that at this day
 any formal evidence should be adduced in  proof.
   I might content myself with a reference to this general con-
 sent ; but I will add farther, that besides  the  impalpable com-
 munication from the diseased  body  through  the  surrounding
 atmosphere, experimenters have succeeded  in transmitting it by
 inoculation with  blood  taken from  patients laboring under it.
 Puncturing or making an incision where the deepest  and  most
 florid hue was noticeable on the surface, or where the skin was
 most thickened and elevated with papular  roughness,  the fresh
 fluid thus received upon the lancet, has been found  efficient in
 communicating it to a healthy subject.
   When it becomes epidemic in its extension, and spreads rap-
 idly over wide tracts of country, it may be doubted whether we
 are to attribute this dissemination of  it to a diffusion of conta-
 gious matter, or  to a coincident  concurrence of the unknown
 agencies that generate it in separate and distant localities.   I do
 not hesitate, however, to avow my opinion, that like many other
 epidemics, it widens its  range by an actual elimination and diffu-
 sion of a contagious principle, a true materies morbi.
   The matter of  contagion in scarlet  fever, I fully agree  with
 Watson in regarding as  singularly subtle, active, and  tenacious.
 In well  marked,  violent cases, especially  if long protracted, I
 have noted a peculiar odor exhaled by the patient, perfectly dis-
 tinguishable, and indeed, not to be mistaken.  It is highly offen-
 sive and disgusting, nay, I have known it occasion very depres-
 sing sickness  and nausea,  in attendants and visitors.  In one
 instance, occurring in the winter of 1S43, I could perceive this
 offensive smell, immediately on  opening the front door below,
while my little patient lay in a chamber above  stairs.   To pal-
liate the abomination, we removed him from room to room, but 
588
SCARLATINA.
it was never got rid of till the family left  the  house for a  fort-
night, and had it thoroughly scoured, white-washed and ventila-
ted.   I may venture to affirm, that cases in which this exhala-
tion was remarkably strong  and abundant, were in an  obvious
degree centres of infection.
  Symptoms and History.   In depicting scarlatina, we may pro-
ceed with reference to the three forms usually recognized, the
simple, anginose, and malignant.  These, I have  said, are  spo-
ken  of as mere differences  of degree or of violence;  perhaps
they may be looked  upon more  properly,  as distinguishing the
greater or less extension  of  the  influence of the  diseases over
the several organs and tissues.   Thus the most simple and mild-
est variety of scarlatina shows itself merely  on the cutaneous
surface, with little or no constitutional disturbance,  febrile or
otherwise.   In the anginose, we have the  mucous  lining mem-
brane of  the digestive tube irritated and inflamed, with soreness
of the throat and glandular swellings about the neck, and a long
train of consequences depending upon this condition; and lastly,
in the malignant form, the internal organs are also assailed, with
prompt congestion or destructive inflammation of  vital parts.
  You will meet with all these,  during the same epidemic, nay,
in the same household, and at the very same time.  One child
in a family will be carried off by the pestilence in a day or two,
or in a few hours; while another shall not willingly lose a meal,
or be confined to bed,  though covered  with the  characteristic
eruption.  Willan, combating the idea of any specific differences
among these classes of cases, concludes  with the positive deci-
sion, that "they all proceed from the same source,  because,  un-
der the same roof, in large families, some  individuals have the
disease in one form, and some in another, at the same period."
  The simple variety of scarlatina, comes on like other pyrectic
affections, with or without chilliness—though  there is scarcely
ever a marked rigor.  This  may be followed by some headache,
gastric uneasiness, and pain in the  back and limbs; vomiting
very generally attends, with thirst, redness of the eyes, frequent,
quick hard pulse, and a hot dry skin ; there is restlessness, with
anxiety and depression.  On  the second day, the eruption or
efflorescence shows itself; first about the face, then the chest, the
axilla, the arms, and so on, progressively spreading over the 
SCARLATINA.
589
body and limbs, and assumes a deeper and more florid hue. You
will find that authors differ somewhat, in their minute descrip-
tion of this rash or eruption.   Tweedie paints it as consisting of
"innumerable red points or dots, which are at first of a pale red
color, but afterwards assumes a deeper tint, giving the affected
portions  of skin, not only a uniform red appearance, but a per-
ceptible  roughness, which  is  most evident on the breast and
extremities."   It is disposed in patches of  irregular shape, with
intervals, at first, of a marked paleness ; the skin, at the bending
of the joints, is first colored, and  thence  it  extends,  until  in
severe cases it becomes, as  I have frequently seen it, absolutely
confluent.
  Other  writers tell us that it is at first papular, and that it oc-
casionally presents an  intermingling  of small  miliary  vesicles,
which are said to resemble the  sudamina of typhoid fevers.  In
one patient in whom the cuticular  inflammation was more in-
tense than I have ever seen it, with quasi erysipelatous deformi-
ty of the visage and enormous swelling  of the eyelids, which
could not be  separated for some days, the skin, on being exam-
ined by a lens  of good magnifying  power, offered  to  view an
almost continuous series of lenticular vesicles,  which, indeed,
were elevated perceptibly to the touch—filled seemingly, with a
thin transparent fluid.   I readily distinguish,  I think,  these va-
rieties  of scarlatinous efflorescence,  of each  of which I  have
seen numerous examples—the miliary, the erysipelatous, and the
diffused ; the first  has been described, the last  is that  which is
most commonly regarded as  characteristic.  But we meet with
a soft, glossy, tumid inflammation of the skin, in  some  cases}
coming out in stripes or weals; less  fixed,  too,  than the other
forms, but occasionally changing place, not of so deep a red, nor
of so high a temperature.   This, if it were not for  the concur-
rent circumstances, would scarcely  be known from what nurses
call "hives," the "erysipelas erraticum" of children.   I have seen
it connected both with the milder and the fatal varieties of the
disease.
  The eruption, of whatever form,  arrives at its height on the
fourth day, and begins to decline on the fifth; its duration may
vary a little in relation to its intensity, the milder and more scat-
tered subsiding rather earlier, and the more diffused and intense
      vol. n.—50 
590
SCARLATINA.
 remaining with little change, even as  late as the seventh and
 eighth.  It recedes as it spreads;  the alternating paleness of in-
 tervals of skin returning,  widening more and more, and the
 cuticle beginning to desquamate; generally in small branny scales,
 but not unfrequently in large patches, and sometimes coming off
 the hand and foot  in one continuous piece, like a glove or stock-
 ing.  This process is generally attended with  troublesome itch-
 ing of the skin; and the cuticular irritation is occasionally pro-
 ductive of secondary eruptions, irregular in appearance, difficult
 to describe, and tenaciously annoying.
   The febrile  symptoms usually  subside pari passu with the
 eruption, the gastric  disorder ceasing in ordinary attacks when
 that has come out  fully.  About  the third or fourth  day, the
 tongue puts on  in greater or less  degree  an appearance well
 known and characteristic. Through a whitish mucous fur which
 overspreads it, bright red points project, and increase in number,
 until the whole organ is at  last intensely red and somewhat sore
 to> the touch.   The lips and cheeks, and, indeed, the whole sur-
 face of the mouth, fauces and pharynx, assume the same aspect,
 sometimes becoming dry, and  even slightly  brownish.  This
 state of things remains a day or two after the cutaneous erup-
 tion, and may leave for a still longer period, a degree of soreness
 and susceptibility to  heat or cold,  or acridness or  harshness of
 substances taken into the mouth.
  2. Scarlatina Anginosa presents, in  addition to the train of
symptoms above enumerated as belonging to the simple forrm
and in connection  with a greater  prominence and higher vio-
lence  of the constitutional disturbance, a series of grave and
troublesome ailments.  The throat is much swollen  and vehe-
mently inflamed; there is sometimes ulceration of the surface of
the tonsils and uvula, but more generally a crust of plastic lymph
covers the membrane and passes down the pharynx,  grievously
impeding deglutition.  For the most part, the respiratory organs
 are but little affected, yet this dyphtheritic crust is  sometimes
 continuously deposited to the rima glottidis, and even within the
larynx, constituting a very  alarming, dangerous, and  often fatal
 complication of croup.   In some  cases indeed, it is  impossible
 to- swallow at all, fluids being regurgitated instantly,  and pass-
 ing through the nose.  The secretions  from these surfaces are 
SCARLATINA.
591
often in a singular degree acid and irritating; if swallowed, they
bring on nausea and diarrhoea, and from  the nostrils an  offen-
sive matter is poured out, which inflames and ulcerates the lip.
Ulcers  of disgusting  smell and horrid  aspect form upon the
cheeks and lip,  and the gums are swollen and  spongy.   The
parotid, submaxillary, and cervical glands are hard  and en-
larged, so as by their pressure to occasion dyspnoea ;  and impe-
ding the circulation, they give rise  to cerebral disorder,  coma,
and convulsions.  The redness and heat of skin  are  intense;
the temperature is said to have risen to 112° of Fahrenheit.
  3.  Malignant Scarlatina  deserves to be  regarded, perhaps, as
one of  the most uncontrollable forms of pestilence.  It assumes
such a protean  diversity of character  that it would be vain to
attempt to  pourtray all  its anomalies.   It makes its  invasion
sometimes, by attacking the  brain, and  this affection  may be
either inflammatory or congestive ; phrenitis being developed, on
the one hand, or on the other, coma and convulsions.  The little
patients thus assailed, die not unfrequently within twenty-four
or thirty-six hours, without offering  any cutaneous  eruption
whatever,  the  nature of the case being rather  inferred than
clearly known,  from the repeated concurrence of such fatal acci-
dents, with the  presence of well marked  scarlatina, or  unques-
tionable exposure to its contagion.
  Again, the attendant fever is, either from the first, or  becomes
at some stage of the attack, of low or typhus type.  The erup-
tion is  never well or  floridly thrown out; the skin is pale or
livid, and cold; the  face loses its turgidness and looks shrunken,
while the adnata of  the eye puts on a deeper red;  the rash
sometimes  "strikes  in" or disappears suddenly, with low mut-
tering delirium, a feeble, fluttering pulse, nausea, difficult respi-
ration,  and convulsions or coma.  This state of things is most
apt to supervene about the fourth day.  When the fever assumes
the low or typhoid character, of which I  have  just spoken, the
ulcers in the throat, or inflammation of the fauces and pharynx,
are apt to become gangrenous, and  sloughing more or  less ex-
tensive, may take place.  This  sloughing is by  no means so
common as  has been supposed—the sloughs  so called, being
generally portions of false membrane  or  plastic lymph thrown
off and discolored with  grumous and half putrid blood, but oc- 
592
SCARLATINA.
 casionally, there is  actual loss of substance.   In Dr. Morton's
 case, an abscess in the neck filled with blood, which flowed out
 through a leech bite so  rapidly  that the patient died in a few
 hours.   A friend tells me of an  instance in which  the  slough-
 ing of the throat was deep enough to implicate the carotid.  The
 child dying instantly of the hemorrhage.
   There are numerous derangements  of organs  and tissues so
 generally connected with scarlatina, that it is  not easy to decide
 whether they should be described as constituent portions of this
 terrible malady, or more properly regarded as incidental sequelae.
 In its progress, it is  capable of affecting, and indeed does  affect,
 in masses of cases, every tissue and organ of the body.  Opthal-
 mia assails the eyes, which remain weak and  intolerant of light
 for a long time, and the lids reddened, heavy and swollen.  The
 ears discharge for weeks, a noisome  fluid; nay, the organ is de-
 stroyed, and its bones fall out in a  state of caries or necrosis.
 The nostrils are corroded  and the septum  eaten away by the
 acrimonious secretion.  A chronic pleuritis or pneumonia is left
 behind, which may  become fatal weeks after apparent  conva-
 lescence,  with  pulmonary abscess  or empyema.   A chronic
 diarrhoea is  often troublesome.   There is a tedious  arthritis  or
 inflammation of the joints, quasi rheumatic.  The kidneys, how-
 ever, seem to me more uniformly implicated than any other por-
 tion of the  body, besides the skin and throat.  I am  indeed
 doubtful whether they escape entirely in any case.
   Since I have learned to be particular in my  inquiries as to the
 renal secretion, I find it uniformly altered from the beginning,
 in quality, or deficient in  quantity.   It is apt to be thrown  out
 at first,  in very small quantities, and not only  high colored but
 dark and turbid.   It is often more or less bloody, and this state
 of the urine I have seen continue for weeks.  It is  thus  that I
account for the well  known and familiar fact,  that dropsy is the
most uniform of the sequelae, so called, of scarlatina.  And the
essential nature of the connection seems  to me  to be fairly in-
ferable from the observation so extensively made, that the mild-
est cases of  this exanthem, are quite as likely  to  be  followed
ultimately by anasarca, as the most severe.  The intumescence
becomes notable, on  the average, from the sixteenth to the twen-
tieth day, and increases, so that the distension  of the skin  of the 
SCARLATINA.
593
 trunk is painful, the face is  deformed into a doughy  mass,  the
 eyes can scarcely be opened, the inability to move or  the indis-
 position to motion, probably combined with languor  and mus-
 cular debility,  confines the patient to  one position,  while he
 suffers too much from dyspnoea to permit him  to lie down a
 moment.   He is drowsy, dejected, loses his appetite, retches often,
 passes little  urine,  which is  albuminous, often bloody, turbid,
 brownish, offensive,  full of a  cloudy mucus, and depositing a
 dark, thick sediment.
   As a general rule, scarlatina affects the constitution but once,
 though  there are  many exceptions recorded.  Sir Gilbert Blane
 asserts truly,  that the majority of our patients are children;  yet
 I  have  had numerous  adults under my care  affected  with it.
 These seem  to me to be rather less liable than children, to the
 secondary series of symptoms, or so called sequelae.   With  Dr.
 Willan  I may affirm, that as yet it has never happened to me to
 meet with a second attack.
   All the exanthemata  offer for the embarrassment of the prac-
 titioner  numerous complications and irregularities, and scarlatina
 perhaps  most of all.  These show  themselves too, not only as '
 one would expect, in individual instances, but in considerable
 numbers of case's.  Thus you will hear of the occurrence of an
 eruptive fever in a particular neighborhood, which  for  some time
 the physicians in  attendance have been unable and unwilling to
 name.  I well recollect, in the spring of 1842, watching several
 patients through  an eruptive fever, in which  the  symptoms of
 urticaria, measles and scarlatina were so curiously  intermingled,
 that I was unable to satisfy myself of the predominance of either.
   An individual picture or two of the irregularity of our present
 subject may be instructive and interesting.   In  a little girl three
 years old, the eruption  and attendant circumstances were such
 as we usually meet  with in  anginose attacks of average force.
 The throat had not been very badly affected, and the inflamma-
 tion seated there subsided with the cutaneous efflorescence.  But
 the tongue and lips ulcerated foully and angrily, and the glands
 under the jaw  were swollen and  indurated.  There  came  on,
 about the tenth day, a second  eruption, resembling the first,  ex-
cept that the cutis was more thickened, and the inflammation was
more elevated and diffused over the body, showing itself little on
      50* 
594
SCARLATINA.
the face;  it was of less intense redness too, and was fading into
a brownish leathery tinge, when  a third eruption showed itself,
papular, conical, and gathering specially about the joints, attend-
ed with itching.  The skin at the date of the second was puffed,
as if oedematous  effusion had begun.   The lips, tongue, gums
and cheek all this while continued ulcerated—the stomach dis-
turbed with  nausea—the bowels irregularly lose—with emacia-
tion and loss of strength.  The dropsical  appearances soon sub-
sided, but the other ailments were tenacious and protracted.
  In a female patient aged seven years the ordinary scarlet rash
was, from  the  first, attended  with a papular conical eruption,
especially  distinct about  the  hands ; «its  roughness contrasting
strongly with the smooth velvety feel of the first, which assumed
what I have called the erysipelatous form.  The pointed erup-
tion disappeared first in this instance.
  Convalescence from scarlatina  is rarely  uninterrupted, as has
been already stated—or  regularly progressive.   Yet this some-
times happens; more frequently,  in proportion, with adults than
children ;  and  although it may  seem  paradoxical to make the
assertion,  more frequently among these latter when the attack
has been  severe  than if mild or moderate.  This, noticed by
many writers, has been variously explained, and is generally as-
cribed to some carelessness or imprudence  committed; but I re-
gard it differently, believing that the susceptibilities of the sys-
tem are in the one  case exhausted by the force of the malady,
and in the other left  ready to be affected by its tendencies diffu-
sive as we know  them to be,  and progressively extending  over
one tissue and organ after another.
  The best convalescence is here rather tedious, as the mucous
lining membrane of the digestive tube regains  slowly its capa-
city for its functions, and thus there can be no rapid recovery of
strength.   As to the removal of the secondary ailments  or se-
quelae, it is impossible to fix any limit  to their duration, and the
invalid improves so imperceptibly, that he can scarcely tell where
to date his restoration to health ;  weeks and months often elapse
before we can pronounce him well.
  Diagnosis.  It is not generally difficult  to distinguish scarla-
tina, but I have confessed that some obscurity may now and then
hang over particular cases.   The  early period  of the eruption 
SCARLATINA.
595
coming out, on the second or even the first day, as 1 have repeat-
edly seen; the promptness  of its spreading;  the  florid hue of
the surface ; the deep red clear glistening tongue; these are all
characteristic marks. The general smoothness of the eruption—-
its form not tending  to  the circular  shape  of the  rubeolous
patches,  and the absence of  catarrhal symptoms, distinguish
it from measles, with which  it has been confounded.
  So may excellent pathologists contend for its absolute identity
with cynanche  maligna—which  I still continue to regard and
have  elsewhere  treated of as a  separate malady-—that I have
litttle inclination to urge the controversy, which  indeed is of
little or no therapeutical consequence.  But I may be permitted
to repeat, that though the affection of the throat be  apparently
similar and the cutaneous  efflorescence,  (of which  I deny the
similarity,) be somewhat analogous,  yet the  condition  of the
tongue, the want of the peculiar scarlatinous heat of skin and
the absence  of  scarlatinous contagion—these taken together,
yield us a satisfactory diagnosis.
   Of the Prognosis I must speak in some detail.  It is not safe
to pronounce carelessly upon  the ultimate result of  cases com-
mencing with the most trivial symptoms.  In the same family
I came very near losing (when  they were  apparently convales-
cent, one from pulmonum anasarca, the other from diarrhoea,)
two fine  boys, for whom it had been unnecessary to prescribe
during the course of the eruptive fever  a single dose of medicine,
so lightly had they been assailed.  Of  the first I had been care-
ful, because of the morbid appearance of the  urine which he
had passed ; the second had given no premonition  to warn us of
his danger.   The  anginose  cases threaten most in proportion,  I
think, to the dysphagia, the  acrimony  of the mucous secretions3
and the glandular  derangement.  These two  latter sources, ac-
cording to Watson, become centres  of a  reinfection, a  sort of
secondary inoculation or contamination of the system.   Under
judicious management, this  modification, though never free from
risk especially among scrofulous subjects—will rarely prove fa-
tal in an ordinary constitution, under good  management and
prudent nursing.
   But in the malignant variety, the  proportional mortality is
very great,  and some  of the histories of such epidemics are 
596
SCARLATINA,
 really  terrible  to  read.   The particular  symptoms  denoting
 special danger, are, an  eruption only partially thrown out, or of
 dusky hue or mingled with petechiae.  If it disappear suddenly,
 "strike in," as the phrase is, or become purplish in color, with a
 cold skin, and pulse feeble and quick, there is imminent risk of
 death.   Dyspnoea, sighing and  syncope, are bad signs.  We
 infer unfavorably  from a  very  foetid breath, acrid discharge
 from the nostrils, ulcers in the mouth, and throat angry looking
 or sloughing  or disposed to bleed.   I have not often met with
 the sloughing ulcer; the sore  throat is membranous, more fre-
 quently quasi-dyphtheritic.   It is in these cases that the super-
 vention of croup is most to be feared.  Large glandular swel-
 lings coming  on early, or persisting long, threaten  evil.   It is
 very unpleasant to meet with great  determination to the brain,
 with phrenitis  or muttering  delirium, coma  or convulsions.
 Worst of all,  and  most hopeless, are the marks of strongly pro*
 nounced congestion, oppression of vital organs, collapse—capil-
 lary paralysis.  Such attacks, as Magendie said of similar cases
 of cholera,  commence  where  other  diseases  terminate in the
 death of the patient.
  As to the sequelae or secondary ailments, they are never to be
 disregarded.  Yet it is truly surprising how seldom the hydropic
 effusions prove fatal, especially as we know them  to be so gene-
 rally connected with a deeply engorged, congested, irritated and
 inflamed state of the kidney.   When the renal excretion is  suf-
 ficiently abundant, and of ordinary appearance and composition,
 we may hope  much ; the disappearance of glandular swellings,
 the return of appetite, of flesh  and strength, prove the validity
 of our patients' convalescence.
  Autopsy.   You will have inferred from the brief history just
 recited, the infinite variety and extent of lesions  discovered in
 bodies dead of scarlet  fever.  A minute recapitulation from the
 records would occupy too much  time, and would not, indeed,
 prove of any very great value.  Suffice it to say, that the results
of inflammation are every where traceable—in the brain by its
 increased vascularity, the thickening and opacity of its mem-
 branes, and  the various fluids effused within the ventricles upon
its surface and at its base ; in the  thorax, by abscess, and  effu-
sions  of pus  and  serum.  Ulceration of the cartilages of the 
SCARLATINA.
597
larynx has been met with.  Inflammation of the intestines, peri-
toneal effusions and  induration  of the  mesenteric glands, are
described.  The kidneys show all the consequences of morbid
determination to their surfaces and parenchyma, among which,
the most serious, is the granular degeneration of their Substance,
or "Bright's disease."
   Of the Treatment.  In the mild and simple cases of scarlatina,
which so often present themselves, whether sporadically or  du-
ring a prevalent epidemic, the patient, I  think with Sydenham,
has more to dread from the  "nimia diligentia medici," and the
anxiety of his attendants, than  from the  malady itself.   He
should be kept apart in a well ventilated chamber, and be placed
on absolute diet.  In many subjects, no farther interference will
be necessary.
   The gastric  irritation may be oppressive and annoying.   If
the stomach  be not  emptied of  its  contents  by spontaneous
vomiting, warm water or  a mild  emetic  may be  given for that
purpose; after the  accomplishment of which, a mustard  poul-
tice may be laid upon the  epigastrium, and small doses of pare-
goric exhibited, to quiet the disturbed organ.  When the pulse
rises, the skin becomes hot and dry, and head-ache is complained
of, a mild cathartic may be prescribed.   If convulsions threaten,
the lancet may be resorted to, or leeches put to the angle of  the
jaw or  temples, while cold  is applied to the head.  Let  me
repeat to you, that these  more impressive  means of depletion
are seldom  necessary, and even when most obviously  indicated,
require to be employed with caution.  Willan gives us a warn-
ing as to the  use of the lancet in this disease, and I  have  but
rarely been driven to it.  Cups and leeches are less objectiona-
ble.   Of purgatives, I usually select for children the  castor oil,
and calomel for adults, followed by a solution of Epsom salts
with rhubarb.  If any further  medicine seem demanded, it is a
diaphoretic, and the alkaline  mixture with tinct:  opii camph:
will suffice.   When the efflorescence upon the surface is  fully
thrown out, the heat of skin in this disorder is higher than we
ever meet with elsewhere, attaining to 106, 108 and even 112°
Fahrenheit.  This  suggested, naturally enough, the cold affu-
sion, urcred by Currie as so  important  a palliative  or remedy,
and recommended by Bateman, Tweedie, Craigie, etc.  Now, 
598
SCARLATINA.
although I do not belong to that  school which represents  the
cutaneous  affection in the  exanthema as metastatic and revul-
sive of, or alternating wfth the concurrent gastro-enteric irrita-
tion, I cannot help regarding the morbid action, or influence of
the morbid poison, as diffused over many tissues,  of which  the
skin must and ought to bear a very large proportion, and which,
indeed, this surface bears  most safely and with  least  risk of
injury.  I am, therefore, somewhat unwilling to relieve the skin
by any means of very forcible repulsion, at the risk of an undue
concentration of the force of vascular  determination  upon  the
more delicate and important internal structures.  The eruption,
indeed, is among the most active and tenacious that we know,
yet it can be unseated, and will occasionally disappear, as in  the
other exanthems, an accident always betokening, if not produc-
tive of, great danger,   Rayer  expresses the opinion, that there
is more liability to subsequent dropsy where cold affusion has
been employed.  The cold affusion  forms no part of my treat-
ment of scarlatina.  I sometimes venture upon partial sponging
of the face, arms, breast and feet,  with cool or  tepid water.
This is refreshing and not unsafe.
  In  anginose  cases, it is customary to apply leeches in proper
number to the angle of the jaw and around the neck, for the
relief both of the throat and the tumified  cervical glands, pro-
moting the flow of blood, and fomenting the part afterwards by
warm poultices.  Gargles  are generally irritating and injurious
in the early stages, but the steam of warm water may be  in-
haled with advantage.  Scarification of the tonsils has been
advised.  It was once customary to vesicate the throat beneath
the jaw, but this is inconvenient, and, as  some maintain, inju-
rious, as  likely to  bring a troublesome membranous ulceration
and  inflammation  of a quasi-erysipelatous character.  I have,
however, derived some  benefit from blisters applied to the back
of the neck and between  the shoulders, where  the  dysphagia
and  dyspnoea were severe.  It  is,  perhaps, on  account of the
pressure  upon  the vessels which carry blood to  the brain and
return it, made  by the indurated glands, that so many of this
class of cases present the  symptoms of cerebral disorder, some-
times phrenitis, but more usually coma or convulsions.  These
require the hair to be cut close, the head kept cool, and revulsion 
SCARLATINA.
599
 to be attempted by mild cathartics and counter-irritation to the
 extremities.
   Under  these  circumstances, we are urged by  many to  the
 repeated  and assiduous  administration of  emetics, of which
 ipecac:, tart: antimon: and sulph: cupri are preferred.  I do not,
 by any means, approve of their general or indiscriminate em-
 ployment ; but there are contingencies which call imperatively
 for the resort to one  or other of them.  The ipecac:  is best
 adapted for the mere relief of a stomach oppressed  by foul secre-
 tions or irritating exudations from the inflamed surface.   When
 there is an offensive ulcer or a dyphtheritic crust on the  tonsils,
 etc., I prefer the sulph: cupri, which is especially indicated, if
 the  symptoms threaten  croup.  This contingency I have wit-
 nessed, and have seen  fatal results from the extension  of this
 crust into the larynx, an occurrence which  Rayer  says never
 happens, and  Alison  speaks of as not uncommon.   Diarrhoea
 supervening, whether  from the irritating  nature  of the fluids
 swallowed, or from an affection of the mucous lining membrane
 of the bowels themselves, you will be  forced to prescribe ano-
 dynes and astringents, of which  the  cretaceous  mixture with
 kino and tinct: opii, or  the solution of acetate of lead with some
 preparation of morphine, will be the best.  The last mentioned
 formula will often quiet  the irritable stomach, relieve pain, and
 procure sleep, when every thing else is immediately rejected.
  The only fatal cases I have seen in adults,  were of this intes-
 tinal  combination.  One of them  sinking under  cholera, with
 immense  alvine discharges  of serous quality—the other being
 assailed,  on  the third day, with vehement and indomitable
 dysentery.
  Under  the general head of "malignant" scarlatina, there  are
 probably included some of the most  pestilential and  helplessly
 destructive modifications of  disease.   When assuming their
 most  exquisite intensity, some of these  attacks are altogether
 beyond the reach of our resources ; but  it is unnecessary to
 remind you that the gradations are infinite, from the mildest to
 the most violent; and  that vast numbers occupy that intermedi-
ate  and doubtful position which constitutes  the true field  for
professional skill and sagacity.  The very character of an attack
may undergo  the most  definite changes, from the  simple  be- 
 600                    SCARLATINA.

 coming anginose and malignant;  and the most threatening may
 subside into  comparative or absolute mildness.  The circum-
 stances cannot be  clearly pointed out which aggravate or ame-
 liorate this  pestilence.   In some families and  neighborhoods
 well nurtured and well attended,  it is in large proportion fatal
 during the same season in which  it has  spared the children of
 the poor and destitute.  Throughout  the last  quarter of  a cen-
 tury, while its character  has undergone notable variation as it
 prevailed from time to time in our city, it has uniformly exhibi-
 ted among the inmates of our Orphan-house its minimum ratio
 of mortality, a fact which is undoubtedly creditable  in a high
 degree to the physician, attendants and supervisors of that be-
 neficent institution.
  In the management of the serious cases of scarlatina,  which
 we are now  about to consider, it will be impossible to follow any
 general rule.   The condition of the patient must be carefully
 considered, and the closest attention paid to the symptoms  which
 from hour to hour, and  often with great rapidity of movement,
 present themselves.  When  collapse  threatens, stimulants will
 frequently be  demanded from the  very beginning.   Of these,
 each practitioner has his favorite.  Ammonia has,  by almost
 universal consent, come to be regarded as very generally  adap-
 ted, and the  carbonate may be prescribed, dissolved with mucil-
 age.  Capsicum is very extensively employed, and at one time
 enjoyed a high  reputation.  Besides  its stimulant quality it is
 supposed to exert locally a very beneficial influence upon the in-
flamed surfaces.  For myself I have  never derived any advan-
tage from it  in scarlatina.  Nay,  I have  never known a patient
who did not most earnestly refuse it, even when profusely dilu-
 ted, as burning  pungently the irritable  surface  of the tongue,
fauces, pharynx, etc. These are on the other hand, in cynanche
 maligna, entirely insensible to  it,  and  here I depend very much
upon the capsicum.  Wine whey, wine and camphor may all be
used in turn.  When the surface is  cold and livid the patient
should be placed in  the hot bath, and on his  removal mustard
 poultices and stimulating frictions resorted to.
  Our stimulants must, in such contingencies, be exhibited with
great boldness and decision, or our patient is lost.  A low mut-
tering  delirium—a  glazed, unsteady  eye—a livid or  bronzed 
SCARLATINA.
601
 countenance—a  faint and  fluttering pulse: such symptoms as
 these demand instant aid.   iEther, laudanum and brandy, must
 be given internally in no  timid doses, and heat, in  the most
 convenient forms, applied  to the extremities, while we irritate
 the surface of the trunk and limbs with warm sinapisms, tere-
 binthenate embrocations, or frictions with  other acrids.  And if
 we thus succeed  in re-lighting the almost extinguished lamp of
 life, we must not suffer it again to expire by too soon withdraw-
 ing the stimulants which have restored its flame.  In such cases
 the throat when examined is often  found  more or less swollen,
 of a brownish red color, spotted with masses of adhering lymph
 or aphthous crusts, or livid with ulcers of an ashy aspect.  The
 rapidity with  which  this gangrenous inflammation sometimes
 spreads, is truly  frightful,  including the  tonsils, arches of the
 palate and  uvula, the  lining membrane of the nostrils, eusta-
 chian tube, pharynx,  aesophagus, and, though rarely, the larynx
 also.   If an emetic be thought  necessary, under these circum-
 stances of feeble  circulation and general  depression of constitu-
 tion, I would  prefer the sulph: zinci or cupri, or mustard and
 salt, to the nauseating drugs, ipecac: or tart: antimon.
   When it is thought  proper to act upon  the bowels, if an enema
 be not sufficient, calomel is among the safest cathartics, and may
 be combined with  camphor or  the vol:  alkali.  The  spts.  of
 turpentine have been found appropriate  in certain instances  of
 remarkable  torpor and feebleness.   Cinchona may, in its several
 preparations, be advantageously united with our stimulants and
 diaphoretic  formulae.    Its  infusion  with  serpentaria,  perhaps,
 deserves a preference.
   As local  applications or washes  for the mouth, fauces and
 throat, the chlorides and chlorates, and even chlorine itself, are
 strongly recommended.  Watson eulogizes the chlorate of potass:
 which  should  be  drunk freely. If  the patient  cannot swallow
 nor gargle, the chlorides of lime and of  soda may be used with
 a mop, or injected forcibly into the mouth and nostrils.
  The sequelae of scarlatina, the  long train of maladies which
 result from the several congestions, irritations and inflammations
 of the organs and tissues implicated in the course of  the attack,
must be briefly spoken of. The ophthalmia, otitis, bronchial and
pulmonary derangements, dyspepsia and diarrhoea, present, as it
      VOL.  II.—51 
602
SCARLATINA.
has seemed to me, no peculiar phenomena, although rather more
tenacious than similar attacks arising  otherwise, and are best
managed by the  ordinary treatment discussed elsewhere.  Not
so with the hydropic affections so commonly met with in this
relation.   These have  two obvious sources.  Anasarca, of dis-
tinct and insulated character, may arise simply from the cuta-
neous inflammation which has run so high ;  and when depen-
dent solely on this cause, will probably soon subside of itself, or
be found readily curable.  But the dropsies which result from a
diseased  condition of the kidneys, are evidently far more serious,
and are likely to be found troublesome  and obstinate.  In both,
the urine will be  found albuminous—in the  latter, it will also
be turbid, and perhaps bloody.   The  general  health will be
more disturbed—there  will be  pain  and weakness of the loins,
where  pressure will probably give some uneasiness, and may
detect fulness and enlargement of the organ.
  I am uncertain whether the renal affection is properly inflam-
matory—at any rate, the  remedies applicable to diseases  truly
inflammatory, are seldom appropriate  or  useful  here.    Some
have resorted to V. S., they tell us, with benefit.   More fre-
quently the loins  have been cupped or  leeched, the  saline and
neutral cathartics have been administered, and  many  regard the
sup:  tart: potass: as'singularly serviceable.
  I prefer, for my own part, to depend on  the cautious employ-
ment of digitalis and colchicum, keeping the  bowels carefully
soluble, rather with the oily, resinous  and  mercurial,  than with
the saline purgatives.  Poultices should Be frequently applied
over  the kidneys, and the tepid or warm bath used often.  The
patient should be warmly  clothed, and carefully protected from
draughts of air or vicissitudes of weather.   When the tempera-
ture is  comfortable, and the  sky clear,  let  him have moderate
exercise in the open  air, and adapt his diet, with nice attention,
to the  capacity of his digestive apparatus.  This course will
prove very generally successful;  it  has happened to me among
all the threatening  cases  of scarlatinous dropsy, and they are
very numerous for which I have been consulted, to witness but
a single  death.  This occurred  in a  child of particularly bad
constitution, whose life had been nothing but a long disease, and
who bore every mark of universal scrofula. 
SCARLATINA,
603
  The terror and dismay naturally consequent upon the preva-
lence of scarlatina, especially when  as  an epidemic it has exhi-
bited the malignant influences which so frequently characterize
it, have given much importance to the discussion of the means
of prophylaxis or prevention.
  When experimenters discovered the  possibility of communi-
cating  the disease by sanguineous inoculation, a transient hope
arose, that, like small pox, it might, when  thus spontaneously
brought on, prove of more benign character, or that some advan-
tage might be gained  by the choice of time and circumstance.
Nothing, however, seemed to give any confirmation to this hope,
which  soon  died away, and  is  now  never heard  of.  Yet, as
different scarlatinous  epidemics differ so extremely and so obvi-
ously in their ratio of  proportional mortality, it does not seem to
me unreasonable to  avail ourselves of the fact, and choose, for
our young subjects, who, when brought up in cities, at least can
hardly escape an attack  at some  time  or other, a period when
they will run less than the  average risk, as, for instance, when
the prevailing epidemic  is of specially mild character and small
proportional mortality.
  Another prophylactic method, which has  of late years gained
ground, and received much notice from the  profession, consists
in the employment of belladonna.   This was first suggested by
the celebrated Hahneman, the father of the Homeopathic school
of medicine.  He was led to this discovery, if it be one, by his
peculiar views of the  modus operandi medicaminum.  The doc-
trines of homeopathy, as the word indeed implies, are  founded
on the  belief, that diseases are to be successfully combated by
such remedies, and such only as produce effects upon the system
similar to their characteristic symptoms.  He observed, that bel-
ladonna, when taken internally, gave rise to heat and dryness of
the throat, swelling of the sub-maxillary glands and a cutaneous
eruption—sometimes  a mere efflorescence, at others a  papular
rash.   Hence, he inferred boldly, or sagaciously, that  as these
symptoms were analogous to those of scarlatina, he had found,
in the source of them, not only a remedy for, but a preventive
of that  exanthem.  Since 1807, it  has  been very extensively
experimented with, not only in  Germany, but in France also,
England, and our own  country, and  a very large mass of evi- 
604
SCARLATINA.
dence has been  accumulated  in  its  favor.  The quantity of
belladonna which he advises, is  of course very minute.  The
general mode of  prescription, recently in use, is as follows :—
Three grains of the extract are to be dissolved in one ounce of
distilled water, and of this solution two or three drops are to be
given, twice  a day, to a  child under twelve months, and one
drop more for  every year above.  The  length  of time  during
which we should persist in this  course, does not seem to be
pointed out with distinctness.  Professor Koreff thinks it should
be carried on eight or nine days at least before  exposure.  Nor
do I find any definite statement, or even any calculation, as to
the duration or permanence of its  protective influence upon the
constitution.
  Its advocates farther maintain, that even when it has failed,
from  any adverse circumstances, to  prevent the attack, it is
certain to render  it obviously milder, a very important  fact, if
established.
  You are aware of my unwillingness to set  in array negative
against positive testimony, and my readiness, always, to acknow-
ledge the  preponderance due to  the  latter over  the former.  I
mention, therefore, without  laying any undue stress  upon, the
numerous records of unavailing efforts to prevent, or even to
modify, in any notable degree, the attack  of scarlatina in exposed
subjects, by the use of belladonna, that I myself have  repeat-
edly tried  it both in the small dose above mentioned, and  in four
or five times the amount, hitherto, without having derived  the
least perceptible good effect from it.
  But I would  not be justified, if I omitted to press upon your
attention  the claims of a prophylactic, which, as far as is  yet
known, has been productive of no evil whatever, and which, on
the other hand, is asserted upon very respectable and increasing
evidence, to have  been followed by the  most beneficial and satis-
factory results. 
DENGUE.
605
                     CHAPTER LXI.

                         DENGUE.

  By this name is known an eruptive fever, or exanthematous
affection, which, in 1827-2S, spread extensively over the West
Indian Islands and the neighboring coast of the American con-
tinent.  It seems to have  appeared first  in  the  island  of St.
Thomas,  the  chief town of which, it invaded in  September,
1827, attacking in rapid succession almost every individual in a
population of about 12,000.  Towards  the end of October,  it
passed over to the neighboring island of St. Croix.   We hear of
it, in November, in St. Bartholomew's, and in Antigua in January,
1828.  It prevailed at Havana in the succeeding April,  at New-
Orleans in May and June; and in July and August affected very
generally the inhabitants of this city, and  reached Savannah
(Georgia) in September and October.  During the same summer,
it is said to have shown itself at several points of the  Gulf of
Mexico, south of  the Mississippi, and even along the  Atlantic
coast of South America ; but we have no authentic details of these
occurrences, which were merely noticed in  the newspapers  of
the day.   As winter approached, it ceased gradually, either hav-
ing no new subjects to attack, or subsiding like other epidemics,
and has not, since that period, been met with any  where in a
definite or regularly recognized form; in this its brief duration,
in the suddenness of its appearance, in the rapidity of its spread,
and in its total subsequent extinction, offering a striking resem-
blance to the  black death  of the fourteenth century,  and the
sweating sickness of the sixteenth, and  several other shapes  of
pestilence which have, at different points of time arisen and died
away, scattering among the nations  horror and affright.  Hap-
pily, however, as  the record will show, it was much unlike these
plagues in proportional mortality; bringing in its train infinitely
less of danger and of  death than of mere suffering.
  No definite signification is attached to  the title by which it
came to be universally known.  The negroes at St. Thomas called
it "the dandy fever," from the stiff,  affected gait of those labor-
       51* 
606
DENGUE.
 ing under it.  In  Cuba  it was termed  "Dengue or Dunga;"
 whether this is merely a modification of the English slang-word
 dandy, thus altered in Spanish pronunciation, is not clear.  One
 writer  affirms that the word occurs in the vulgar cant of the
 lower classes in Havana, and is used to denote the staggering un-
 certain walk of an intoxicated man.  We shall see, as we pro-
 ceed in the description of the disease, the application of these
 phrases.
   Symptoms.  Dengue usually made its  attack with pain, stiff-
 ness, and swelling of some of the  smaller joints, often of the
 muscles of a limb, rigidity of the neck, aching of the back and
 loins.   These  pains  were  followed, after an uncertain though
 generally brief period, by headache—suffusion of  the eyes—ab-
 rupt, full, frequent pulse—hot, pungent, dry skin—restlessness,
 thirst, and other tokens of febrile excitement.  The fever did  not
 remit, but declined and  disappeared in a great majority of cases
 on the second or third day.   In this early stage the tongue was
 generally clean, and the stomach quiet, but sometimes there was
 nausea or even vomiting.   The  determination to the head was
 occasionally violent.  Instances occurred in which delirium was
 among the first symptoms, coming on at the commencement, and
 enduring until the subsidence of the febrile paroxysm.  At this
 time the skin lost its heat and dryness, becoming  relaxed, with
 abundant perspiration ; and the local pains were all lessened in
 degree. A sort of miliary eruption  or rash in some persons at-
 tended this sweating stage, and in a few others preceded both the
 local pains and the fever.   It  was, however, as  connected with
 this first stage of dengue, a very  inconstant affection, seeming
 rather a mere accidental coincident than a symptom.  The pains
 of the joints and muscles which, as has been said, were diminish-
 ed in severity at the subsidence  of the febrile exacerbation, did
 not go off entirely;  a degree of  swelling, stiffness, and tender-
 ness of the affected parts  remaining  permanently, though vary-
 ing much  in intensity in different individuals. This condition of
 things constituted a sort of deceptive  interval between what may
 be described as the first and second stages  of this strange disease.
 Many now believed themselves to have past through the attack,
and attempted to resume  their ordinary occupations ;  but soon
had occasion to discover that their sufferings were  by no means 
DENGUE.
607
 at an end.  On the third or fourth day, there being no fever pre-
 sent, or a very obscure degree of it, the tongue would begin to
 be coated with a yellowish fur,  and the stomach would become
 distressed, uneasy, and irritable.  The patient was now low-spi-
 rited,  fretful, and anxious.  Vomiting came  on in  some, with
 great  languor, lassitude  and debility, and restlessness at night,
 This was regarded as the most oppressive and insufferable of the
 stages of the malady.  On the fifth or sixth day from the inva-
 sion, the  period varying  somewhat in different individuals, the
 annoying symptoms just described were relieved by the coming
 out of an abundant  eruption, met with so constantly and in so
 very great a proportion of the  cases, that it clearly demands to
 be considered a characteristic and essential circumstance in the
 history of the disease.   It consisted  of minute papulae, some-
 what  elevated, of a florid  red, and distributed  in  irregularly-
 shaped patches;  the feet and  hands being somewhat swollen,
 with a sense of numbness and  thickening.  It appeared first on
 the face, then on the trunk and thighs, gradually  spreading to
 the extremities.   It resembled  scarlatina more than measles in
 the hue and  aspect of the skin, but was less diffused or  conflu-
 ent than either.  When  fully developed, it was attended with
 some itching and burning of the surface, and at this time a se-
 cond febrile paroxysm came on with return  or aggravation of
 the muscular and arthritic pains.  Inflammation and enlarge-
 ment of the  lymphatic glands in the  neck, axilla, and groin at-
 tended in a good many cases ; these parts being apt to continue
 swollen and  painful for some time after convalescence was fairly
 established.   In a few instances, suppuration of these tumors took
 place.   The  eruption disappeared after two or three  days' dura-
 tion, becoming gradually paler,  with some  desquamation of the
 cuticle.
   Of all the symptoms of dengue the affection of the joints was
 the most tenacious and troublesome, adhering for weeks to some
 patients, and constituting a  sort of permanent lameness  or loss
 of mobility.   Nay, even  now (January 1835,)  some of the popu-
 lation of cities visited by this plague, persist in speaking of  the
 rheumatic or quasi-rheumatic decrepitude and pain under  which
'they labor as "the effects of the dengue."
  All classes of persons were subject to this singular exanthem, 
60S
DENGUE.
 and all equally and alike.  The aged and the young, the infirm
 and the  robust, the native and the stranger, the black and the
 white, all  shared  the  same  sufferings.  Very  young  children
 were liable to the disease, even from a few days after birth ;  nay,
 some were supposed to be actually born with it.  The circum-
 stances of these latter cases are  described as  follows:— The
 mother having recently passed through the attack, or still labor-
 ing under it, the skin of the infant at delivery was observed to
 be of a scarlet red, the tongue and lips smooth and fiery ; it was
 obviously in pain,  and  could  not bear  to be disturbed, screaming
 violently  if lifted, or if its limbs  were  moved ever so gently.
 Below the fifth year of age, convulsions very often attended the
 invasion, and in some instances were repeated  with frequency
 throughout the whole  course of the attack.  In very advanced
 life, there were from the first, great debility and  extreme prostra-
 tion.   Some old people were  afflicted  with erysipelatous inflam-
 mation of the lower extremities, supervening after the eruption
 had disappeared.
  Bregnant women when attacked, were very liable to abortion,
 and a remarkable number of miscarriages and premature labors
 occurred.   The violent pains in the back and loins, which came
 on so generally at the invasion, extended downward into the
 thighs, and the uterus being thus excited, the foetus was ultimate-
 ly expelled.   A sore mouth was among the frequent symptoms
 of dengue, and one or  two instances of pretty severe  glossitis
 occurred.   In the  worst  of these,  the appearance of the organ
 has been completely altered, and its  functions much impaired,
 indeed nearly abolished ;  the articulation being  extremely indis-
 tinct, and the  capacity  of appreciating taste and flavors singu-
 larly defective.  The surface of the member is  intersected with
deep lines, which divide it in every direction, like flesh which
has been "chopped" for culinary purposes.  The ulcers formed
in the mouth were often  very irritable and painful, and  healed
 slowly and with difficulty.  Then  followed a free flow of offen-
 sive saliva, with lividness and sponginess of the gums, offering
considerable resemblance to the symptoms of mercurial ptyalism.
In a few cases hemorrhage occurred from the gums and fauces.
  Pathology.  Dengue is  to be classed properly among the ex-"
anthemata.  It is an eruptive fever of  distinct and specific char- 
DENGUE.
609
acter.  Its essential symptoms are, in the  first stage, a painful
affection of the joints and muscles; and  in the second,  divided
by an interval obvious and sufficiently regular, a cutaneous erup-
tion.  The arthritic inflammation of the first stage, was attended
by fever of the ordinary inflammatory type, of twenty-four to
forty-eight hours' duration.  The eruption  was preceded, as is
usual in the exanthemata, by considerable gastric oppression,
with  nausea,  and sometimes vomiting.   Let  us separate  the
characteristic from the  incidental circumstances  of its  history,
and from the former proceed to designate its correct name and
true pathology.   1. An  arthritis—a painful and  apparently in-
flammatory  affection of the joints—was in a vast majority of
instances its earliest symptom.  The attack was rarely  ushered
in by a  formed chill  or  febrile rigor.   In general, the  very first
indication of seizure consisted merely in a painful affection of
some joint or limb.  In  my  own case, a single  finger of the right
hand became swollen and stiff, for more than an  hour before
any other symptom of the invasion was observed.   Other joints
then became successively painful, and after a considerable inter-
val, fever supervened, ushered in by  headache,  etc.   A child,
four years old, complained,  on rising early in the  morning, of
pain in  the  foot; his hand  next became stiff,  then his knees,
etc., but he ate his breakfast as heartily  as usual—the disease
gradually developing itself during a space  of at least  five hours
before any febrile exacerbation could  be perceived ; though the
pulse, breathing, and condition of the  surface were frequently
examined.   A very old negro  woman was ascending  a stair,
when she was suddenly seized with  such severe  pain, that  she
was utterly unable to proceed.  Her fingers, the chief seat of her
complaints, were  all of them bent, and could not be straitened,
and the intensity of  suffering was such that she lay prostrate,
with tears, and loud cries, and sobs.  Some hours elapsed before
she had any fever, and  then there was  but a moderate parox-
ysm.  In a very stout and manly youth, the  pain  at the very
tips of the fingers was so intolerably severe, that he wept  bit-
terly.  He had been much relieved by fomentations and opiates,
before any degree of fever supervened.
  As  it  was the almost  universal fact, that  these arthritic affec-
tions had thus endured for some time before the invasion  of fever, 
610
DENGUE,
 with its ordinary concomitants, headache, red eyes, full, abrupt,
 frequent pulse,  hot, pungent, dry skin,  thirst, etc., so it was
 rather uncommon to find the stomach notably disturbed at this
 period or stage.  Among the other irregular or incidental symp-
 toms, was an eruption already mentioned, which  showed itself
 occasionally thus early.   It was a mere rash, and was met with
 oftener in children than  in adults.
   2.  The characteristic eruption made its appearance later, after
 the subsidence of the febrile paroxysm,  and constituted a dis-
 tinct second stage.   After a duration, varying in different cases,
 the pain and inflammatory fever above described, abated, or went
 off, to the great relief of patients, who often thought themselves
 now quite well, and whose sufferings indeed, sometimes, though
 in a very small minority  of examples, ended here.  But it should
 be remembered, that when the case was thus abruptly termina-
 ted without a second stage, the patient was liable to be attacked
 again and again, with the arthritic affections and other ailments
 of the first stage.
   The eruption which has been thus indicated as essential, was
 preceded by great gastric distress,  which,  as in all the other ex-
 anthemata, diminished, as the skin became suffused, and was
 followed by a sort of secondary febrile exacerbation.  It should
 be remarked, too, that the arthritis, which had been  greatly re-
 lieved, returned at this time, henceforward remaining  pertina-
 ciously annoying for an indefinite  period.
  This  singular union of an eruptive fever with inflammatory
 affection of the joints, deserves surely to be regarded as a new
 and peculiar malady—a form of disease hitherto unknown and
 undescribed.   The West Indian practitioners, who first met with
 it, did not fail to notice this combination of circumstances, which
 formed the prominent points  in its history, and indeed gave it
character.  Hence  one styles it  scarlatina rheumatica.*   An-
 other, exanthesis arthrosia,t and a  third designates it  "an  erup-
 tive articular" or rheumatic fever.*  But the vulgar appellations
given it by the English negroes at St. Thomas, and by the com-
 mon people of Cuba, have prevailed, and are in general use.
  As it extended itself in various  directions,  some of its more

  * Cocke, Edin. Jour.          t Nicholson, ib.          t Stedman, ib. 
DENGUE.
611
striking features may have been softened down, or it may have
been impressed with certain modifications, by the  influences of
locality, or by mingling with  endemic diseases.  In this way,
perhaps, we may best account for the fact, that some of the phy-
sicians who met with it in the latter months of its brief exis-
tence, have suggested its resemblance to, or identity with other
and well known forms of fever.   Thus  Osgood  and Lehman,
who saw it in Cuba, seem disposed to regard it as  the  ordinary
fever of that region, under certain peculiarities of circumstances
not well explained;  and Waring, of Savannah, dwells upon its
close analogy with the "breakbone fever of 1S26,  and  the epi-
demic fever of 1827," (a bilious remittent,) in that city.  Still
closer are the points of similarity which  may be  found  in the
history of the breakbone fever or remittent, described by Rush,*
as prevailing in Philadelphia, in the summer and autumn of
1780, and the epidemic of Calcutta and Berhampore, pourtrayed
by Dr. Mellis, in 1824-25.
   Rush's fever was met with in July.  It affected  all  ages and
both sexes.   Medical men would seem  to have been  specially
liable to it.   No other febrile  disease was observed during its
prevalence.   It came on sometimes with  rigor, seldom with a
chilly fit, and often without any sensation of cold.  Many in-
stances occurred, in which it was introduced by a delirium. The
pains which accompanied it were excessively severe in the head,
back, and limbs;  in some they affected  the neck and arms, and
in one case, produced a difficulty of moving  the fingers  of the
right hand.   Hence the disease was sometimes believed to be a
rheumatism, but its  more  general  name,  among  all classes of
people, was the "breakbone fever."  A nausea universally, and
in some instances, vomiting, attended.  A screatus or  constant
spitting was in many cases observed through the whole disease.
The bowels were  in most cases regular.   The tongue was gen-
erally moist, and of a yellow hue.   The skin was moist, espe-
cially when the case terminated on  the third or fourth day. The
pulse was quick and full, but never hard;  there was little or no
thirst.  A rash often appeared on the third or fourth day,  which
proved favorable;  it was accompanied by a burning in the palms
* Vol. i. p. 216. 
612
DENGUE.
 of the hand and soles of the feet.  At this  time, many  people
 who were not confined to bed, and some who had no fever, had
 an efflorescence on their skins.   Convalescence was  slow and
 tedious.   A bitter taste in the mouth, and a yellow tongue, con-
 tinued for nearly a week.   Most of those who recovered, com-
 plained of nausea and total want of appetite.  Great dejection
 of spirits was the most remarkable attendant on convalescence.
 A young lady proposed, he says, to change the name of the dis-
 ease, and to call it in that stage, the breakheart instead  of the
 breakbone fever.   A remark to the same purport, and almost in
 the same words, was made to me by a Spanish woman recover-
 ing from dengue, who had never heard of Rush or his writings.
 The mildness of the requisite treatment, and the small propor-
 tional mortality, are, also,  points  of resemblance.  The  differ-
 ences, however, are not less marked and striking.  In  Rush's
 fever, there were remissions every morning,  and sometimes in
 the evening.   The exacerbations were more severe every second
 day, and sometimes  two exacerbations  occurred in  one day.
 When the fever did not terminate on the third or fourth day, it
 often ran on to the  eleventh, fourteenth, and  even twentieth
 days, assuming in its progress typhoid  symptoms.   Rush does
 not regard the eruption as an essential,  or even a very  promi-
 nent part of the disease.  Indeed, he does not describe it  at all,
 merely terming it "a rash ;" though he speaks of it as a frequent
 and favorable symptom.  On the  whole, it seems reasonable to
 conclude, that the two maladies, although presenting some curi-
 ous coincidences, are, in nature,  essentially distinct  and  differ-
 ent ; one being an eruptive fever, new, specific, and  peculiar,
 while the other is nothing more than an autumnal  remittent, a
 malaria fever, somewhat modified by an unknown agency.  And
 the same remark applies with equal correctness, but with  more
 force, to the epidemics referred to by Dr. Waring, of Savannah,
 who makes his breakbone fever of 1826, identical with the au-
 tumnal fever of 1827, which again he looks  upon as  identical
 with yellow fever; thus mingling in promiscuous confusion yel-
 low fever, ordinary bilious remittent, breakbone fever, and den-
 gue.  Dr. Daniel, of the same city, considers  "dengue to be cer-
tainly an  exanthematic fever," though  he does not regard its
invasion in 1828, as its first occurrence,  but  believes it to have 
DENGUE.
613
existed previously, in 1S26, when it bore the name of the break-
bone fever.  He contends justly for the essential nature of the
eruption, and remarks forcibly upon the danger of treating it as
an accidental symptom.  He states, that  when it has been re-
pelled or prevented from appearing by mismanagement, almost
every part of the system is liable to be attacked.  Several cases
of mania, consequent upon repelled eruption, he affirms, occurred
within his observation, and refers to a case of  tetanus thus pro-
duced, which terminated fatally.
  Dr. Osgood, of Havana, has suggested, that  the cause, origin,
and the nature of dengue, are identical with  those  of yellow
fever.  It would seem scarcely necessary to do more than  com-
pare the descriptions of the two, to be struck  with  a  strong im-
pression of their utter dissimilarity; the following discrepancies,
however, may be briefly alluded to,  as clearly disproving any
relation between forms of disease so distinct. In this city, where
yellow fever is frequently met with, it prevails only in the autum-
nal months, August, September, and October; very few cases hav-
ing even been known to occur in July.  It is the disease of un-
acclimated  constitutions—emphatically  "the  stranger's fever."
Native children are occasionally attacked by  it; adult natives-
and old residents may be said to be secure  from its  invasion; a
rule to which the exceptions  are as infrequent as second attacks
of small  pox or measles.  African negroes  are not susceptible of
it.  It never extends into the surrounding country,  and  noto-
riously respects such portions of the suburbs as are particularly
elevated, dry,  and  airy.  But  dengue  made  its entrance into
Charleston  in June, and spent its force before  the end of July;
it  attacked promiscuously native adults, the  oldest residents,
strangers, children, and negroes, whether  natives or Africans.
It allowed no exemption to any locality of suburban  residence,
and spread, though to no great extent, in the neighboring country.
  It is still  doubtful where dengue originated or  first showed
itself.   Allusion has been already  made to  an  epidemic which
prevailed in Calcutta.and its environs, in  1824-25.  From the
description  of that pestilence, in a paper published in the Trans-
actions of the Medical and Physical  Society,  by Dr. Mellis, it
would really seem to be  identical with the dengue  of the West
Indies  and  Charleston.   Its universal sway,  "attacking alike
      vol.  ii.—52 
614
DENGUE.
 the new-born infant, the aged, the robust and the weak, the rich
 and the poor—the suddenness of its invasion, intensity of pain
 in the muscles and joints, the heat and scarlet red color  of the
 skin, the eruption or rash being  succeeded by  exfoliation  of
 cuticle"—these are phenomena common to both.   The sequelae
 are equally analogous.  Dr. Mellis notices "great  prostration  of
 strength and  general debility, weakness of the stomach, con-
 tinued pains in the joints and oedematous swellings of the ex-
 tremities."  Such are the familiar effects of the dengue.
  It is proper, next, to inquire into the cause or source of this
 exanthem. Nothing has been distinctly indicated on this point in
 the history of the Calcutta and Berhampore epidemic, assuming
 this to have been the dengue.   Of the West Indian  Islands, St.
 Thomas was first attacked.  This is considered one of the most
 unhealthy situations among them; the  town being a free port,
 rich and populous, and possessing an excellent harbor, is always
 crowded with vessels from every part of the world.   St. Croix,
 described as the very reverse of St. Thomas, in its physical  and
 political character, and universally reckoned one of the healthiest
 islands, was next assailed.  "So high," says Stedman, "is its
 reputation for salubrity, that it has of late years become a favo-
 rite resort for invalids from the United States of America, where
 it is considered the Montpelier of the West Indies."
  The writers on this singular disease may be divided into two
 classes,  one of whom, confounding it with other malaria fevers,
 regard all investigation into any special  or particular cause of
its production as superfluous;  while their antagonists,  consider-
ing it as of novel and specific  character, conceive it necessary to
follow up the inquiry, and trace it to its peculiar source or origin.
From what has been said above of its history  and characteristic
phenomena, it will be readily  inferred that I belong to the latter
class of physicians, and believe it to  be capable of proof, that
dengue  is a  mafady  of contagious nature.   We  hear of it in
Bengal, in 1825.  After the silent progress of a year and  more,
it shows  itself in 1827,  in a free port,  in the Caribbean Sea,
where ships from every quarter of the world find ready entrance.
Stedman says, it was  alleged to  have been brought there by a
vessel from Africa.  He thence traces it satisfactorily to St. Croix,
Successively affecting the remaining islands, it reaches Cuba in 
DENGUE,
615
the spring of 1828, whence, in June, it obtains  easy access  to
Charleston, New-Orleans, Vera Cruz, and Carthagena.  In each
of these cities, it is attributed to contagion as an obvious source,
and is regarded as having been  imported from some point at
which it was known previously to exist.
  It is, however, a matter of acknowledged difficulty to prove
to absolute demonstration,  the  contagiousness  of  any form  of
disease which is not capable of being communicated by  inocu-
lation.   In the instance of such maladies, an  attentive observa-
tion of all the circumstances of their origin, history and progress,
offers us the only means of arriving  at a probable  conclusion
concerning their nature and properties.  Rational probability,
indeed, is the utmost that we can here attain, and an  ingenious
caviller  may always succeed in throwing in our way  objections
and difficulties, which shall oppose themselves to any positive deci-
sion of the point in dispute.  Two special objections are offered by
those who  deny the contagiousness of dengue, and the same
have been, with equal  correctness, applied to the cases of mea-
sles, scarlatina, and hooping cough.  The first is  the fact,  that
when you have traced  such disease as far back as you can,  you
still must arrive at a spontaneous origin, or its production from
loeal and obvious causes, and they perceive, or affect to feel, no
more hesitation in supposing several  spontaneous  sources than
one.   They also assume the principle, that no disease which has
been generated in  any  other  mode, or  by the operation of other
influences, can take on, in its progress  a contagion, and  beeome
capable  of spreading itself  in this way.
   But even small pox must have had a beginning, and syphilis
and psora, both of which may be produced by uncleanliness of
person, are capable of communication to the  cleanly.  Still far-
ther, although we  are here  entering upon debateable ground, it
is not always  possible  to trace  continuously from  step  to step
the course of measles, or hooping cough, or scarlet fever.  They
seem occasionally  to arise in positions  insulated from all  chance
of contagious transmission by any mode.   Few physicians  at
the present day, doubt  the contagiousness of typhus—a doctrine,
to the support of which, as large and  weighty a mass of testi-
mony could be adduced, as  to any other in medical  science. 
616
DENGUE.
 But it is well understood, that typhus is often  generated  under
 certain concurrent circumstances, with which the profession is
 familiar, and that one  case  so  generated, may become a centre
 from  which the disease shall diffuse itself on all  sides.   The
 second objection alluded to, is the rapid spread of dengue when-
 ever it has appeared.   The circumstance forms a striking fea-
 ture in its character.  But there is nothing peculiar in this part
 of its  history, and it is most illogical and unscientific to regard
 the epidemic prevalence of disease as disproving its  contagious
 power.  The phrases epidemic, epidemic constitution of the air,
 and the like, which are in common use among practitioners  of
 physic, have no definite meaning;  they refer exclusively to the
 general extension of disease.   But no one, at all conversant with
 the history of disease, can entertain a doubt of the tendency of all
 febrile maladies whether contagious or not, to become epidemic;
 that is, to spread themselves  in thjs prompt,  universal, and irre-
 sistible manner.   Small pox, measles, hooping cough—all afford
 frequent illustrations of this  principle.   It would be ridiculous
 to pretend to trace all the cases of these that occur,  when  they
 prevail in any population,  from one to another,  and thus to ac-
 count  for every  individual instance of its  supervention.  As in
 dengue, so in small  pox, persons are attacked who have  been
 altogether secluded,  whether accidentally or through caution.
   In all discussions of  this kind, the first step to be taken  is to
 decide upon the relative value of negative and affirmative state-
 ments—the proper rule being that which Haller has laid down
 in philosophising upon physiological experiments and inferences,
 "that negative observations are entitled to little  or no weight,
 when in opposition to  positive assertions."  If, for example, a
 very few instances were brought forward upon good testimony,
 of the  spread of any infection in  certain specified communities,
 additional numbers would  be of no farther importance than this,
 that they should, by diversity of position and circumstance, ob-
 viate the suspicion of a local cause common  to  all affected.
Suppose it to be  made out,  that a given malady being introduced
into five such communities, had spread itself among them, seizing
a few,  many, or  all within  its sphere, it would be to no purpose
to reply to the inference of its contagiousness drawn from such 
dengue.
617
 Statement, that in twenty, fifty, or one  hundred other instances
 of similar introduction, it had failed to occasion  any such ex-
 tension, or give rise to new cases.
   Contagion, perhaps, of all the morbid agents which produce
 disease in the animal constitution, would seem, on first conside-
 ration, the weakest—inasmuch as it requires the greatest  num-
 ber and Variety of concurrent  circumstances  to favor or ensure
 its impression ;  while on the other hand, that which  we  term,
 after Sydenham, the epidemic  constitution of the  air,  is vastly
 the most pervading and powerful.  Every physician fails  occa-
 sionally in transmitting vaccine and small  pox by  inoculation.
 But when the latter becomes epidemic, it is known to affect per-
 sons most perfectly Secluded, and guarded with all possible nicety
 against every imaginable approach of diseased subjects and every
 shape of fomites.  What is the epidemic condition of the air in this
 latter case, but the solution or  diffusion within it of the matter
 of contagion 1  What is it in any case but the diffusion through-
 out  the atmosphere of the cause of disease, whether contagion,
 or malaria, or some other unknown and undefined agent 1
   Not only is the impression of contagion thus uncertain, as is
 proved by its failure, but its sphere of action is contracted with-
 in narrow limits—a few feet  probably, as  most writers agree.
 Whether this is the mere result of dilution, or whether  the eli-
 minated virus undergoes some  alteration in its specific properties,
 in consequence of its admixture  with  air, is not  determined.
 When we take into consideration these circumstances, and reflect
 farther upon the ordinary healthfulness of communities among
 whom contagious diseases are  suddenly intruded, and  the gene-
 ral absence or negation of that predisposition upon which disease
 requires so uniformly to be built up, we shall rather wonder that
 contagious maladies  spread themselves so often  and so far as
 they do, than that they should be confined usually within certain
 observable limits as to the extent of transmission and number of
 subjects, and  that  they should so frequently be suddenly lost,
 and seem to terminate abruptly, as in the case before us, a short
 though very  remarkable existence.
   It  is for the most part a difficult task to point out the precise
 origin of any form of disease, and with respect to what are called,
vaguely, general epidemics, the attempt has  been notoriously
      52*- 
618
DENGUE.
 futile.  Local epidemics, however, among which dengue must
 of course be ranked, if its contagious nature be denied, are al-
 ways, as pneumonia typhoides, for example, limited to particular
 season and  temperature ;  or, as in the case  of bilious remittent,
 dysentery, and  yellow fever, to  certain localities and  circum-
 stances of soil and surface, conjointly with season and tempera-
 ture.  But dengue has, in its brief career and well known his-
 tory, shown no correspondence with any of these, being neither
 limited by season, local  position, nor atmospheric change.  Its
 gradual progression from one place to another, allowing abundant
 room for the anticipation  of  its arrival, and the fact that "it fol-
 lowed," from the time when it first appeared upon the American
 coast,  "the great routes of commercial intercourse," are strong
 evidence in favor of its contagiousness.   But there are positive
 and marked facts which seem to us leave no room for reasonable
 doubt on  the subject.
   Dr. Stedman traces the communication of dengue clearly from
 St. Thomas to St. Croix.  Christianstoedt, which is the seat of
 government of the latter, and on this account, and from its prox-
 imity to the former island, enjoys a freer intercourse with it, was
 invaded a week or two  before the town in  which he resided
 Frederickstoedt.   The first patient whom he saw  had arrived
 three days before  from St. Thomas, and  the disease appeared
 first in the family with whom this patient had  come to reside;
 among them, indeed, it raged exclusively for some time, with the
 exception of a family residing opposite, the  head of which had
 frequent mercantile business with Christianstoedt.  From there
 it extended through the town.  "The disease," he says, explicit-
 ly, "spread from  family to family, and from estate to estate ex-
 actly in proportion to their contiguity,  or to the intercourse  that
might happen to exist;" and gives an instance of the latter kind,
 when, from the communication between  two estates belonging
 to the same master, the one near town  and the other four or five
 miles distant, the negroes on the latter estate "got the disease at
 a time when it had not spread to any other in that neighborhood."
   In the city of  Charleston, the earliest cases happened in per-
 sons connected with vessels that had arrived  from the Island of
 Cuba, where dengue then prevailed.   This fact is clearly made
 out upon the authority of two physicians of the highest respec- 
DENGUE.
619
tability. Professor T. Prioleau attended the first patient, a negro,
who was  put on  board the  brig  Emmeline just in port, whose
captain had been ill  with dengue a few days before  he left Ha-
vana.  The  next persons attacked were the ship-carpenter and
his family, who went on board to effect some repairs in the same
vessel.  From these the disease spread as from a centre. A short
time after these events  occurred, Dr. P. G. Prioleau was called
to attend the  family of the captain of another vessel  who had
arrived here about the same  period, laboring under the disease.
The dates in these  instances are worth recording.  Captain W.
arrived in Charleston on the  31st of May, ill of dengue :  on the
20th of June, his wife  was  seized; on the 1st of July, two of
his daughters; on the 2d, his son ; "it soon extended to the rest
of the family."  Prof. Prioleau's first case, the negro  above men-
tioned, was taken ill on  the 10th of June ;  his second case  on
the 23d.   Here we have two central  spots whence  the dengue
rapidly diffused itself throughout the city.   These early patients
were far from being in the same neighborhood.   The brig Em-
meline lay at Knox and Pritchard's wharf, in  the upper part of
the town.  Capt. W. resided in  Tradd-street, nearly or quite a
mile distant.
   Farther circumstances of a similar nature deserve notice,  as
tending to throw some  light on the nature and  history of this
strange affection.   It made its appearance at two points in the
vicinity of the city,  the  qualities of the  soil and atmosphere of
which were  as strongly contrasted  as possible.  One of them,
Haddrill's point, is an elevated sandy bluff, about four miles from
Charleston, across the bay, noted for the salubrity of its air, and
the health of its inhabitants.  It has never been invaded by  the
yellow fever, even in the most pestilential seasons of its epidemic
prevalence.  Yet some  cases of dengue  occurred there, intro-
duced, as he  himself had stated, by a  clergyman whose family
resided at Haddrill's, while  he attended  to his official duties in
the city, and by  "a neighbor similarly situated."  The  second
instance was that of a plantation lying  about four  miles from
Charleston, in the opposite direction, in  a low malaria country,
the residents upon  which were annually subject to ordinary re-
mittent fevers.   The head of the family and a negro having vis-
ited the city, were both taken ill in about a week afterward;  the 
620
DENGUE,
  Wife of the former  was next seized, and the disease afterwards
 extended among  both the  whites and  the negroes in the place,
    Prognosis.  The prognosis in this singular affection was re*
  niarkably favorable.  Perhaps  no form of disease is known in
 which the proportion  of deaths  is so  small, compared with the
 numbers attacked.  Influenza alone spreads  with a universality
 of invasion at all resembling it, and even influenza is inferior  in
 the infrequency of exceptions to its  attack.  "In a population
 of about 12,000  souls who occupy the town of St. Thomas,"
 says Stedman, "scarcely a single individual escaped."  In all its
 seats few died; whether managed by  the best professional skill
 or mere domestic  attention, or totally neglected.  Yet there  was
 a vast difference  in the degrees of this suffering  undergone by
 different patients, and not a little  in the duration of this suffering
 and in the rapidity and perfectness of  their convalescence. The
 aged were  most severely handled, remaining frequently infirm
 and debilitated, with languor and emaciation.  Corpulent persons
 usually suffered much, and recovered very slowly.  The intem-
 perate paid  in this, as in  every other form of disease, a heavy tax
 for their degrading indulgences.  In many it served to usher in
 formidable paroxysms of delirium tremens.   Dengue, indeed,
 can hardly be said to have ever proved  fatal of itself.  The
 rare instances in which patients died, while  laboring under it,
 presented some complication under whose incidental symptoms
 the patient  sank ;  or some extreme feebleness of constitution in
 which the remedies employed were productive of fatal effects,
 More than one example of this nature  is placed on record.
   Treatment.   The violence of the early symptoms of this sin-
 gular malady seemed to call imperatively for  the  most prompt
 and impressive measures.   The lancet was the favorite resort of
 a majority of practitioners,  who ascribe to it a notable power in
controlling the force of the attack, and  lessening the duration of
the patient's sufferings.   Cathartics and diaphoretics were also
almost  universally employed—each physician selecting those
formulae in which  he had most confidence.  Both the saline and
mercurial purgatives had their advocates, and were maintained
to be specially adapted to  the case.  The antimonials, in the
earlier stages,  and afterwards Dover's powder, and the other
stimulating  diaphoretics,  were in general use.  The  ordinary 
DENGUE.
621
domestic practice, and a  large majority of cases were treated
without professional aid,  consisted in  the administration of a
mild purgative combined with or followed by a sudorific, as the
solution of Epsom salts in infusion of seneka, or serpentaria, or
hot lemonade, until the bowels were freely opened ; the patient
was then covered up moderately warm,  and warm drinks given
from time  to  time to  produce and keep  up free  perspiration,
while the parts most pained were fomented with warm water, or
bathed in spirits.   Such, with slight modification, was the prac-
tice that I followed in the few first cases  that fell under my care;
but an early observation of the happy influence of opium over
the extreme sufferings of the sick, led me ultimately to depend
on it exclusively, or nearly so, from the  invasion to the termina-
tion of the attack;  and   the  progress of the  season,  and  the
spread  of the disease gave  multiplied opportunities of noting the
propriety and value of the practice.   A  lady, in  the seventh
month of pregnancy, being  attacked by dengue, and menaced
most urgently with premature labor, one hundred and twenty
drops of tinct: opii were prescribed immediately, and ordered to
be repeated within a proper interval.  After three or  four such
doses, she fell  asleep, and  woke almost entirely free from pain.
Another, within a few days of her time, was not only quieted in
a similar manner, but absolutely relieved from all inconvenience
by the same treatment; rising out of bed the second day, going
through the eruptive stage without  illness  or suffering, and in
ten days after, being delivered of a fine healthy child.  When
summoned to a patient, it soon became my custom to administer,
without delay or preparation, such a dose  of opiate as  seemed
proportioned to and indicated by the severity of the  attack, from
a teaspoonful  of common  laudanum down  to such a lesser dose
of this preparation, or  of  the  tinct: op:  camphor: as was  suited
to the age and other circumstances.   If the head was the seat of
great pain and vehement determination, cold affusion was made,
or it was bathed  with spirits, while  the  feet were immersed in
hot water ; to  the swollen and suffering joints and limbs, warm
fomentations and  poultices  were applied.   The above dose of
anodyne, which acted, also, as diaphoretic, was repeated at inter-
vals of one or  two hours, until the symptoms were relieved.  It
was usually prescribed unmingled, sometimes however, in com- 
622
DENGUE,
 bination with the acet: ammoniae, a combination which seemed
 applicable when the pains were less severe, with a continuance
 of heat and dryness of skin, and persistence of febrile  excite-
 ment.  On  the return of pain or fever, forming the second stage
 as above described, the same  remedies were  again resorted  to,
 and with the same advantage, controlling, as it seemed, the gas-
 tric  distress, no less effectually than the arthritic pain and irri-
 tation.
   In comparing the several modes of treatment, it would seem
 fair  to remark that, if the patients subjected to the mild remedial
 regimen just  detailed, suffered  no more at the time than those
 who were more actively depleted  by the lancet, and cathartics,
 and  emetics, and passed through a convalescence not more pro-
 tracted than those, they must certainly be considered as gainers,
 inasmuch as they were put to far less annoyance and discomfort.
 Yet  it would not be  too much to affirm, that  the arthritic pains
 which they endured were  more promptly relieved;  that they
 underwent less constitutional  derangement;  that they fell into
 a less degree of general debility, and  consequently convalesced
 more rapidly; and  that, though  they did not, perhaps, obtain
 the privilege of absolute exemption from the rheumatic pains,
 stiffness, and incapacity, which  so long haunted every commu-
 nity in which dengue had shown  itself, yet they were notably
 less  subject  than others, to these inconveniences.
   In this singular disorder, the local pains usually preceded, by
 periods of considerable length, any symptom of fever or consti-
 tutional  derangement.  Hours would  often  intervene, during
 which the patient would limp  through  his  usual occupation  or
 amusement, and even eat heartily, and apparently digest well.
 Cases, indeed, occurred, in which the whole of the first or quasi-
 rheumatic stage would be gone through in  this way, and the
 nature of  the attack displayed at last, only by the breaking forth
of the characteristic eruption.   Now, it would hardly be  in ac-
cordance with received opinions, to affirm that the arthritic pains
here were of an ordinary inflammatory nature;  obscure as they
are,  they may  be regarded as congestive, or simply irritative.
The  opiate  was here as  applicable as  in the  cold stage of an
intermittent.  And even subsequently, if fever did supervene, it
did not seem to contra-indicate the opiate, as being the effect of 
B>ENGUE.
623
a peculiar  and specific form of inflammatory irritation transient
in duration, and happily determined by the nature of its proxi-
mate cause to external parts, or  parts of no vital importance.
In  this early stage, opium was, indeed,  specially serviceable.
All physicians were apt to resort  to  the  opiate  in the  second
stage, administering it freely in some  form of combination ;  the
Dover's powder  being  a general favorite.  But although  its
exhibition  was even  here of undoubted advantage, the  golden
opportunity for obtaining its highest benefit was past;  the main
object of our  art, the prevention of evil, was  unaccomplished ;
the storm had swept by, and its consequences were, with special
difficulty, if at all, remediable.  It is no easy matter to account
for the great  prostration of muscular strength  and restorative
energy so often left by a paroxysm so transient, and not unfre-
quently so little violent in degree; yet this circumstance consti-
tuted a prominent feature in the  history of the  case under con-
sideration.   The contest was still to be carried on.  We had to
deal with an eruptive disease, and if the forces of the constitu-
tion had been impaired, either by the intensity of the attack, or
by the remedies employed, as the lancet, cathartics, antimonials,
etc., the centrifugal determination which formed the next essen-
tial step in its progress  would be  slow and imperfect, and  the
stomach and other  internal  organs would  suffer in proportion.
At this juncture, many  were tempted, by the great gastric unea-
siness  and  oppression, to direct purgatives of various quality,
mercurial, saline, or resinous, but usually with  an increase of the
internal disturbance, a postponement of the period of cutaneous
inflammation, and a consequent protraction  necessarily, of the
duration of the  attack.   This was attended, too, for the most
part, with  an ultimate  aggravation of the violence of the local
pains, and  an increase  of their tendency to become  fixed, and
assume a  chronic inflammatory  disposition.   The  miserable
stage of restlessness and oppression was soonest  ended in those
who remained at rest in  a recumbent posture, confining them-
selves to the lightest diet, and avoiding  all exposure to changes
of temperature.   In the  old  and infirm, and in such as had
weakened  themselves,  and  given tenacity to  the centripetal
determination, by the previous employment of improper medi-
cines it became  necessary sometimes to  resort  to the highest 
624
DENGUE.
 order of diffusible stimulants, in addition to the opiate;  as cam-
 phor, brandy, vol: alkali and aether, with sinapisms  to the epi-
 gastrium and extremities.
   The vivid eulogium which Rush passes upon the  usefulness
 of opium, in the somewhat similar affection  described by him as
 occurring in Philadelphia in 1780, is  worthy of notice in this
 connection.  "Its salutary effects in procuring  sweat and a re-
 mission of the fever, led me," he says, "to prescribe it in almost
 every case, and always with the happiest effects.  Those physi-
 cians enjoy but little pleasure in practising  physic, who  know
 not how much of the pain and anguish  in fevers of a certain
 kind may be lessened by a judicious use of opium."   In a more
 extended experience, this  benevolent  man would have   been
 delighted to find that it was entirely  unnecessary, at least in a
 large majority of the cases, to wait for what he styles "the pro-
 per evacuations," but that this  relief or diminution of pain and
 anguish  might safely be accorded  to  the patient at the  very
 commencement of  the  attack,  and thus  his  severe  sufferings
 shortened by many hours, or lessened  at once most notably in
 degree.
  I will  take this opportunity of expressing, in  conclusion, my
 belief that our profession has  much to learn  upon the subject of
 the admissibility of opium in the treatment  of fevers  generally,
and declaring, as I do with entire sincerity, that the most agreea-
ble and satisfactory of all my experience in the healing art, has
consisted in the employment of this divine remedy in states  of
 the system, and  under circumstances which  dogmatists  of all
sects have taught to offer positive contra-indications to its exhi-
bition. 
DISEASES OF URINARY ORGANS.
625
                     CHAPTER LXII.

               DISEASES OP URINARY ORGANS.

  The kidneys, I have already said, are the only organs of the
body of which we  can affirm that  their office is exclusively
excernent.  The  lungs and  skin both absorb or  admit the
entrance of oxygen, and probably many other substances, while
engaged in the elimination of carbon from the blood.  Some of
the azote taken into the system with  the food,  escapes perhaps
by the lungs, for some of the experimenters say they have found
in the expired air a proportion of nitrogen, though it is denied
by  others.  Some may find  its way through the liver in the
bile ;  but to the kidneys is entrusted the duty of excreting this
effete  agent, almost entirely.   The peculiar constituent of urine,
hence called Urea, is composed of it in great measure, consisting,
according to  different analyses,  of  one-third,  or  two-fifths, or
nearly one-half of azote, combined with  carbon, hydrogen, and
oxygen.
  Urea is proved to  exist always in the blood; it must be got
rid  of by incessant  elimination, its retention being followed not
only by injurious consequences, but being soon  and inevitably
fatal.  The organs destined to  throw it  off, are also the  great
outlets for a thousand varied matters  into the body, which are
readily detected passing through them and  escaping with the
urine, impregnated obviously with their characteristic properties
of taste, smell, chemical affinity, etc.   Thus we see the quali-
ties of asparagus, of rhubarb, aether,  alcoholic liquids of various
kinds, turpentine and so  forth, in the fluid which  is  ejected,
within a short period after swallowing them.
  The healthy urine is itself a most compound  solution of salts,
acids, and other ingredients.   Fourcroy gives  us a list of its
constituent matters, extending  to thirty.   Henry enumerates
twenty-one.   Berzelius, regarded  as  one of the best authorities,
fifteen.   Brande  has  no  more than  eleven,, viz.: water, urea,
uric acid  carbonic acid, phosphoric acid, common salt, sulphate
of soda, phosphate of lime, phosphate of ammonia,.phosphate of
      vol. n.—53 
626
DISEASES OF URINARY ORGANS.
 soda, albumen.   To  these  silex is added by both Henry and
 Berzelius; and sulphur  is  considered by Bostock, after Henry
 and Prout, as also established.
   Conceive the play of chemical affinities among these thirteen
 principles, and then add the numeral accidental additions made
 to them occasionally in good  health, and often in disease, and
 you may imagine the infinite diversity  of  morbid urines—of
 only a few of which is it necessary or proper to treat here.
   I ought to  say, in entering upon this  subject, that, although
 in ancient times  an  undue  stress was, doubtless, laid upon the
 changes in the appearance and constitution of the urinary secre-
 tion as  affording information concerning the condition of the
 patient  in diseases generally, yet that I know no single point in
 which my professional brethren of  the present day are so  much
 to blame as in their indifference to, or, I might almost phrase it,
 their total neglect of this mode of enquiry.
   The healthy urine is  always  acid, as exhibited in its  effect
 upon test-papers properly prepared.  Some attribute  this to the
 presence of a free acid, the  uric or lithic; and in this view, I
 am disposed to coincide.   Bostock,  however,  agrees with Prout,
 that the acid is  not in a free state, but combined with a  base
 forming, some super-salt.   The quantity of urine poured out in
 health, is differently estimated, from Prout,  who places  it  at
 thirty-two ounces, to Haller, who rates it  as high as forty-nine
 ounces  in  the twenty-four  hours.   The  specific gravity is, as
 you  would  suppose, a  little  above that of  water.  Its color,
slightly yellow, may depend upon the salts it holds in solution j
but Prout supposes it, as  well  as  the peculiar odor, to be owing
to a separate principle or principles.   In all these respects it will,
in the same individual, differ very remarkably  within  a few
hours ; being affected readily, andyet, it may ber not morbidly,
by almost every article of food or drink  taken, by the varying
states of the atmosphere  as  to heat, dryness, etc., and by many
of the  emotions of the mind.  Remember that many of these
changes, some of them quite striking, too, are entirely compati-
ble with the enjoyment of good health.
  Of the morbid  states of the urine, let us, first, consider briefly
those which are principally exhibited in  mere departure  from
the natural standard of quantity.   It may be  excessive or defi- 
DISEASES OF URINARY ORGANS.
627
cient in amount.  Of the first, we have  two varieties.  1.  Sub-
aqueous urine, as some have called it.  In a large class of nerv-
ous affections, at the head of which stands hysteria, the kidneys
secrete a prodigious flow of limpid urine, almost destitute of its
well known hue  and smell.  I  know of no importance to be
attached to this observation, farther than, that in doubtful cases,
it may assist  us in  diagnosing  hysteria, and distinguishing it
from  other maladies which it may simulate.  I have not been
able to ascertain whether in the  analogous cases of somnam-
bulistic  and  mesmeric  excitement, the kidneys are similarly
acted on.  Heberden, in his  commentaries, enumerates the fre-
quent discharge of a sub-aqueous urine, as one among the symp-
toms  of what he styles  "valetudo conquassata," a state almost
identical with  Sir  Henry Halford's  "climacteric disease," or
breaking up  of  the constitution.
  2. Diabetes, a  most untractable  malady, consists in  the  too
rapid passage through  the kidneys of  the  ingesta, imperfectly
subjected to  the processes of assimilation;  and as we are to
infer from the prompt emaciation and complete atrophy of  the
patient, of all the absorbable portions of  the body besides.  In
one form of diabetes—D. insipidus, the  urine is limpid and ino-
dorous ;  in another, diabetes  mellitus, it is'quite saccharine.  In
the latter case, the uric acid, one of the  constant ingredients, as
you were told, of healthy urine, disappears, and it was thought
the urea itself went to form sugar ;  but a more careful examina-
tion has proved that such is not the fact.   The urea continues
to be formed, and exists in its usual  quantity,  but  is detected
with  difficulty, being "masked  by the  presence of the sugar."
Diabetic urine, of this kind, has  a pale straw or yellowish green
tint and a smell resembling whey or milk.   The disease is with
us so rare, that I have never seen it, nor known of its existence
here ;  in other places it is so much the reverse, that, as Willis
tells us, the  younger Dr. Babington  was shown by his father
twenty-three cases  at one time.
  I once met with a prodigious and exhausting flow of urine in
an  old mulatto woman, who discharged, in one night, upwards
of twenty-four pounds, which I saw  collected  in the morning.
It was not limpid, but of  ordinary appearance as to color, and of
the  usual  odor.   She  seemed somewhat  enfeebled  by it,  but 
628
DISEASES OF URINARY ORGANS.
 presented no other definite ailment, and was  not  prescribed for,
 recovering spontaneously.
   The quantities of urine poured out by some diabetics continu-
 ously, for days and weeks, are almost incredible.  Craigie says,
 that thirty pints  have been discharged every twenty-four hours,
 for  months together.   In an instance given by  Morgagni, the
 average was  forty-two pounds;  the amount of from  eight to
 sixteen  pounds may  be  stated as  not very uncommon.   This
 profuse flow is attended of course with great and rapid emacia-
 tion and debility; digestion is impaired, but the appetite is often
 urgent and insatiable;  the thirst, too, is ceaseless and  intolera-
 ble ; the skin is hot, harsh and dry;  the mind becomes  imbe-
 cile as the body wastes away.
   On the other hand, there is the contrasted state  of the  secre-
 tion—defect of urine—anuria (Willis)—ischuria  renalis  (Cul-
 len)—paruria inops  (Good.)   This is often a symptomatic affec-
 tion, as in cholera and in  yellow  fever, you will remember there
 occurs in bad cases, sometimes a total suppression of the function
 of the kidneys.   This  suppression takes  place, though happily
 not  very often, as a separate  malady, and it is a serious, nay, in
 large proportion,  a fatal one.   It soon connects itself, if unre-
 lieved, with cerebral disorder, and  the patient  dies apoplectic.
 It is affirmed, that  at times a vicarious elimination of urine
 goes on from some other organ or part, Avhile the kidney is thus
 inactive, as from  the navel, in one  instance,  from the stomach,
 by vomiting,  in  another; and thus the  life of the  patient is
 prolonged indefinitely—perhaps he recovers.   These stories are
 told us on excellent authority, but are difficult to  believe.  We
 have, on authentic record, accounts of the total suspension of
 this  excretion for  many days—from  four to  nine—without any
 vicarious discharge; after which it was  resumed, and  the pa-
 tients recovered.  In most of these, there was a urinous  smell
 given off from the surface  of the body, and found  to belong to
 several of the secretions.   So in  dogs, after  extirpation of the
 kidneys, the blood is found to contain notable quantities of urea.
  Urines morbid by their  quality, are of two kinds.—1. Those
which differ from healthy urine merely  in  the proportion of
some of its usual constituents; and, 2.  Those  which  contain
some super-added ingredient.   Of the first, we have a considera- 
DISEASES OF URINARY ORGANS.
629
ble variety.  As the urea and the uric or lithic acid are the truly
specific excretions of the kidney, so it is in the proportion of this
latter, that we shall have  to notice the most common, and per-
haps the most important alteration in the urine. And this seems
to me the proper place to announce to you my full assent to the
doctrine taught by the best authorities  among modern patholo-
gists, that the changes in the quality of this very variable secre-
tion  do not generally depend upon  any local disorder  in  the
organ  by which  it is separated.  I do not deny  that  this is
sometimes the fact with many or most of them, and will en-
deavor to draw a proper distinction on the subject when speak-
ing of the diseases of the organs themselves ;  but I am satisfied
that  most of the morbid states of the urine are consequent upon,
and  arise from, derangement of the digestive system  and func-
tion.   Craigie is so fully impressed with this view, that he in-
cludes the changes of which we are about  to treat, under the
head of indigestion,  and gives a graphic, and,  so far as my
experience goes, a faithful picture of the constitutronal condition
of the subjects  in whom  they are developed.  I formerly told
you  that the concretions found in the joints of gouty  persons,
are lithates or urates, proving that the lithic acid may be formed
elsewhere than in the kidneys; and thus we have been led to
infer the existence of a state of the system to which  the phrase
"lithic diathesis" is applied.  It is in this  lithic diathesis, con-
nected closely with the signs of dyspepsia, in the great majority
of those who are affected with renal disorders, that we have the
lithic acid deposites from the urine,  forming what is called "red
sand," gravel, renal calculi, and stone in the bladder; a series of
the most  grievous and tormenting maladies that afflict  the un-
happy race of man.
   Holland, however, takes the opposite side of the question, and
suggests that the lithic diathesis  is based upon or grows out of
the  inability or indisposition  of the kidneys—whether from a
vice of structure or mere function, he does not decide—to  sepa-'
rate or get rid of the urea; which remaining in the blood, now
too highly azotized, is the  origin and cause of all  the symptoms
and results.
   When  the uric acid is deposited within the kidney, the urine
is often scanty, sometimes  high colored and turbid.  It frequently
       53* 
630
DISEASES OF URINARY ORGANS.
 lets fall a crust of yellowish brown or pink color on the side and
 bottom of the vessel, which when examined by the microscope,
 presents crystals of prismatic  or rhomboidal shape, well figured
 by rayer in plate, (at end of Vol. I.)   This condition of the fluid
 voided, may either precede or attend or follow an attack of what
 was fomerly known as nephritic colic, exactly similar to the des-
 cription given you under the head of visceral neuralgia.  There
 is pain in the back and loins, in the region of the kidneys, fixing
 in addition upon a point in the front of the abdomeii, about  half
 way between the superior spinous process of the ilium and the
 umbilicus.   These are  intensely  violent, and are  attended by
 micturition or frequent  and  uneasy efforts to  pass  urine,  and
 sometimes by tenesmus,  pain in the groin, in the testicle and pe-
 nis, in the bladder and indeed by pain spreading over the whole
 abdomen and pelvis.  The pulse is usually tranquil, if not slower
 than natural; the stomach becomes irritable, with much nausea
 and occasional retching ; there is great thirst.   These sufferings
 at last go off spontaneously, or are relieved by the treatment,  and
 the patient enjoys a transient respite.  But most ordinarily, in  a
 day or two, the micturition returns with pain in the bladder, pe-
 nis and testicle, and  down the thighs, and after many efforts  and
 with more  or less difficulty,  a calculus  concretion is extruded
 through the urethra.  This  is  often  of.  rounded shape, in  size
 and form like a small pea ; sometimes it is  a congeries of crys-
 tals of a fawn color, or  brownish yellow.  Unless the morbid
 qualities of the  urine be corrected, this  scene will be repeated
 from time to time until the powers of life  give way, and the pa-
 tient dies  exhausted  by the irritation  of such paroxysms.  Yet
 some vigorous or tenacious constitutions endure  them  long.
 There is  now living  among  us an old  revolutionary soldier
 of about ninety  years, who has  for the greater  part of his  life
 been a sufferer in this way, and  had discharged a  great num-
 ber of calculi.  When the symptoms above detailed, which we
 refer to the  disturbance aroused by the passage of  a renal con-
 cretion along the ureter into the bladder, are not followed by its
 exit through the urethra, the patient of course is likely to under-
go the infliction of its increase in the bladder, with all the terri-
ble consequences resulting therefrom.  Yet  we must not fail to
remark that the formation of stone in  the bladder does not al- 
DISEASES OF URINARY ORGANS.
631
ways succeed  the most definite attacks  of this nature ; where
we have been most  fully persuaded of the escape of a calculus
from the kidney, and its  passage into the bladder, from whence
it has not been discharged.   It is  not easy to account for such
facts, but their occurrence is undeniable.  I have myself known
several of these paroxysms, whether  nephralgia, nephritic colic
or neuralgia, happen  to  the same and to different individuals,
among whom, one  at least was proved to be  a subject of the li-
thic diathesis,  by the actual passage  at other times, both before
and  after  of renal  calculi, of very small size.   I have known
several of these paroxysms,  and some of  them of great severity,
happen without the escape of any calculi or concretions from the
bladder, and yet the sufferers exhibited subsequently no tokens
of the presence of stone in the bladder.
  Willis supposes that in such  instances  the calculus or concre-
tion, whose  uniform existence as the cause of all the symptoms
he does not  seem to doubt, undergoes a re-solution in the urine,
which from some transient  variation  in  its qualities, has in the
intervals become  capable of dissolving  it.   I am by no means
content with this view of the matter, but would propose the fol-
lowing, which, like his, is conjectural to be sure, but as it seems
to me  more reasonable and probable. It  scarcely admits of  a
doubt that neuralgia of the urinary organs may occur indepen-
dently of  the presence and mechanical irritation of a renal  cal-
culus.   Many persons have been  frequently assailed  by parox-
ysms such  as were described  under that head, without  ever
becoming cognizant of the passage of any concretion or gravel,
and without ever observing any undue or morbid deposit in the
urine.   We do not  know clearly the  efficient causes which give
rise to it, but believe it to be connected with some vice of assim-
ilation likely to result in renal disorder and irritation.   I do not
think we can assert that  the only irritating or morbid urines are
necessarily  such  as contain insoluble constituents or materials
which they  uniformly deposit in  solid form.  Nay, I know  not
why the most soluble and best dissolved constituents may not
impart  highly irritating  qualities  to this fluid.   Why may not
such morbid and irritating urine excite in the organs, primarily
and sympathetically, all  the spasm, disturbance  and pain occa-
sioned by the  presence and progress  downward of a renal calcu- 
 $32           DISEASES OF URINARY ORGANS.

 lus ?  We must not imagine that all the annoyance and mischief
 brought about by  the latter is  simply mechanical or the conse-
 quence of mere distention.  I have  known very small concre-
 tions which passed out of the urethra so readily with the stream
 of urine, as not to be felt at all, or detected except by the light,
 and of course could not have filled  the distensible ureter, give
 protracted and intensely severe tortures in their passage from the
 kidney to the bladder;  these sufferings being relieved entirely on
 their reaching that cavity, of which fact the patient himself was
 in one instance clearly conscious.
   The explanation which I suggest here is in close analogy with
 what sometimes happens in apparent spasm of the bile-ducts,
 no gall stone having been passed by the patient or found after
 death in the gall bladder, the duct or  the  intestine.  It seems
 reasonable, as I  fomerly contended, to ascribe the symptoms in
 such cases to the irritation of morbidly acrid bile passing through
 the ducts.
   Besides the superabundance of lithic acid, of which  I have
 spoken, and its combination with certain of the earths and alka-
 lies enumerated, as entering into the composition of urine, we
 have phosphoric and oxalic acid also combining and forming bi-
 salts and triple salts—oxalate of lime—phospate of lime and the
 triple or ammoniaco-magnesian phosphate,  resulting from the
 play of chemical affinities.  It is out of my power to enter into
 minute detail on these subjects, but must refer you for all requi-
 site information  concerning them, to Prout, Willis  and Rayer.
 Lithic acid and  the lithates, it is  said, constitute two-thirds of
 all the deposites that are  likely  to occur.   And you will avoid
 error by the careful employment of the proper chemical tests.
   Albumen  is another of the constituents  of urine, which is
 occasionally found morbidly abundant.  Its undue proportion is
 the characteristic of the albuminous urine, so much talked of,
 in its relation to, or coincidence with certain dropsical affections.
 When present in any  notable quantity, it will  coagulate upon
 exposure to heat, or on the addition of nitric acid; at 120° Fah-
 renheit,  the fluid begins to grow turbid, and as the heat increases
deposites a flaky or cloudy sediment; the acid producing a simi-
 lar precipitate.   The connection of this change in the urine with
 the hydropic  diathesis, on the one hand, and  on the other, with 
DISEASES OF URINARY ORGANS.
633
the presence of renal inflammation, are doctrines warmly  dis-
puted.   The general truth of the latter proposition, if so quali-
fied,  I am not disposed to deny; the  exceptions,  however, are
very numerous.   It has  been shown  that the urine becomes
transiently albuminous, during the course of many  diseases, in
which we have no reason to suppose the kidneys to be inflamed;
among them,  intermittent  fever and pleurisy, as well as the
doubtful examples of small pox and scarlatina.  Similar observa-
tion has removed all foundation  for the  first of the above as-
sumptions.  Bostock noticed the  proportional quantity of albu-
men in the urine to be considerably increased, by  very slight
contingencies.   Graves regards it as "depending on  mere func-
tional derangement of the  secreting organ."   It  has been fre-
quently seen to follow the  use of certain medicines.  I cannot
help looking upon it as a contingency of undefined  or irregular
relations; its persistence  may lead to a reasonable suspicion of
a present inflammation of the kidney; but it does not certainly
prove nor betoken absolutely such inflammation.
   Of the alterations of urine, from  the addition of new ingre-
dients, there are not many  necessary to be here considered.   I
have already spoken of the appearance of sugar in  this fluid, a
matter of  far less consequence by its  own nature, than  by its
essential connection with the wasting and exhausting superabun-
dance of the quantity of the excretion.
   Purpuric  urine deserves a moment's attention, from  its fre-
quent coincidence with the lithic, and its occurrence  in a large
class of familiar diseases.  It forms the  "lateritious  sediment,"
so often met with in our  autumnal fevers and in  hepatic affec-
tions.  Prout attributes "all the  shades of color observed in the
deposites, from reddish brown to pink and purple,"  to the  new
substance discovered and named by him "purpuric acid," in its
mixture with the lithic acid, and with the phosphates  of lime
and magnesia.   Bostock  affirms, that it is frequently present and
liable to be produced by very slight derangements of the system.
   Blood is found mingled with  the urine, not  very  rarely.  It
flows from the kidney and ureter, not  only when mechanically
hurt by a calculus in passing, but is effused from  the  vessels in
engorgement of the organs, from any irritation which produces
determination to  them,  and local hyperaemia.  Bloody urine 
634
DISEASES OF URINARY ORGANS.
 sometimes precedes, and sometimes follows the paroxysms  of
 nephralgia, above described.  A stone in the  bladder  will  give
 rise to sanguine effusion from the inner  surface  of that viscus,
 from which, indeed, it takes place also, under mere engorgement
 or hyperaemia.  Purulent urine may attend inflammations, both
 of the bladder and kidneys; and we must carefully endeavor to
 draw  a correct diagnosis, from a consideration of all the  symp-
 toms which go to show the  locality of previously existing dis-
 ease.   If, for example, there have been pains or aching  in the
 loins,  with tenderness on pressure, we will suspect renal suppu-
 ration ; if the uneasiness have been confined to the pubic region,
 the bladder is probably affected.
   But the organic diseases of these viscera demand a more spe-
 cial examination, to which we now  proceed.  It is proper that I
 should remark in passing, that nephritic  disorders, for whatever
 reason, are specially rare in this immediate vicinity.   Calculous
 affections are as seldom  met with  here as any where in the
 world; I have seen, in my own  practice, not more than three
 cases of stone in the bladder, and the surgical history of Charles-
 ton records less than a dozen operations of lithotomy, including
 those coming hither from a distance.  Our experience in regard
 to the  various renal calculi, concretions, gravel, etc., is also com-
 paratively  limited, so that I do not pretend to go into  any full
 or precise detail on these subjects; my purpose is merely to lay
 before  you an outline, which you may so fill up for yourselves,
 that you will be prepared to examine properly  and apprehend
 clearly, such cases as may hereafter fall into your hands.
  The kidneys do not seem to be liable to any very great diver-
 sity of maladies.  Anemia and hyperaemia, atrophy and hyper-
 trophy, are enumerated by authors.   Tuberculation within their
 substance sometimes occurs, and  hydatids form within them, or
 are attached to  their investing membrane.   There is no practical
 importance in dwelling on these conditions.
  We  must, however, pay a more particular attention to  ne
 phritis, nephralgia, and granular degeneration or Bright's disease
 of the  kidneys.  Nephritis, or true inflammation  of the organ?
 may be either acute or chronic.  The first, you  will not often
 meet with.   Rayer is disposed, however, to regard it as of more
frequent occurrence than  is generally imagined, and  recognizes 
DISEASES OF URINARY ORGANS.
635
four varieties of it—nephritis proper, the gland itself being in-
flamed ; pyelitis—inflammation of the pelvis and calices  of the
renal  structure; peri-nephritis—inflammation of the investing
membrane;  and  pyelo-nephritis—inflammation of both  pelvis
and granular structure.
  The Causes of idiopathic nephritis  are obscure.   It is more
common in men than in women, and in  cold  than warm  cli-
mates.  It has resulted from a blow on the loins ; from violent,
rough exercise, as in dancing, riding in a carriage over bad roads,
or on a hard-going horse ; from certain medicines injudiciously
taken, such as turpentine and cantharides ; and from metastases
of gout, rheumatism, or any of the exanthemata.
  Symptoms.   There is pain in one side of the back or lorn, in-
creased on pressure,  at  first a dull, heavy aching,  but  rapidly
augmenting, becoming acute and lancinating, accompanied with
a feeling of" heat, and extending itself down t&e ureter into  the
bladder.   The testicle of the affected side is uneasy, and  some-
times  retracted, with wide spread aching of the hip  and  thigh.
The urine is scanty and high-colored ; and if both  kidneys are
inflamed, may be suppressed  entirely.  These viscera you must
remember, are of dull sensibility, and you will not therefore lay
much stress upon the degree  of  pain complained of; there are
instances of vehement inflammation proceeding to the worst re-
sults,  in which there was no  pain in the back or loins; all  the
suffering being that which was sympathetically aroused  in  the
bladder or- along the course of the ureter.  There are early to-
kens of constitutional disturbance.  A chill often occurs, followed
by violent febrile reaction, with  intense  thirst, a hot, dry, harsh
skin, and very distressing nausea.
  Treatment.   If there be  no decided contra-indication,  the
lancet must be used promptly and freely, and  cups or  leeches
applied to the lumbar region.  The warm bath is serviceable.
Mercurial and oily purgatives are to be administered forthwith,
in efficient amount and with  some perseverance, both as  deple-
tory and revulsive; the saline, we are advised to avoid.   Some
inculcate abstinence from fluids, but this seems unnecessary and
cruel.  Pure water and thin mucilages can do no injury.
  Chronic nephritis may either succeed  to the acute form or de-
velope itself spontaneously.   In the latter instance, its access is 
 636           DISEASES OF URINARY ORGANS.

 slow and obscure.  It is to be suspected, when motion or pres-
 sure produces uneasiness in the loin, deep seated and somewhat
 tenacious—we must not anticipate sharp pain; or when a sense
 of great fatigue, with aching of the back over the kidneys  fol-
 lows standing or walking, or rough horse-back exercise.   There
 is often aching, too, in the hip, the groin, the thigh, and the  tes-
 ticle, with or without retraction.  Owing to the torpid sensibility
 of the organ really affected, the patient will sometimes refer all
 his uneasiness  to the bladder, and many are examined for  the
 stone, and treated for cystitis.
   Fever of a low, irritative type supervenes, with emaciation, great
 languor, and despondency.  The urine varies much in condition
 and appearance, being  high-colored,  turbid, mucous,  bloody,
 sometimes purulent.  The whole kidney has, in some examples,
 become a mere abscess, or undergone  induration or  tubercula-
 tion.  The treatment must be similar to that advised in the acute
 form, with the  requisite modifications.   Cups and leeches to  the
 loins, must be  followed by  fomentations and counter-irritants-
 The warm bath must be frequently employed.  We  have long
 since learned from the statistics of experimenters—Lining among
 them, in our own climate—the contrasted amounts of excretion
 under opposite  circumstances, through  the skin and the kidney.
 The function of this latter organ  seems to be carried on with an
 increased energy whenever that of the former is by any con-
 tingency, such  as change of atmospheric temperature, impaired
 in a notable degree, and vice versa.   Hence  we  are  led to the
 obvious inference,  that to relieve the  irritated kidney,  it will
 always be useful to create as steady and forcible a revulsive de-
 termination as may be,  to  the cutaneous surface.  Purgatives
 must be administered from time to time, and are the more neces-
 sary as the alimentary  tube is always  disordered and uneasy;
constipation is present, with  nausea and flatulence.  As  before,
we avoid the saline cathartics.  I agree with  Stokes, in his pre-
ference for the mercurial, which if too  slow, may be  aided  by
proper combination, and addition with castor oil and rhubarb or
magnesia.  In both forms of nephritis,  after properly reducing
the force of local vascular action and febrile  excitement, opium
becomes one of our most available  remedies.  If there be too
much irritability of stomach  to allow of its retention in full dose, 
DISEASES OF URINARY ORGANS.
637
 it may be given with great advantage mingled in enemata.   Its
 sudorific action may be sought for,  if there be no  gastric  dis-
 turbance, by uniting it with tart: antimon:,  which will often be
 well tolerated when exhibited thus;  or by  prescribing the Do-
 ver's powder.
   Nephralgia may be  perhaps correctly defined—the irritation
 of the kidney and  its  appendages, from  the presence of renal
 calculi, of whatever variety.  The symptoms, locally considered,
 resemble those of nephritis, but the diagnosis between them
 does not seem to be attended with any great degree of difficulty.
 The latter is essentially and from its origin, a pyrectic affection,
 often commencing  with a chill, and always exhibiting in its pro-
 gress vehement  febrile excitement  of the  general system, the
 pulse being full,  hard  and  frequent, the skin hot, dry and harsh.
 In nephralgia, with far greater  intensity of pain, for  the most
 part, there is seldom or never  any  perceptible  degree  of fever;
 nay, the pulse beats languidly and slowly.   I have found it for
 days together, at fifty and  sixty—the skin remaining  cool, pale
 and soft.   There is also less nausea,  though the bowels  are un-
 easy, costive and flatulent.  Nothing can  exceed the extremity
 of anguish experienced by the  unhappy patient.  Sometimes it
 is seated in the kidney itself, and he cannot bear the slightest
 pressure upon the loin, or the least motion of the trunk;  vomit-
 ing and coughing are  torture to  him.  Again, it is  often deep
 seated in the abdomen, but in front, between the ileum and  the
 navel, at a point which he  can  cover with his thumb.  Or the
 bladder is the seat  of  startling, sharp,  lancinating pangs, just
 above the pubes or across the whole pelvis; the testicle is drawn
 forcibly perhaps to  the ring, by sympathetic involuntary contrac-
 tion  of the cremaster, with a sickening, depressing, overpowering
 agony.   The penis is subjected to shooting pangs of intolerable
 severity,  which resemble the electric flashes  of tic douleureux—
 neuralgia of the face.  The whole  side becomes painful, from
 the diaphragm to the hip, and reaching  down to the mid thigh,
 or affecting with  harsh cramp the calf of the leg.
  This irritation  of the kidney from a mechanical cause, may
give rise to consecutive nephritis; and it is  difficult  to conjec-
ture  indeed, why this  result is not uniform, or at least,  vastly
more frequent than  we find it to be.   I cannot  say that I have
       vol. n.—54 
638
DISEASES OF URINARY ORGANS.
 ever seen it definitely developed in this way.  But on the other
 hand, I have known vehement nephralgia,  such as I have  de-
 scribed, last for six, eight and fifteen days, without  lighting  up
 any pyrectic disturbance in the system, or,  as far as could be
 noted, any degree of local inflammation.  There is another striking
 circumstance in the history of nephralgia, which marks strongly
 the distinction which separates  it from nephritis.   The symp-
 toms  of  this latter disease  are continuous, proceeding to the
 highest point of danger and intensity, and thence declining with
 a steady progress, while nephralgia, which I hold to consist in
 a train of phenomena essentially and characteristically neuralgic,
 has its exacerbations and intermissions, or strongly  pronounced
 remissions,  falling readily under some law of regular periodicity;
 the patient  soon learning at what periods of the day he is  most
 liable to recurrence or aggravation of his tormentor.  The par-
 oxysms differ much in duration.  The longest I have known,
 lasted about thirteen hours, and although in a calculous subject,
 was not followed either then or for months after, by the discharge
 of any concretion, nor by any tokens of the presence of stone
 in the bladder.
   It is of much consequence to ascertain exactly, the nature  of
 the case, and to know the cause to which we are to attribute the
 symptoms.  Assurance is  made doubly sure, of course, when
 after some one of these attacks, a calculus passes  out  of the
 urethra, or we find in the turbid or bloody  urine, the grey sand
 or gravel, or any of the undue deposites  formerly  spoken of.
 When we have thus obtained a certainty, or from  carefully col-
 lecting all the  symptoms,  have decided that there is a strong
 probability of the formation of renal calculi, we must do all that
 is in our power to promote  their discharge or their solution, and
 to prevent the repetition of such deposites  within the body.
   During the paroxysm, we must in every way endeavor to re-
lieve pain and subdue irritation.   The  lancet is occasionally re-
quired or admissible as a relaxant, and cannot be dispensed with
when we  become  aware of the transition,  which,  however, I
have never witnessed, from nephralgia to nephritis.   Cupping is
frequently beneficial, as a  revulsive, I  suppose,  and I would
always employ it, if the pain in the loins continued urgent more
than three or four hours.   Granville's  counter-irritating  lotion 
DISEASES OF URINARY ORGANS.
639
often does prompt service, and the ordinary mustard poultice gives
great relief.   But upon opium and  the  warm bath, we are to
place our chief reliance.  John Hunter used often, in the course
of his illustrious, laborious and  painful life, to exclaim "thank
God for opium!"  Willis says forcibly, that  in  no disease are
the virtues of this valuable drug so strikingly  beneficial and
available.   The  sufferers from this terrible  morbid condition,
myself among them, will accord fully with the judgment of the
latter, and join heartily in the gratitude of the former.   We need
not delay a moment the exhibition of opiates, in the case before
us;  nay, it is best to commence as early as possible, and arrest
at once the incipient movements of  the attack, for fear that nau-
sea, not so common or so urgent a symptom here as in nephritis,
but yet frequently troublesome,  may surpervene and  interfere
with the retention of our best and admirable remedy.   Use it in
large doses; I prefer the muriate of morphine to  all other pre-
parations,  and prescribe from half  a grain to one or even two
grains, according to the intensity of apparent suffering.   In a
very severe case, we may repeat the dose in from half an hour
to an hour.  The anodyne influence expected from it, will be
exhibited more or less promptly, according to circumstances. I
have watched this point attentively.  The  shortest  period in
which I have been satisfied of its beneficent effect,  in the nota-
ble subdual of pain, was forty-five minutes; it will not usually
show itself in less than an  hour and a quarter, or from an hour
to two hours; if the pain has  had time to fix itself and extend
from one point to another, it will be removed  with the greater
difficulty,  and our narcotic  must be repeated  often,  and assidu-
ously persevered in.   If rejected by the stomach, give it largely
in enemata, after having emptied the bowels by  relaxing  injec-
tions, which if warm, will  act well, too,  as fomentations.  Em-
ploy the hot bath  again and again, and keep the  patient  im-
mersed until he  becomes faint and prostrate.   When the parox-
ysm has gone off and ease is restored, rest must be enjoined, the
diet reduced for  a few days, and  poultices or other  counter-irri-
tants occasionally applied about the loins.
  The urine should be inspected carefully, and  its appearance
and qualities accurately noted  from time to time.  Any deposite
which it may let fall, ought to be submitted to a  minute chemi- 
640
DISEASES OF URINARY ORGANS.
  cal analysis, from which we may often  learn the proper course
  to be followed.  We must keep in view always, the probability
  that a concretion has been formed in the kidney,  and found its
  way into the bladder, and that the most serious evils impend, if
  it be not soon expelled from  that cavity.  Remaining there, it
  can hardly fail to serve as a nucleus  upon  which  deposites of
  various composition will take place, augmenting in size until it
  will require for its removal one of the  most formidable opera-
  tions in surgery, to  say nothing of the distress and injury to the
  constitution occasioned by its presence and incessant irritation.
   The patient should be made to  drink  largely of diluents, and
  should be desired to retain his urine until the bladder is pretty
  well distended.  Then let him discharge it with as  much force
 and rapidity as he can, leaning himself forward and in a stoop-
 ing posture.  If not too large for the urethra, he will thus  get
 rid  of it.   Generally speaking, the morbid urines contain an
 undue proportion of acid, and it  is advised that the alkalies shall
 be taken largely—the bi-carbonates of soda  and potash being
 preferred.
   I  have already more than once adverted to the fact, that it is
 not  every paroxysm of nephralgia that is followed by the escape
 of a renal calculus;  nor does every nephralgic become the sub-
 ject  of lithotrity or lithotomy.  We do  not know what may have
 become of the calculus that has  passed into the bladder in such
 case—taking for granted that the symptoms always indicate the
 actual occurrence of this event.  Willis  believes  that they are
 sometimes spontaneously re-dissolved,  and that the use of alka-
 lies in the fluids drank, will thus dissolve them—for which pur-
 pose the patient must perseveringly take alkali enough to change
 the chemical condition of his urine and more than neutralize its
 acid, as is easily perceived through the test papers.   There seems
 indeed, to be abundant proof of the solution  of stone in  the
 bladder, under the employment of  artificial and natural alkaline
 waters, the latter especially.  The fountains of Vichy, in France,
and hi our own country of Ballston and Saratoga, have attained
the highest  reputation in  this regard, but perhaps any pure
waters taken in great abundance may affect the same purpose,
and thus even Preissneitz's absurd system,  as has been asserted!
may avail. 
DISEASES OF URINARY ORGANS.
641
   In the intervals, and with  a view to the eradication of the li-
thic diathesis, not the mere prevention of paroxysms through the
chemical  action of medicine and  drinks, in dissolving  concre-
tions or correcting the  morbid  qualities  of the urine secreted,
the nephralgic  patient will require another course of manage-
ment.  I have already endeavored to impress upon you the opi-
nion that all this class of disorders of excretion—or at any rate
a vast majority of them, have their root in some vice of  assimi-
lation ; that digestion is imperfectly performed, that the conver-
sion of food into nutriment is morbidly defective; and that there
is extensive general impairment of the constitution, coincident
and connected with this renal  derangement.  The  disease is
rarely met with before  the middle term of life is reached, and
decline has  begun—say from forty to sixty years of age.  In
great numbers it is obviously connected  with a gouty  state of
system, the lithic diathesis, whether inherited or newly built up,
being common to both.  In  very many  too, it is as obviously
connected with  long protracted  indigestion or  dyspepsia.  It is
said to be met with most frequently in those who use most ani-
mal food,  especially after the growth  of  the body is fully com-
pleted—the  system being thus unduly azotized; and in those
who take  habitually but little exercise, thus failing to incorpo-
rate the azote in their imperfectly developed muscles, and  render-
ing its prompt  and ceaseless  elimination  a matter of somewhat
urgent necessity.  I need not then surely  dwell upon the impor-
tance of a due regulation of the diet, regimen, and whole habits
of the patient.   All excess must be shunned, whether moral, in-
tellectual or physical. Animal food must be taken in moderation,
and the food light and easily digestible; a  preference being given
generally to the farinaceous preparations and rice.   The  discus-
sions concerning wines, cider and  malt liquors prepare us to for-
bid the use  of  them all.  Alcoholic drinks can do nothing but
injury by their ordinary use as beverages.  As  far as possible
care and anxiety must be lessened, by the avoidance of such en-
gagements and occupations  as  disturb the mind.  Occasional
journeys are of great benefit, and  the citizen may derive  advan-
tage from a temporary residence in the country, and an entire
change of his mode of living A visit to some of the  fashiona-
ble watering places often improves the health decidedly; I have
       54* 
642
DISEASES OF URINARY ORGANS.
 already indicated the preferable qualities of the mineral waters
 employed, and  the  likelihood of being benefitted by  any one
 among them.
   The only remaining affection of the kidney which I shall no-
 tice, is that which is known, from the name of the pathologists
 who first drew  the  attention  of the  profession especially to it,
 "Bright's disease;" from its nature as "the granular degeneration
 of the kidney ;" and from its prominent symptom as "albuminu-
 ria."   I shall not take up your  time  with the discussion of the
 disputed  question,  whether or  not  it should  be regarded as a
 mode of chronic inflammation.  Its whole history is so peculiar,
 that it deserves to be considered apart from nephritis ; and indeed
 from its associations and results, we may fairly infer that certain
 morbid derangements are going on  throughout its whole dura-
 tion, absolutely independent of the quasi-inflammatory condition
 coincident with it.
   Its connection with the exanthemata—scarlet fever especially,
 on the one hand, and on the other, with some forms of dropsy,
 and the invariable presence of an undue proportion of albumen
in the urine, constitute its pathognomonic signs.  Its causes are
 not clearly made out.  Bright  speaks impressively of intempe-
 rance as producing it.  Christison ascribes it to varied constitu-
 tional circumstances, among which he notes "mercurial deterio-
 ration," and "a scrofulous habit."  Osborne attributes it to sup-
 pressed perspiration, and to excessive use of diuretics.   It is
 most frequently  met with in men, and in middle life.  It arises
from, is coincident with, and gives origin to many modes of dis-
 order of the general health, of which the  ultimate  results are
 almost uniformly ascites and anasarca, and the proportional  mor-
 tality that attends is very great.  The  principal  diagnostic is
 drawn from the albuminous quality of the urine discharged  ; the
 quantity of this fluid is often increased too, and it is sometimes
 tinged with blood.  Micturition  annoys  the patient  with  diar-
 rhoea frequently ;  and he dies dropsical and exhausted,  or  may
 suddenly  perish with asphyxia, or coma, or convulsions.   The
coloring matter of the blood meanwhile  is singularly deficient;
the heart very often in a morbid state; Osborne found bronchi-
tis associated with full half his  cases, and Christison remarks
the same thing of pulmonary  oedema.  Arachnitis has several 
DISEASES OF URINARY ORGANS.
643
times concurred with it, attended by serous infiltration, and from
the fluid thus effused Dr. Barlow obtained urea.
  Autopsy shows "the whole cortical part of the kidney conver-
ted into a granulated texture, with copious morbid interstitial
deposit of an opaque white substance.   Externally the organ is
rough and scabrous to the touch ; it feels hard and of semi-car-
tilaginous firmness." Bright says its size is generally increased.
Martin Solon  says it  is  almost always hypertrophied.  Rayer
describes different forms, varying in this regard ;  and Holland
gives us a case in which the kidney was much  smaller than
natural.
  Of the treatment of this very serious and unpromising malady
I can say  little from experience.   Venaesection is  generally re-
commended in the early stage, and the blood drawn is affirmed
to be remarkably buffy.  Christison, however, offers a caution
against carrying this mode of depletion too far, "on account of
the  impoverished state of the blood."  Next  to the lancet, the
employment of purgatives  is confided  in.  Bright prefers elate-
rium and jalap, with bi-tartrate of potass.  Stokes eulogizes the
mercurial.   All avoid the neutral salts.   Diaphoretics stand next
in order, and our last named authority enumerates the antimoni-
als,  sulphur and guiac:, the acetate of ammonia  and  Dover's
powder, as well adapted.  Practitioners differ  widely as to the
administration of diuretics. Digitalis and colchicum  seem, how-
ever, to be liable to little objection.  Rayer uses the acetate of
potass: with decoction of wild horse radish.
  Tonics become absolutely necessary in the progress of the
case.  Iron, cinchona, and  buchu, are  particularly  extolled,
The diet should be mild and  nutritious.   Milk and  other light
animal  food often  agree very well.  Flannel  should be worn
next the skin ; and if the patient can  choose, he should fix his
residence in a climate of warm and equable  temperature.
  I  spoke formerly of the deficiency  and  superabundance  of
urine, anuria  and diabetes, without  stopping  to  make any re-
marks concerning their treatment, because I regard  them both
as symptomatic  either of some general  and  constitutional affec-
tion  or of disease of the kidney itself.  When suppression  of
urine occurs, it is requisite to ascertain clearly, if we can, the
condition of the organ.   When congested or  inflamed, cups or 
644
DISEASES OF URINARY ORGANS,
leeches should be applied to the loins, with subsequent fomenta-
tions continued assiduously.  The hip bath  and the  hot  bath
should be repeatedly used.   Laxatives and large, relaxing ene-
mata, should be administered.  If the pulse did not forbid it, I
would bleed freely.   The acetate or super-tartrate of potass:
may be prescribed as diuretic with colchicum  or  digitalis and
opium given to relieve pain.  If the strength  were much im-
paired, I  would,  perhaps, select the  more stimulant diuretics,
prescribing, though with caution, the spts: terebinth:  or tinct:
cantharides with opium, determining to the bowels with the
mercurial and  resinous cathartics, immersing the patient, from
time to time, in the hot bath, and fomenting and poulticing his
loins, or applying over  the back Granville's ammoniated  lini-
ment.
  The Treatment  of diabetes  is, in  every point, warmly dis-
puted.  The Pathology of the disease is so exceedingly obscure,
that it is matter of absolute conjecture where it begins.  Rollo,
and the majority of writers, fix its  primary locality in the sto-
mach,  asserting that the saccharine substance characteristic of it
is formed there, and that the kidneys and general system are
affected secondarily.   "McGregor demonstrated," says  Willis,
"that the sugar was formed in the stomach.  The faeces of one
of the patients being allowed to dry, became colored with crys-
tals of sugar."  McGregor  found sugar also in the blood  and  in
the saliva.  Watt and others contend, that the blood  is in a
highly morbid state,  presenting often no separation of serum
and crassamentum, and forming, on exposure, a soft black mass
almost devoid of cohesion and  tenacity.  Nevertheless, venae-
section has been employed  in the early stages, and, Craigie tells
us,  with great advantage.   Rollo's views, as stated above, led  to
a dietetic management carefully adapted to the supposed exigen-
cies ; and an absolute confinement to animal  food was expected
to prevent the formation of sugar and afford the deficient azote.
Much testimony has been accumulated in favor of this course,
but Craigie decides,  positively,  that "although it had the effect
of disguising the sugar by increasing the azote in the urine, it
did not alleviate  all  the symptoms, much less did it cure the
disease."
  It has been found  very  difficult to control the patient's appe- 
DISEASES OF URINARY ORGANS.
645
tite in many cases, and I am inclined to think that a mixed diet,
avoiding acescent vegetables and articles of saccharine qualities,
will best  answer our purposes.  The thirst, which is also ex-
tremely annoying, is advised to be quenched with fluids that
"require some digestion, and do not run off at once by the kid-
neys," such as beef-tea, veal-broth, etc.  Wines, and all liquors,
must be abstained from.   The bowels must be kept soluble  by
oily and resinous laxatives.  If the strength permit such  deple-
tion, cups and leeches should be applied over the kidneys ; and,
at any rate, counter-irritants along  the lower part of the spine
and about the loins. The warm bath must be used occasionally,
flannel worn next the skin, and the flesh-brush often employed
to the  whole surface.   Of all  internal remedies,  opium has
acquired most of the  confidence of the  profession, and its free
and persevering administration is believed to have done more to
benefit these intractable cases, than  any or all other medicines
given for their relief.  Diabetes is a chronic malady, running its
course sometimes in a few weeks, but often enduring for months
or even years.  The changes found in the dead body, are none
of them characteristic or instructive.  Willis agrees with Rollo
in regarding it as a merely functional  affection of the stomach,
and says, emphatically, "could we discover any means of pre-
venting the stomach from forming sugar, we should, I believe,
succeed in curing the  disease."  He recommends an occasional
emetic, and advises the union of tartarized antimony with opium,
both of them being well adapted "to  subdue the inordinate cra-
ving, and to determine to the skin."
   Before we conclude, it is incumbent on me to  say a word or
two of  the diseases of  the urinary bladder. This organ, like
every other, is liable  to inflammation, both  acute and chronic.
In the former, a very painful affection, there is a sense of fulness,
weight  and heat above the pubes, with micturition and dysuria,
or perhaps complete retention of urine.   When it comes away,
it is scanty, high colored, and seems to scald the passages, while
the bladder,  in expelling it, suffers intense agony.  Fever comes
on with hard pulse, hot skin, restlessness, and delirium.   I have
seen a  promptly fatal case, in which acute supervened upon
chronic cystitis, the patient dying in torture.   We found the 
646
DISEASES OF URINARY ORGANS.
bladder as thick in its substance throughout as the palm of one's
hand, and its cavity very much lessened.
  The same sufferings, inferior in  degree and protracted for a
great length, attend upon the chronic form of the disease, known
generally under the term cytherismus, and spoken of as irrita-
bility of the bladder.   Our treatment of the case must be guided
by the same  principles  that apply to  the  management of the
phlegmasia? generally.   If the pulse and strength  permit, the
lancet must be used, and with a freedom proportioned to  the
urgency of circumstances.  Leeches should be  applied to  the
perineum and over the  pubes; the hip-bath and general warm-
bath resorted to from time to time, and fomentations assiduously
kept upon the lower part of  the  abdomen and between  the
thighs.  The bowels must be well evacuated, and as promptly
as may be, by the oily and resinous cathartics, and large relax-
ant enemata repeatedly thrown up, which act  also as fomenta-
tions.  Opium must  afterwards be administered in full doses,
both by the mouth and  per  anum, as  in the glyster of starch
with laudanum.
  When the attacks run  on into a chronic protraction, the  uva
ursi and buchu (diosma  crenata) are highly recommended;  and
Willis advises, under such contingencies, the injection into the
bladder of some one  of the bland mucilaginous  solutions, the
quantity of which may be gradually increased, and  the time of
retaining it lengthened.   Rest, and a  low diet,  with a careful
avoidance of all such ingesta as are likely to  excite  or irritate
the kidneys,  or impart  any morbid qualities to the urine, must
be strictly enjoined. 
INDEX TO VOLS. I. AND II.
VOL.		PAGE.	VOL.		page.
Acclimation,	i	80, 285	c.		
Adhesion,	i«	223			
^Igophony,	ii	223	Burial,	i	154
.ZErial Poisons,	i	50	Carbonic Acid,	i	51
Age,	<«	25	Catalepsy,	ii	448
_ Ague,	«	265	Causes of Disease,	i	12
Ague Cake,	ii	190	" " " Accidental	ii	28
Alternations,	i	40	" " " Constituent"		17
Amentia,	ii	367	" " " Efficient,	ii	17
Amnesia,	it	367	" " " Exciting,	u	17
Anasarca,	i	520	" " " Existing,	ii	18
" Cerebri,	u	564	" " " External,	ii	30
" Pulmon.,	11	547	" " " Hereditary	ii	21
Anatomy Pathological,	11	143	" " " Internal,	"	19
Anemia,	u	169,220	" " " Predisposing		18
Anger,	k	47	" " " Proximate	"	17
Animalculae,	11	84	" " " Remote,	"	17
Animal Poisons,	ii	88	Cardiac Affections,	ii	459
" Putrefaction,	11	82	Cardialgia,	ii	12,17
Angina,	ii	197	Chemical Pathology,	i	135
" Pectoris,	i	465	Cholera,	ii	67
Apoplexy,	ii	400	" Sporadic-,	"	69
" Pulmon.,	a	261,406	" Asphyxia,	ii	76
Ascarides,	»	148	" Epidemic,	ii	76
Ascites,	i	536	" Maligna,	"	76
Asthenology, Asthenia,	11 ii	553 323	" Infantum, Chorea Sancti Viti,	ii	133 436
Asthma,	u	323	Chronic Sore Throat,	u	203
Atrophy,	i	229	Circulatory System,	i	241
Aura Epileptica,	ii	446	" " Diseases of" Climate, "		161 30
B.			Coffee,	ii	18
			Cold,	i	39
Ballston Spa.	ii	29	Colic,	ii	51
Bed Curtains,	u	396	" Varieties of,	u	52
Bilious Colic,	i<	61	" Simple or Flatulent,	ii	52
" Pleurisy,	u	272	" Bilious,	ii	61
" Remittent,	i	284	" Painter's or Lead,	"	63
" " Conges-			Colour,	i	26
tive variety of,	i	290	Coma,	"	407
Bilious Remittent, Malig			Combustion, Spontaneous,	ii	389
nant,	11	292	Condiments,	i	23
\ Bilious Remittent, Propor			Condition,	ii	34
tional mortality of	ci	292	Congestion,	"	217
1 Black Vomit,	u	355	Constipation,	ii	25
Bright's Disease, Bronchitis,	ii	642	Consumption,	"	274
	ii	241	" Apostematous,	k	278
" Acute,	u	242	" Catarrhal,	u	250,277
" Chronic,	■i	250	" Gallopping,	u	284
Bonaparte's Case, Raffy Blood,	n	39	" Tubercular,	ii	299
	u	171	Contagion,	i	93
 
64S
INDEX.
VOL.		PAGE.	vc
Contagious Diseases,	i	102	Epidemics,
Convalescence,	i	197	" Chronic,
Convulsion,	ii	441	Epilepsy,
Cooing rale,	u	222	Epileptic Aura,
Cough,	i	211	Epilepsy, Idiopathic,
Countenance,	11	181	" Sympathetic,
Coup de Soleil,	ii	401	Etiology,
Cramp,	i	176	Excretory Function,
Crepitus rale,	ii	222	Expectoration,
Crisis,	i	257	Exploration of Thorax,
Critical days,	ii	258	Extirpation of Uvula,
Croup,	ii	225	
Cynanche Maligna,	ii	198	F.
" Trachealis,	u	225	Facial Paralysis,
D.			Facies Hippocratica, Fatuity,
Death,	i	150	Fear,
" Modes of,	u	151	Fever, Continued,
" Signs of,	u	153	" Intermittent,
Debility,	ii	249	" Symptomatic,
Decubitus,	K	181	" Idiopathic,
Delirium,	II	367	" Bilious,
" Tremens,	II	382	" Catarrhal,
Dengue,	ii	605	" Causes of,
Diabetes,	ii	627	" Congestive,
Diarrhoea,	ii	99	" Continued,
Diagnosis,	i	142	" Country,
Diet,	i<	41	" Effects of,
Disease denned,	ii	15	" Intermittent,
" Functional,	u	15	" Latent period of,
" Organic,	u	15	" Remittent,
Diseases, Seats of,	ii	133	" Tables of Necropsy,
" of Digestive Sys-			" Types of,
tem, ii 9	, i	157	" Typhous & Typhoid,
Diseases of Respiratorj	f		" Worm,
System,	ii	213	" Yellow,
Diseases, Tendency of,	ii	146	Flatulence,
Digitalis,	i	530	Fomites,
Diphtherite,	ii	199	
Dissection, Wounds in,	i	89	G.
Diuretics in Dropsy,	i	518	
Diurnal revolutions,	ii	183	Gall Stone,
Dothenenterite,	u	411	Gangrene,
Drinks,	ii	42	Gastralgia,
Dry culture,	ii	79	Gastritis,
Dysentery,	ii	108	" Acute,
" Chronic,	u	128	" Chronic,
Dyspepsia,	ii	11	Gastrodynia,
Dyspeptic Phthisis,	u	13	Glanders,
Dyspnoea,	i	172	Granulations, Grippe, La,
E.			Gout, " Regular,
Egophony, Emotion, Mental,	i	223 460	" Atonic, " Misplaced,
Emigration,	ii	37	" Retrocedent,
Enemata of Tart: Antimon:	i		
etc.,	ii	59	H.
Endemics.	i	116	
Enteritis,	ii	42	Habits,
" Acute,	ii	42	Haemoptysis,
PAGE.
  117
   47
  442
  446
  444
  445
  202
  177
  173
  214
  204
    434
    181
    368
     48
237,448
239,450
239,448
264,240
    284
    377
260,248
    290
    332
    320
    261
    265
    251
    284
    263
    264
    397
    326
    333
     27
     98
177,183
    234
     11
     30
     31
     38
     26
     95
    233
    395
    485
    490
    491
    491
    491
 36
491 
INDEX.
649
                         VOL.
 Hallucination,            ii
 Hay Fever,                i
 Heat,                     "
 Heart, Exploration of,     ii
 Heart-burn,
 Hsematemesis,             i
 Hematuria,                ''
 Hemiplegia,              ii
 Haemorrhage,              i
       "       Vicarious,    "
       "       from  mouth
   and fauces,              "
 Hsemorrhagia Proctica,    "
^Hemostasis,
 Hepatic Abscess,         ii
 Hepatitis,
     "    Acute,           "
     "    Chronic,         "
 Hiccup,                   i
 Hippocratic Succussion,   ii
 Hooping-cough,
 Humoralism,              i
 Hydrops,                 "
     "    Abdominis,       "
     "    Cellularis,        "
 Hydro-thorax,             "
 Hydro-cephalus,
 Hydro-pericardii,
 Hydropic diathesis,        "
 Hydrops, Metastatic,
     "    Chronic,
     "    Cases of,
 Hydrophobia,
 Hyperanthraxis,           ii
 Hyperaemia,              i
 Hypertrophy,              "
 Hysteric Imbecility,        ii
 Hydatids,                 "
560,
  PAGE.
    377
    386
     38
    234
     12
    499
    503
    421
    472
    481

    489
    502
    272
    161
    157
    159
    164
    211
    217
    339
    137
  •  504
    536
    520
    544
    554
    547
    507
    555
    560
561, 562
     91
     76
473,220
    228
    367
    161
I.
  Icterus,                   "
    "   Viridis,            "
-Idiosyncrasy,              "
  Ileus,                     "
  Iliac passion,
  Impatience,
  Inanition,                 "
  Incoherence,
  Indigestion,
  Inflammation,
  Infantile Remittent Fever,   i
  Inflammation of sinus and
   artrum,
-Influenza,                  ''
  Insolation,                «
- Intestinal Haemorrhage,    i
  Intermittent Fever,         "
      n       "   Causes of,"
      ««       »   Effects of,"
      u       «   Marked,  "
      ii       »   Types of,"

          vol. n.—55
	VOL.	PAGE.
Intussusception,	ii	53,56
Irritability,	i	210
Irritation,	ii	207
Kentucky Jerks,
K.
L.
Laryngitis, Acute,
     "     Chronic,
Laryngeal Phthisis,
Latent period,
Love,
Lumbricus,
Lunar influences,

                 M.
ii  442,452
225
237
237
107
 48
142
197
171
173
 27
 52
 52
461
460
375
 13
213
326

392
384
401
502
265
269
269
266
267
Malaria,               *  "
    "   Animal cular origin "
    "   Effects of,         "
    "   Influence of Tree
  foliage,                  "
Malaria, Jussieuia Grandi-
  flora,                   "
Malaria latent period,
    "   Liability of races,  "
    "   Modeofimpression,"
    "   Mode of spreading, "
    "   Nature of,         "
    "   pine-lands,        "
    "   vegetable origin,   "
    "   volcanic    "      "
Malignant Sore-throat.     ii
Mania,                   "
Mania a. Potu,            "
Marasmus,                 i
Melancholy,              ii
Melcena,                   i
Mercurial Sore-throat,
Metallic tinkling,          ii
Meteorism,                 i
Milk-sick,
Milk-sickness,            ii
Mineral poisons,           i
Moisture,
Mono-mania,             ii
Monthly revolutions,       i
Mucous rale,             i
Mumps,

                  N.
     50
     56
     66

     76

     77
     71
     69
     68
     75
     75
     77
     60
     65
198,205
    375
    382
    576
    376
    502
    324
    222
    406
     91
     48
     50
     58
    377
    185
    221
     193
Nephralgia,               "      637
Nephritis,                 "      634
    "    Acute,           '»      635
    «    Chronic,         "      635
Neuralgia,                "      464
    «     Cerebral,       «      477
    «     Genitourinary,  «      479 
650
INDEX.
Neuralgia, Uterine,
Visceral,
0.
Nosology,
 Occupations,
 Oppressed pulse,
-Orthopnoea,
Pain,                     i
Painter's Colic,           ii
Palsy, Local,
  "   Facial,              "
Palsy,                    "
Palpitation,               i
Paracentesis Thoracis,     "
Paralysis,           i 176, ii
   "    General,          "
   "    Partial,           "
   "    Agitans,          "
   "    Vacillans,         "
Parasites,            i 85, "
Paraplegia,               "
Parotitis,                  "
Paristhmitis,               "
Passions,                  i
Pathology,                "
Pectoriloquy,             ii
Pellagra,                  "
Percussion,               "
Peripneumonia Notha,     "
Perforation of Bowel,      i
Periodicity,               "
Pertussis,                ii
Phenomena of Disease,     i
Phlegmon.,              ii
Phlegmonous Sore Throat,  "
Phrenitis, Acute,          "
    "    Chronic,         "
Phthisis, Apostematous,    "
   "    Oatarrhal,         "
   "    Laryngeal,        "
   "    Pulmonalis,       "
   "    Tubercular,       "
Physiological Nosology,    i
Pity,                      "
Plethora,                  "
Pleuritis,                  ii
Plica Polonica,            i
Pneumonia,               ii
    "      .Chronic,    ,  "
    "      Typhoides,     i
    "      Anomalies of,  "
    "      Occurrence in
  Europe,                 "
Poisons,                  i
Puerperal Mania,          ii
Pulmonary Congestion,    i
PAGE.
  482
  476
  200
 45
167
172
    215
     63
    434
    434
    417
    161
    552
    417
    418
    420
    435
    436
    146
    431
    193
    197
     47
     13
    223
    523
    217
    243
    407
    182
    339
    155
    528
    200
    354
    364
    278
250, 277
    237
    274
    299
    203
    461
170, 475
    260
    229
    260
    262
    433
    440

    436
     49
    367
    437
VOL.		PAGE.
Pulse,	i	162
" Depressed,	u	167
" Differential,	"	164
" Oppressed,	ii	167
Purulent Expectoration,	ii	277
Pntrescency of Fluids,	i	407
Pyrosis,	ii	12
a.		
Quarantine,	i	115
Quartan Revolution,	u	184
Gtuinzy,	u	200
R.		
Rachialgia,	ii	63,65
Remittent Fever,	i	284
Remote Causes,	n	17
Respiratory Function,	ci	172
" System,	ii	213
" " Diseases		
of	k	213
Respiratory Sounds,	ii	213
" Natural,	ii	220
" Morbid,	ii	221
Revolutions, Periodical,	i	183
" Diurnal,	ii	183
" Tertian, Quar-		
tan, etc.,	ii	184
Revolutions, Monthly,	ii	185
Rigor, Febrile,	ii	250
Risus Sardonicus, s. St. Anthony's Fire,	u	181
	ii	574
Saratoga Waters,	u	29
Scarlatina,	ii	585
Scarlet Fever,	u	585
" " Simplex,	ii	588
" " Anginosa,	u	590
" " Malignant,	u	591
" " Complications	of"	593
Scrofula,	i	570
Seats of Diseases,	u	133
Secretion,	ii	206
Sedation,	ii	207
Self-Limiting Diseases,	ii	185
Semeiology,	ii	202
Senile Imbecility,	ii	368
Sensorial System,	i	174
" " Diseases ol	ii	353
Sex.	i	25
Sibilant Rale,	ii	222
Sloughing,	i	235
Small Pox,	ii	542
Sneezing,	i	211
Sobbing	u	211
Solar Influence,	<i	196
Solidism,	u	136
Somnambulism,	ii	473, 368
 
INDEX.
651
                       VOL.   PAGE.
Sore Throat,              ii      197
Sordes,                   i      405
Spasm,                   "      216
Spinal Irritation,          ii      469
Splenitis,                 "      189
Spontaneous Combustion,  "      389
State of Society           i       32
Sternalgia.                "      466
Stethoscope,              ii      220
Stimulation,              i      208
Stomach Pump,           ii       34
Subsultus,                "      406
Sudamina,                i      414
Sudden Deaths,           "      462
Sun Headache,            "      392
Symptomatic Fever,       "      448
      "    Inflammatory,  "      448
      "    Hectic,        "      450
Syncope,            i 161  ii      457
Synocha,                 i      397
Synochus,                "      397

                T.

Taenia,                   ii      149
Tea,                     "       18
Temperaments,            i       19
Tendency of Disease,     "      148
Tertian Revolution,        "      184
Thoracic Sounds,         ii      220
    "    Capacity,        "      216
    "    Symmetry,       "      216
Tic Douleureux,  "        ii      467
Tickling,                 i      211
Tobacco Enema,          ii       59
Tobacco,                 "       18
Tongue,                  i      157
Toxicological Table,       ii       34
Tubercle,                 "      306
Types, Division of Febrile,  i      264
Typhus and Tyhoid Fevers "      397
        "    "    "  Iden-
  tity of,                 "      401
Typhus and Typhoid Fe-
  vers, distinctions offered,  "      401
Typhus and Typhoid Fe-
  vers, Eruptions of,        i      413
Typhus Gravior,           "      422
Typhus among Negroes,    "      430

                u.

Ulceration,                i      232
    "     Folicular,       "      412
Ulcerous Sore Throat,      "      260
Urinary Excretion,               178
   "  Bladder, Diseases of ii      645
   "  Organs,     "    "   "      625
Urine, Albuminous,        i      518
Urine, Subaqueous,       ii      627

                V.
Venom of Snakes, etc.	i	88
Virus,	u	97
Vis Medicatrix Naturae,	u	146 -4-
Vocal Sounds,	u	223
w.		
Water Brash,	ii	12
White Sulphur Springs,	ci	169
Worms,	u	146
Y.		
Yaws,	i	527
Yellow Fever,	u	333
" " Anomalies of,	it	351
" " Black Vomit in	u	355
" " Causes of,	n	336
" " Congestive va-		
riety of,	ii	350
Yellow Fever, Contagious-		
ness of,	u	339
Yellow Fever, Stadia of,	u	349
" " Treatment of,	tc	357
" " Type of,	II	334
 
k 
 
 
 
 
 
NLM032779041