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y, 
 
 
MEMORANDA  MEDICA
OR,
NOTE-BOOK
MEDICAL  PRINCIPLES.


              BEING A CONCISE SYLLABUS OF


    ETIOLOGY, SEMEIOLOGY, GENERAL PATHOLOGY, NOS-
         OLOGY AND GENERAL THERAPEUTICS.


                 WITH A GLOSSARY.
$ax t\t l\n at  Shunts.
    BY HENRY HARTSHORNE, A.M., M.D.,
              'it
PROFESSOR OP THEORY AND PRACTICE OF MEDICINE IN THE MEDICAL DEPARTMENT OP
    PENNSYLVANIA COLLEGE; PHYSICIAN TO THE PROTESTANT EPISCOPAL
        HOSPITAL OF PHILADELPHIA; FELLOW OF THE PHILA-
           DELPHIA COLLEGE OF PHYSICIANS, ETC.
  Qcpskeetv, rj firj fiXdmeiv.    \

"TO HEAL, OR, NOT TO HARM."   *~(/r\       ^im
V^h&e^1
      PHILADELPHIA :

J. B. LIPPINCOTT & CO.

         18 60. 
                                      >\335w,








           Entered, according to Act of Congress, in the year 1860, by
                    HENRY HARTSHORNE, A.M., M.D.,
In the Clerk's OflBce of the District Court of the United States for the Eastern District
                              of Pennsylvania.
i 
PREFACE.
  The title of this volume is descriptive of its  nature  and pur-
pose.
  Its contents are, literally, memoranda of the most important
points of the fundamental and introductory portion of the course
of lectures  delivered by  the author in the  department of the
Theory and Practice of Medicine.   It has been prepared  under
the conviction that, notwithstanding the excellence of the  works
in use upon  the different subjects connected with Pathology and
Practice,  and the  existence of several upon the  Principles of
Medicine, yet no one text-book presents such a view of all the
topics  appropriate  to this part of the course, as to form a brief,
lucid, and available manual of Medical Principles.
  Not having the leisure, if even conscious of the ability, to ma-
ture a work of such pretensions, this little volume is offered as
an outline, or ■partial substitute for it.   It aspires, therefore, only
to a position intermediate  between  the professor's  skeleton
synopsis  or syllabus, and  the  elaborate  treatise or text-book.
The opinion  may, however, be candidly expressed, that there is a
need rather for small than for large books, for  the student's use
during the over-busy period of his attendance upon lectures. The
desideratum for  such works, irrespective of their  size, is, that
                                                  (Hi) 
IV
PREFACE.
 they should be perspicuous, and should embrace the most import-
 ant  points, relating  to  their subjects, correctly stated, without
 redundance.  At the  same time, the author is aware that the pre-
 sent volume exhibits many imperfections in these respects.
   In such an outline, it may be, perhaps, superfluous to abjure all
 claim to originality, except in arrangement, and in an occasional
^rain of reasoning or observation.   I believe it to be the duty of
 the teacher to  collate, from  whatever sources,  all that can be
 made useful to his class ; while a constant reference to authorities
 would tend only to confuse the student's memory.
   It may be mentioned, however, that I have been chiefly indebted,
 on the subject of Semeiology, to Barclay's Treatise on Medical
 Diagnosis, Walshe's  on Diseases of the  Lungs, Stokes' on  the
 Heart  and Aorta, Bennett's  and  Tanner's  Clinical Medicine;
 and  on General Pathology, to Simon's  Lectures on General,  and
 Paget's on Surgical  Pathology, and  Eokitansky's Pathological
 Anatomy.  The section on the "Inspection of the Dead Body"
 was  prepared by my friend Dr. T. A. Demme, of this city.
   There is, I trust, in the volume, enough of individuality to
 redeem it from the charge of  being a mere compilation.  Should
 it be found to answer, in any degree, the  purpose for which it is
 designed, it may hereafter be rendered more useful, by the addition
 of  parallel  " memoranda" upon  the  subjects  of  Xosography,
 Special Pathology, aud Practice of Medicine.
                                                     H. H. 
CON  T E N T S.
Subjects......................................................................

                          PART  I.
                        ETIOLOGY.
Definition of disease.....................................................
Classification of causes of disease....................................
Hereditary causation......................................................
Degenerating influences affecting the  race...........................
Dynamic and mechanical causes.......................................
Obstructive causes.........................................................
Conditional causes.........................................................
Ingestive causes............................................................
Modifying influences of sex, temperament, and age..............
Tendencies of infancy and childhood................................
     Adolescence..........................................................
     Middle life...........................................................
     Old age.............................................•..................
Special etiology of—
     Autumnal fevers....................................................
     Yellow fever..........................................................
     Typhus fever.........................................................
     Typhoid fever........................................................
     Cholera...................................•.............................
     Plague ...............................................................
     Cholera infantum....................................................
     Erysipelas...........................................................
     Puerperal fever.....................................................
     Diphtheria.............................................. .......:•■•
                                                     (v) 
VI                        CONTENTS.
                          PART II.

                      S E M E I 0 L 0 G Y.
                           SECTION I.
                                                           PAGE
Rational Symptomatology..............................................   43
Definitions.......................................................................   43
Symptoms connected with the digestive apparatus.........................   43
    The tongue.......................................................•........   43
    The teeth and gums....................................................   43
    Taste.......................................................................   44
    Appetite..................................................................   44
    Thirst......................................................................   44
    Deglutition............................................ ..................   44
    Nausea  and vomiting...................................................   45
Symptoms connected with the circulatory system..........................   45
    Palpitation of the heart...............................................   4-5
    The pulse..................................................................   46
    Capillary and venous circulation....................................   48
    State of the blood, in  disease.......................................   48
    Hemorrhages............................  ...............................   49
    Epistaxis..................................................................   49
    Haemoptysis..............................................................   49
    Hoematemesis__'........................................................   50
    Uterine  hemorrhage.....................................................   50
    Intestinal hemorrhage.................................................   51
    Htematuria...............................................................   51
Symptoms connected with the respiratory organs..........................   51
    Dyspnoea..................................................................   51
    Cough.......................................................................   52
    Expectoration............................................................   52
    Temperature  and odor of the breath  .............................   52
    Hiccough............v......................................................   53
    Stertorous respiration..................................................   53 
                          CONTENTS.                       vii
                                                            PAGE
Symptoms connected with the tegumentary apparatus...................  53
    Temperature of the skin..............................................  53
    Dryness or moisture.................................v................  53
    Emaciation.................................................................  53
    Color of the face,  etc...................................................  53
    Eruptions..................................................................  54
Symptoms connected with the secretions.....................................  54
    Constipation..............................................................  54
    Dysentery................................................................  54
    Diarrhoea..................................................................  54
    Urinary symptoms......................................................  55
    Properties of healthy urine...........................................  55
    Retention of urine......................................................  55
    Suppression of urine...................................................  56
    Excessive urination.....................................................  56
    Technical examination of urine.....................................  56
    General appearance.....................................................  57
    Specific gravity..........................................................  57
    Reaction to test-paper..................................................  58
    Chemical examination of sediments................................  59
    Microscopical examination...........................................  59
    Albuminuria..............................................................  60
    Saccharine urine.........................................................  60
    Kyestein......... .........................................................  61
    Chloride of Sodium....................................................  61
    Milk, and  lochial discharge.........................................  61
    Perspiration, odor, etc.................................................  62
 Symptoms connected with the motor apparatus............................  62
    Decubitus..................................................................  62
    Muscular debility.......................................................  63
    Spasm......................................................................  63
 Symptoms connected with the sensory apparatus..........................  63
    Pain........................................................................  63
    Anaesthesia...............................................................  64
    Paralysis...................................................................  64 
Vlll                       CONTENTS.
                                                            PAGE
    The eye, its appearance, color, etc.................................  64
    State of the pupil.......................................................  65
    Photophobia, etc.......................................................  65
    Cephalalgia...............................................................  66
Symptoms connected with the psyschical apparatus.......................  67
    Expression of the  countenance......................................  67
    Delirium...................................................................  67
    Coma........................................................................  67
                           section ii.
Physical Diagnosis.........................................................  68
Modes of  physical exploration.............................................  68
Regions of the chest..............................................."..........  69
Diameters, etc................ .................................................  70
Signs determined by inspection and mensuration....................  70
    Expansion and bulging................................................  70
    Retraction and depression............................................  71
Signs discovered by palpation.............................................  71
    Expansion and elevation of the ribs in breathing..............  71
    Vibration, with the voice and cough...............................  71
Spirometry......................................................................  72
Percussion......................................................................  72
Variations of percussion-resonance......................................  72
Rationale of  diagnosis by percussion...................................  72
    Diminished resonance..................................................  74
    Influence of position...................................................  74
    Increased resonance....................................................  75
    Increased resistance...................................................  75
    Tympanitic resonance..................................................  75
    Amphoric resonance....................................................  75
    Bruit de pot fele'.........................................................  75
Skoda's classification of percussion  sounds...........................  75
Auscultation....................................................................  7(3
Natural breathing sounds...................................................  7(3
Respiratory sounds............................................................  77
Secretory sounds.............................................................  77 
                          CONTENTS.                         ix
                                                           PAGE
Friction sounds.................................................................   77
Modifications of vocal resonance..........................................   77
Skoda's classification.........................................................   77
Normal vesicular murmur...................................................   78
Bronchial respiration.........................................................   78
Cavernous respiration........................................................   78
Sibilant and sonorous rhonchi.............................................   78
Dry crackle.....................................................................   79
Crepitant rale..................................................................   79
Coarse crepitant or "mucous" rale......................................   79
Humid crackle, or gurgling................................................   79
Friction sounds................................................................   79
Bronchophony..................................................................  80
Pectoriloquy....................................................................  80
iEgophony......................................................................  80
Amphoric echo.................................................................  80
 Metallic tinkling...............................................................  81
 Causes of puerile respiration..............................................  81
     Feeble respiration.. ...................................................  81
     Blowing, and bronchial respiration................................   81
     Cavernous respiration..................................................  82
     Amphoric respiration...................................................  82
     Sibilant and sonorous rhonchi.......................................  82
     Dry crackling............................................................  82
     Humid  crackling........................................................  82
     Crepitant rale............................................................  82
     "Mucous" rale..........................................................  °2
     Friction sounds..........................................................   82
     Feeble vocal resonance................................................   82
     Bronchophony............................................................   °3
     jEgophony.................................................................   83
     Pectoriloquy................................•*.............................   83
     Metallic tinkling and echo............................................  83
  Extension of sounds of the heart......................................—   83
  Displacement of heart, liver, etc................................-..........  83
                                 2 
X                         CONTENTS.
                                                            PAGE
Physical diagnosis of diseases of the heart................................  83
    Inspection of the cardiac region....................................  83
    Palpation.:.................................................................  84
    Percussion................................................................  84
    Auscultation..............................................................  84
    Normal sounds of the heart..........................................  84
    Regional anatomy of the heart.....................................  85
    Valvular murmurs......................................................  86
    Harvey's tables..........................................................  86
    The real question of importance ...................................  86
    Friction sounds of pericarditis......................................  87
    Signs of aneurism of  the aorta......................................  87
Physical diagnosis of the abdomen........,.................................  87
    Inspection.................................................................  87
    Palpation.................................................................  87
    Percussion.................................................................  88
    Auscultation..............................................................  88
Inspection of the body after death...........................................  89

                         PART  III.

                   GENERAL PATHOLOGY.

The seats of disease...-.......................................................  94
Morbid states of the system................................................  94
Morbid states of organs.....................................................  94
Fever...............................................................................  95
    Symptoms of fever......................................................  95
    Condition of the excretions..........................................  95
    Increased metamorphosis of tissue.................................  96
    Comprehensive theory of fever......................................  96
Toxxmia.......................v..................................................  96
    Origin of  toxaemia......................................................  97
    Morbid poisons...........................................................  97
    Zymotic hypothesis.....................................................  99
    Deficiency of excretion................................................  99 
                          CONTENTS.                        Xi
                                                           PAGE
Cachexia.........................................................................   99
    Tuberculosis.............................................................  100
Hypertrophy......................................................'............  104
Atrophy.........................................................................  106
Irritation.......................................................................  107
Inflammation..................................................................  108
    Theory.................................................................  109
    Products of inflammation............................................  112
    Biography of exudation.............................................  113
    Suppuration.............................................................  115
    Effects of inflammation...............................................  116
    Specific inflammations................................................  116
    Post-mortem signs of inflammation..............................  116
Hypersemsesthesia, or "chronic inflammation"........................  118
Degeneration...................................................................  119
    Tumors...................................................................  120
    Cancer...................................................................  121
Neuropathology...........'....................................................  123


                         PART IV.
                        NOSOLOGY.-

Classification of Cullen.....................................................  127
Classification of the author...............................................  127
Phlegmasix.....................................................................  1^'
Zymoses........................................................................  1^"
 Cachexise.......................................................................  1"J
     1.  Diatheses.............................................................   120
     2.  Local cachexise.......................................................   130
                                                            1 o(i
Neuroses........................................................................
Ataxise.......................................................... ................   ]31 
Xll                       CONTENTS.
                          PART  V.
              *
                 GENERAL THERAPEUTICS.
                                                            PAGE
Classification of remedies.................................................   132
Most frequent modes of treatment.......................................   133
Antiphlogistic treatment......................................................   133
    Rest, position...........................................................   133
    Cold applications............................•.........................   133
    Blood-letting, general and local....................................   134
    Discussion of the controversy......................................   134
    Rationale of the action of blood-letting..........................   136
    Indications for abstraction of blood..............................   138
    Use of cathartics......................................................   140
    Diet........................................................................   140
    Antimony................................................................   140
     Nitrate of potassa.....................................................   141
     Ipecacuanha............................................................   141
     Yeratrum viride......................................................   141
     Aconite...................................................................   141
     Digitalis..................................................................   141
     Ergot....................'.................................................   141
     Mercury..................................................................   141
     Opium....................................................................   143
     Counter-irritation.....................................................   144
     Sthenic  and asthenic inflammations..............................   146
     Toxaemic inflammations.............................................   146
 Febrifuge treatment...........................................................   147
     Moderate laxatives...................................................   147
     Saline diaphoretics....................................................   147
     Cold drinks, etc........................................................   147
 Supporting treatment.........................................................   149
     Exhaustion, depression, oppression...............................   149
     Stimulants and analeptics...........................................   150
     Treatment for oppressive debility.................................   151 
                          CONTENTS.                        xiii
                                                            PAGE
    Treatment for depression............................................  154
    Debility of typhus and typhoid fevers..........................  154
    Chronic debility or exhaustion........................i............  154
    Iron, quinine, nervine tonics.......................................  154
    Cod-liver oil.............................................................  155
    Phosphates  and hypophosphites...................................  156
    Alcohol as an analeptic..............................................  156
    Theory of stimulation...............................................  156
    Accessory food.........................................................  158
    Absolute repose as a remedy........................................  159
Antidotal treatment...........................................................  159
    Positive antidotes.....................................................  159
    Chemical palliatives...................................................  160
        Antacids............................................................  160
        Anti-lithics........................................................  160
    Chemical antidotes....................................................  160
    Anthelmintics...........................................................  160
    Anti-psorics.............................................................  160
    Constructive  antidotes.................................................  160
        Anti-periodics....................................................  160
        Anti-syphilitics...................................................  161
        Anti-scorbutics...................................................  162
    Tentative antidotal remedies........................................  162
        Anti-arthritic s....................................................  162
        Anti-rheumatics..................................................  163
        Anti-zymotics.....................................................  163
Alterative treatment..........................................................  165
    Explanation and illustrations......................................  165
    Treatment of cutaneous affections................................  166
    Iodide of potassium, etc.............................................  168
    Degenerative diseases................................................  168

Concluding Maxims.......................................................  170

Glossary......................................................................  171 
^
  c*
^
Errata.—On p. 127, 1st line from the top, omit the word phlegma-
v.  In line 2d, of same page, instead of "inflammations," read
six.
"diseases." 
SUBJECTS.
1.  ETIOLOGY (ac-iov) :  the study of the causation  of
      disease.
2.  SEMEIOLOGY (<tz>xzu>v) :  of the signs  and symptoms
      of disease.
3.  GENERAL  PATHOLOGY (-«fl«0 : of the seat and
      nature of disease.
4.  NOSOLOGY (vo<ro<;) :  of the classification of diseases.
5.  GENERAL THERAPEUTICS  (depaneuw) : of the prin-
      ciples of treatment of disease.

                                        (xv) 
 
MEMORANDA  MEDICA.
                    ETIOLOGY.

   Disease may be defined as a perversion either of the
functions or of the  structure of the body or of any of its
parts.
   It is, in other words, a deviation from the normal physi-
ological state  or action of the  organism,  under the dis-
turbing influence of morbid causes.
   Dr. Williams's classification* of the  causes of disease is
full, but not consistent or convenient.
   The older subdivision into Percepta, Ingesta, Gesta,
Excreta, Applicata, and Circumfusa, is more philosophical,
but scarcely complete.
   The following classification  is proposed by the author:—

                CAUSES  OF DISEASE.
Hereditary: e.g. in tuberculosis; gout; epilepsy; insanity;
   cancer.
* Principles of Medicine, pp. 37-53.
             3 
18                MEMORANDA MEDIC A.

Dynamic, or functional  (by excess  or defect of action):
  e.g.  over-exertion; over-excitement;  emotion;  loss of
  rest; indolence ;  sensual excess.
Mechanical:  e.g. wounds and injuries;  tight-lacing; posi-
  tion.
Obstructive:  e.g. uncleanliness; ill ventilation; neglect of
  the bowels.
Conditional: e.g. extremes of heat or  cold;  partial expo-*
  sures or sudden vicissitudes of temperature ; moisture or
  dryness; electrical disturbances.
Ingestive: e.g. poisoning;  improper diet;  intemperance;
  abuse of medicine ; starvation.
Contactive: e.g. syphilis; gonorrhoea;  itch; hydrophobia;
  small-pox, etc.
Atmospheric : e.g. miasmatic fevers;  cholera; yellow fever;
  erysipelas, etc.
  It must be  remembered  that very often  more than one
cause is engaged in the production of an attack of  disease.
All such subdivisions exist, therefore, rather  mentally  than
actually.  But this does not destroy their usefulness.

   Hereditary  dis-eases  tire  not  generally congenital; it
being  a tendency that is transmitted : a special modification
of the organic  law or  germ-force  of  the economy.   The
same  period of life is generally observed in  the manifesta-
tion of this tendency in  actual disease.
   Some members  of a family frequently escape : sometimes
 a whole generation ; the taint again appearing in the next.
   Modification of the  hereditary tendency may occur; as
 when  the children of an insane  person die of meningitis or
 convulsions;  or those of a gouty patient suffer with  neu-
ralgia or dyspepsia, etc. 
ETIOLOGY.
19
  Degenerating influences affecting the race.  (Morel.)
  1. Toxaemia: from  alcohol, opium, haschisch, tobacco ;
diseased food,  as ergoted rye, bad  indian-meal, etc. ; defi-
ciency of food ; lead, mercury, arsenic, phosphorus.
  2. Malaria and pestilences.
  3. The "great town system;"  including private vice
(syphilis) and neglect of public hygiene.

  Dynamic or functional causes are illustrated by extreme
fatigue, general or local; sensual excess;  indolence.

  Mechanical  causes: surgical injuries ; tight-lacing ; posi-
tion, in certain employments.

  Obstructive  causes  are of  great importance.    Typhus
is especially originated by them ; and they aid in develop-
ing, propagating, and making more  malignant all zymotic
diseases : e.g.  yellow fever,  cholera, puerperal fever, erysip-
elas, scarlatina, diphtheria,  etc.

  Conditional  causes :  e.g. excess of heat  predisposes to
diseases of  the liver, stomach, and bowels; cold and damp-
ness, to those of  the thoracic  organs.  (Coup-de-soleil,  and
exhaustion  from extreme heat.)
    Vicissitudes are more often destructive than  extremes.
Electricity.  Ozone.
   Hygrometric state of the air, very important.

   Ingestive causes :  poisoning ; errors of diet;—
     1. As  to  quantity.
        Excess causes indigestion or plethora.
        Deficiency, anaemia and debility ;  perhaps scrofula. 
20
MEMORANDA MEDICA.
     2. As to quality.
        Indigestible food may cause cholera morbus, dysen-
          tery, diarrhoea, dyspepsia; putrid food, septic poi-
          soning.
        Deficiency of fresh vegetable food causes scurvy.
        Deficiency of oleaginous material, tuberculosis.
        Excess of animal food, with  insufficient exercise,
          gout.
        Deficiency of  animal  food, with  cold and   wet,
          rheumatism.

   Modifying influences of sex, temperament, and age.
   The diseases of women constitute a separate department.
   As a general  statement, the  female sex is characterized,
physically, as  compared with the male, by greater impressi-
bility and mobility, and less endurance and resistance.
   The  temperaments,  as  commonly  described, are the
lymphatic, the  sanguine, the  nervous,  and the  bilious.
Each of these  terms is descriptive,* except the last.  I pro-
pose that, instead of bilious, it be called  the sarcous  tem-
perament.   It possesses  the  greatest endurance, combined
with greater activity and energy than the lymphatic, less
arterial excitability than the sanguine, and less irritability
and impressibility than the nervous temperament.
   Influence of age on disease.—In infancy the functions
connected with nutrition are the most active.

  * The term bilious may have some meaning as applied to a morbid
habit of body; but this does  not render it applicable to a tempera-
ment; which is commonly understood to mean such variation of con-
stitution as is compatible with health. 
ETIOLOGY.
21
  The capillary portion  of the  vascular system is most
mature.
  The ganglionic apparatus is predominant in the nervous
system.
  The tegumentary surface is delicate and impressible.
  The heat making processes are less potent  than during
adolescence and  maturity.
  Some  organs, as the lungs,  etc.,  are  not  anatomically
developed to their final state.
  The period of dentition is especially  marked by reflex
excitability.
  During childhood, many of the same characteristics re-
main.  Activity of  the glandular apparatus is  also  con-
spicuous ; and the  spinal  axis begins to assume, in the
nervous system,  a greater relative importance.
  Fibrin  abounds in the exudations  resulting  from  injury
or inflammation  during childhood.
  The diseases most frequent during infancy and childhood
are—
       Cutaneous eruptions ;
       Disorders of digestion ;
       Convulsions;
       Glandular derangements ;
       Pseudo-membranous inflammations ;
       (Lobular pneumonia; epistaxis.)
  The exanthemata, hooping-cough,  and mumps are not
peculiar to childhood; although comparatively few  per-
sons pass through adolescence without having had most of
them.
  During adolescence, the arterial circulation attains its
height of force and  fullness.
                          3* 
22
MEMORANDA MEDICA.
  The voluntary motor energies are especially developed.
  The emotional impulses are most powerful.
  In the female, menstruation assumes great importance.
  The most frequent disorders of youth and early maturity
are—
       Active congestions ;
       Inflammations ;
       Hemorrhages.
   Tuberculosis, which, during  childhood, most frequently
affects the  glands, in adolescence selects much more often
the lungs.
  The period of middle life should present the most nor-
mal balance of development and function, with no special
liability to  disease.  But such  morbid tendencies as either
inheritance or habit  may have produced  are  apt  now to
display their effects.  Thus  gout, lithiasis, dyspepsia, etc.,
arise.
  As  old age  approaches, the venous  circulation becomes
more sluggish.
  The aggregate vital  energy  of the  system is diminished.
  Atrophy and degeneration advance.
  The aged are especially subject to—
       Passive congestions ;
       Dropsies;
       Catarrhal affections ;
       Urinary diseases;
       Apoplexy;
       Morbid adiposity ;
       Fatty and other degenerations  of the heart, brain,
         liver, etc. 
ETIOLOGY.
23
  I propose to conclude these remarks upon the causation
of disease, by some brief consideration of what may  be
called the special etiology of certain diseases; as miasmatic
fevers, yellow  fever, typhus, typhoid fever, cholera, cholera
infantum, plague, puerperal  fever, erysipelas, and  diph-
theria.
  All  of these  might without  impropriety  be included
under the head of atmospheric causation;  as, being all of
them either endemic  or  epidemic, we  can scarcely avoid
the supposition  that, whatever the nature of the cause, the
atmosphere is the medium of its transmission.   Yet, with
the exception  of typhus, we can hardly be said to have any
demonstrable  knowledge  of the cause of either of these
formidable diseases.  But we must not undervalue the sig-
nificance of such facts as  we do possess ; one or two links,
only, being  wanting in the  chain  of  evidence  regarding
each, in order to form  a reasonable theory.
  Xo subject can be more interesting to the medical man in
this country than the history of our own endemic fevers, of
which the autumnal (and  vernal) intermittent and remit-
tent are by far the most prevalent.
  The principal  well-ascertained facts bearing on the origin
of these fevers  are as follows (see Drake  on Diseases of
North America, vol. i.) :
   1.  Autumnal  fevers are always localized in their preva-
lence ; having certain  bounds, even when  considered  epi-
demic.
   2.  They never prevail  in  the thickly-built portions of
cities.
  3.  A mean  summer  temperature of at least C0° is neccs- 
24
MEMORANDA MEDICA.
sary to  their  development;  a  continuance of  decided
warmth for more than two months being required.
  4. They occur with greatest violence in tropical or sub-
tropical climates.  Yet some regions, in which the summers
are both hot and long, are exempt.
  5. They prevail least where the surface of the earth is
rocky, and most where the soil  is loaded  with organic
matter.
  6. The existence of surface-water favors their develop-
ment.  They haunt  chiefly the borders  of marshes, shallow
lakes, and slow streams ;  but not exclusively.
  T. Those dwelling  upon the shores  of large lakes are
more subject to them than those who navigate their central
waters.
  8. The  vicinity of  the sea  is comparatively  free  from
their invasion, unless inland marshes lie near it.
  9. In the midst of unbroken  forests they are rare, but
are apt to follow the clearing away of woodlands.
  10. Heat and moisture may exist together in abundance
(as on the Gulf of  Mexico) without—other conditions
being absent—producing these fevers.
  11. Organic matter has been detected in the air of mias-
matic districts.
  12. No  peculiar  gases or  other  chemical agents, not
found elsewhere, have been  isolated  or recognized in such
regions.
  13. No electrical  peculiarities have been  proved to exist
in miasmatic localities.
  14. The  draining  of dams or  ponds, or  other  exposure
of surfaces, previously  covered  by water, to the  sun, has 
ETIOLOGY.
25
repeatedly been followed by fever.  The first cultivation of
a new soil has been attended in the same way;  but con-
tinued culture is accompanied  by  a  diminution  of  the
endemic.
   15. A period of incubation, often extending to from one
to three weeks, is common after exposure to the circum-
stances  of a miasmatic district.  Persons exposed in the
autumn, and removing, have sometimes been attacked the
following spring.   The cause  has, therefore, a power of
latency in the system.
   16. Some seasons are healthy, and others unhealthy, in
the same place, without any known difference in its physical
conditions or circumstances.
   The hypotheses which have been started upon these facts
are chiefly as follows:—
   1. The electrical hypothesis.   (Sir J. Murray.)
   2. The meteoric hypothesis ;  which considers changes of
atmospheric temperature and moisture sufficient to produce
these disorders.   {Ozone, Gaillard.)
   3. The malarial hypothesis; Avhich  supposes the exist-
ence of  a peculiar  gas, generated under certain circum-
stances, the effect of which upon the body is poisonous.
   4. The vegeto-animalcular hypothesis; which imagines
the  existence  of  microscopic  organized growths,  which
enter the  system and produce these peculiar morbid results.
   The electrical  speculations of Murray, Craig, Littell, and
others are interesting,  as  calling attention to a class of
facts which have been too much neglected.  But they afford
no basis for a theory of the etiology of  autumnal fevers.
  The meteoric  hypothesis is  excluded  by  the following
considerations:— 
26
MEMORANDA MEDICA.
   1.  The  exemption of  some  situations  noted  for  both
 heat  and moisture of the air ; as at Key West, Pensacola,
 Balize, etc.
   2.  The prevalence of remittent and intermittent fevers in
 places but a short distance from the above, or situated pre-
 cisely like them with respect to heat and moisture ; as at
 the head of Pensacola Bay, etc.
   3.  The occurrence of these fevers in a few places where
 the air is comparatively dry.
   4.  The comparative  immunity of in-door operatives, in
 some  large manufactories, in an air constantly saturated
 with heated vapor, and  in miasmatic districts.
   5.  The frequent remoteness of the  attack from the time
 of exposure; unlike all other effects of merely conditional
 or physical causes.
   Driven thus, by  exclusion, to  the view that a material
 poison, malarial  or vegeto-animalcular  (i.e. inorganic  or
 organic), is the  causa causans  of remittent, intermittent,
 and  pernicious fever (all one disease, except in  grade),
 strong reasons urge the further  preference of the organic
 phase of this theory.
   1. The law of  the diffusion of  gases  interferes much
 less with this than with the hypothesis of inorganic ma-
 laria.
   2. Heat and moisture, so favorable to autumnal  fevers,
 also  develope the  greatest  abundance and  luxuriance  of
 animal and vegetable life.  Tropical  regions, too, furnish
 by far  the  most numerous species of plants and animals
having active and destructive properties.
  3.  The non-discovery of microscopic germs or organisms
peculiar  to  the air of miasmatic  regions does not prove 
ETIOLOGY.
27
their non-existence.   It only leaves  us without the power
of demonstrating the theory.
  4. The inequality of different seasons, as to the presence
or absence  of endemic fevers, suggests a parallelism to the
unequal  abundance  of reproduction  among animal  and
vegetable organisms.
  5. The fact that cold, a hard frost, always arrests the
prevalence of autumnal fevers (unless in  persons already
affected by exposure), is significant of the probably organic
nature of their cause.
  6. The  latency of the infection, for  weeks, or  even
months after exposure, is  at  least as well (if not  better)
explained upon this  hypothesis as upon any other.
  The  limited, endemic character of these diseases, more-
over (unlike  that  of cholera  for instance), enables us to
form the still more  definite  conjecture, that the  special
cause of miasmatic or "country fever," the autumnal fever
of this country (bilious, remittent, intermittent, congestive,
etc.), is a microphyte; i.e. a minute vegetable organism,
inhabiting certain localities only.

  The  etiology of yellow  fever has been, and yet is, the
subject of  voluminous and zealous controversy.   It  has
narrowed down  so much,  however, that it  will not, in view
of the  necessity of brevity in  this work, be  too  great an
exercise of dogmatism to pass  over  the argument entirely,
and state only the conclusions  arrived at by the author, in
common with a majority of those who  have devoted much
attention to the facts.  (See La Roche on Yellow Fever.)
  Referring the reader to the method of reasoning followed
in connection with  the subject of  miasmatic  fevers,  and 
28
MEMORANDA MEDICA.
premising that yellow fever is to be considered as entirely
a distinct disease from remittent fever, the important theo-
retical conclusions  (of the truth of which I am very well
satisfied) are these :—
  1. The cause of yellow fever is a specific material, prob-
ably a microscopic organism, the difficult transportation of
which over long distances  makes it also probable that it is
vegetative: a microphyte.
  2. This morbid cause or poison may, upon this theory,
be  assumed to  be  propagated  by or through extremely
minute but numerous  germs; which germs (like all others)
have certain peculiar  conditions of vitality.
  3. They are seldom developed north of 48° north lati-
tude,  or south of the  equator.  Their  "habitat"  is  the
shores and islands of  the Atlantic Ocean and its connected
seas, the Gulf of Mexico, and the Western Mediterranean.
This exclusiveness is  remarkable ; as it is a fatal argument
against the  theory of its contagious transmission.   Thus,
yellow fever never visits
    The Pacific Coast of America;    Bombay ;
    Canton;                         Alexandria;
    Calcutta;                        Constantinople;
    Athens; nor any of the interior cities of either con-
       tinent.
  On the other hand,  it visits often
    The Western Coast  of Africa;     Vera Cruz;
    Tropical islands of the Atlantic ;   New Orleans ;
    North  Coast of South America ;   Mobile ;
    West India Islands ;              Savannah ;
    Charleston ;  and  occasionally, also,
       Rio  Janeiro ;                  Gibraltar ; 
ETIOLOGY.
29
Natchez ;	Marseilles ;
Yicksburg;	Barcelona;
Memphis ;	Cadiz;
Norfolk;	Malaga;
Richmond;	Seville;
Baltimore ;	Xeres;
Philadelphia;	Carthagena;
New York;	Leghorn;
Boston;	Sicily, etc.
  All  of these  places  are  either on the Atlantic, or the
Gulf of  Mexico, or the western part of the Mediterranean
Sea, or  on great rivers emptying into one or  other part
of those waters; all being  portions of that great oceanic
current which sweeps from the  western  shore  of  Africa,
freighted with tropical life and death, against  the midlands
of our western continent; to  return, as the  Gulf Stream,
back upon the European, and finally upon the African Coast.
  4. The germs  of  the yellow fever poison  can live and
multiply only during continuous warm weather (average
of 80° Fahr. for a month), with a high dew point; i.e. an
excess of moisture in the atmosphere.
  5. They require, also, for  their development, abundant
products of vegetative  and animal decay, especially the
former.  As  we  have seen, yellow fever is a disease,  not of
the country, nor of inland towns, but of sea-ports, or cities
on great rivers near the sea.
  6. The infection* of  yellow fever is rarely  diffused over
regions of great extent; mostly its limits may be measured
by fractions of a square mile.
* By infection I mean atmospheric propagation or transmission.
                           4 
30
MEMORANDA MEDICA.
   1. It is never produced or multiplied in the bodies of
the sick ; i.e. is never, correctly speaking, contagious.
   8. It is very seldom, if ever, transported by fomites;
i.e. clothing, bedding, merchandise, etc.  If it exist in any
such material, it is certainly destructible, or removable by
simple cleansing and disinfecting measures.
   9. Ships  sometimes  transport it  by carrying in  their
foul and pent-up holds materials  and an atmosphere
which afford the necessary conditions for its growth and
persistence.
   10.  But when thus carried, no extension or further local
propagation of the morbid cause occurs, unless heat, mois-
ture,  and emanations  of decay abound at the place to
which  it is brought.
   11.  Thorough  cleansing and fumigation of ships, like
that of persons and fomites, will certainly always deprive
them of the power to transport or generate yellow fever.
   12.  The removal of  the population of any infected dis-
trict will  inevitably arrest and  put  an end to  any yellow
fever endemic.

   The mode of causation  of typhus fever  appears to be
placed  beyond  a doubt.   It is not confined  to  any part of
the world, although cold  climates are especially subject to
it; nor to any season, although it occurs most frequently in
the winter.
   Jail fever, camp fever, ship fever, etc., as synonyms for
typhus, indicative of its origin in certain instances, all sug-
gest its dependence, in  the first place, upon one essential
cause—ochlesis or crowd-poison (from oxXoc, a crowd).
   Wherever the excreta of human beings, from their lungs 
ETIOLOGY.
31
and skins, as well as bowels and kidneys, accumulate in an
unrenewed atmosphere, for a considerable period,  typhus
will be produced.
  Then it becomes infectious;  in fact, contagious.  Not
only do certain  places  become tainted with it, so that  all
persons abiding there are liable to it, but a single  patient
with typhus, taken to a new neighborhood, may generate
the disease in other persons.  The  excretory zymotic agent,
which  ordinarily requires  numerous  bodies to afford it in
typhus-breeding quantity, is so concentrated and dynamized
in the body of the patient sick with the fever, as to  have in
it the  poisoning power of a whole crowd.  Thus, in the
case of typhus, infection and contagion  are mutually con-
vertible ;  the morbid poison being originated by the altera-
tion and  accumulation of matters naturally produced in
the body.   It is not so with the  contagion  of  small-pox,
the origin of which is not thus controllable by circumstances,
in the  absence of its specific cause ;  nor is it so with the
localized infection of yellow fever, or the migratory poison-
cause of cholera.

   Typhoid  fever presents, as to its etiology, much  greater
obscurity.
   It cannot be  said that anything is known in regard to
the nature of its causation ; it is  a subject quite open  to,
and important for, investigation.
   The following are the most striking facts bearing upon it:
   1. Typhoid fever is rare in persons over forty years of
age, or under ten.
   2. It scarcely ever (apart from  relapses) occurs twice in
the same person. 
32
MEMORANDA MEDICA.
  3. Agencies  causing depression of the nervous system,
such as anxiety,  fatigue,  home-sickness, etc., promote  the
occurrence of typhoid fever.
  4. Typhoid fever  is  not  unfrequently epidemic or  en-
demic.
  Examples  are  reported in which  typhoid fever has  ap-
peared to be extended by contagion.   Without being able
to deny or disprove  the possibility of such  an occurrence,
it appears to  me more probable that, in  the instances
alluded to, typhus fever has been confounded with typhoid,
or a blending of  the two diseases has taken place.
  The subject of  the blending and conversion of the types
of fever (Dickson) appears to me to  belong most appro-
priately to the  department of nosography and pathology.

  Cholera is an  occasional  epidemic in all  parts of  the
world except Hindostan, where it is endemic.
  Unlike yellow fever, in  which one attack generally gives
exemption for a lifetime, the  same person may, if exposed,
have any number of  attacks of cholera.
  Unlike intermittent and  remittent  fevers,  to the local
conditions productive of which some  races of men (as  the
negroes) become  acclimatized, so  as  not to be susceptible
of miasmatic influence,—in the case of cholera, natives are,
where it  prevails endemically, as liable to be attacked as
foreigners.
  Attention to all the facts  connected with the origination
and migration of  cholera  has convinced me* that its pecu-
  * See a paper "On Animal Decomposition as the Chief rromotive
Cause of Cholera," Philadelphia Medical Examiner, August, 1835. 
ETIOLOGY.
33
liarity, in etiology, is the dependence of its  specific cause,
for development and propagation, upon animal matter in
a state of decomposition.
   Without having space, compatibly with the plan of this
work, to discuss the reasons which urge this opinion upon
my mind, I  may  give  an idea  of their nature, under  the
following heads :—
   1. The Delta of the Ganges, which is the  endemic home
of cholera, and from which it emanates in periodical migra-
tions from east to west  (occupying  about six years each
time in traversing the world), is remarkable for the amount
of animal decomposition it presents  under the influence of
a tropical sun.   This evidently results :  a, from the exten-
sive yearly inundations of the Ganges, and  the subsidence
of the same in  the hot  season ;  b, from the common custom
of  non-interment of  the dead,  who are thrown in vast
numbers into the Ganges, as  a sacred  river; c, from  the
enormous destruction  of life  by  the various  fanatical
practices of  the Hindoos  ; d, from their unhealthy habits as
regards drinking water, etc., such as  are  prevalent in  all
barbarous countries, but whose  morbid  influence is felt
chiefly in tropical climates.
   2. An immense number of  facts have been collected by
Dr. Baly, in  his Report to the Royal  College of Physicians
in 1854, showing  the importance of "human intercourse"
in extending the prevalence of cholera.
  3. Yet human intercourse does  not propagate cholera by
contagion, because contagion has been proved experiment-
ally (as well as incidentally)  not to exist:  as in the careful
trials   made  personally  by Schmidt, Meyer,  Marshall,
Lizars, Coste, and the  surgeons and  students at Moscow
                          4* 
34
MEMORANDA MEDICA.
and Dantzic, in 1832;  and on dogs, by Dr. Lauer Lindsay,
in 1854.*
   4. It is clear, too, that human intercourse is not the only
mode by which cholera is  transmitted.   Thus, I have had
personal cognizance of two instances—and report has been
published  of many  others—in which it broke out on ships
two weeks out at sea, there having been no cholera at the
ports which the ships  sailed from.   The  epidemic  cause
was here, undoubtedly, crossing  the ocean as a cloud, in-
dependently  of all other  agencies.    In one  of  these
instances  (the  ship Tuscarora), the disease was cut short
by the sudden lowering of the temperature of the air at the
approach  of an iceberg.
   5. All testimony agrees  that the  malignancy and extent
of prevalence of cholera are intensified, most of all, by the
filth of towns. Its mortality has been greatest in Moscow,
Paris, Marseilles, Liverpool, Manchester, Edinburgh, New
York, etc. ; and greatest  of all, in  the filthiest parts of
these and other towns.
   6. Mere situation, as to lowness and dampness, does not,
to any great extent, affect the liability of a place to cholera.
This has been fully demonstrated by Dr. Baly in England,
by Orton  and Jameson in India, and by Frettenbacher in
Russia.
   7. Drinking-water is a frequent vehicle for  the  convey-
ance and maintenance of the cholera cause.   Bad water
always increases the mortality from it in a striking manner.
In London, those  districts whose inhabitants used water

   * I am aware that Dr.  Lindsay considered his experiments to sup-
port the theory of contagion ; but their obvious meaning is otherwise.
See Edin. Med. and Surg. Journal, April and October, 1854. 
ETIOLOGY.
35
from the Thames below where the sewers entered it, suffered
a mortality (Baly) about five times as great as those whose
supply was from the river  above the entrance of the sewer-
age.   Bethlehem  Hospital,  with four hundred  lunatics,
having an artesian well,  was the only lunatic hospital in
London in which there was no cholera in 1849.
   8. Yet the  reasons  already  alluded to, proving  that
cholera is not dependent  on  human  intercourse for its ex-
tension, also refute the hypothesis of Dr.  Snow,* that it is
only through drinking water,  food, etc.,  that the cholera
cause propagates itself.
   9.  The epidemic at Columbia, Pennsylvania, in  1854, to
which the author was a visitant, afforded a remarkable con-
firmation of the  view that animal decomposition, of any
kind, is  promotive of cholera.   The town of Columbia is
not large, nor crowded, nor very dirty. There had been no
cholera there any previous year. But in the summer and
fall of  1854, the  Susquehanna, on which it is situated, was
unprecedentedly low ; and large quantities of animal mat-
ter  (dead cattle,  etc., thrown from  the railroad trains)
putrefied rankly in the sun.  When the epidemic commenced,
the wind blew from the river upon the town;  and many of
the inhabitants also drank the water of the tainted river.
   My conclusion, then, from these and other facts,  is this :—
   That the difference in origin  between typhus and cholera
is, that while typhus may always be produced by unfavor-
able sanitary conditions, the essence  of which consists in
accumulation of animal matter in a state of post-organic
change,—cholera is generated  only under the agency of an
* Oration on Continuous Molecular Changes, p. 18. 
 36                 MEMORANDA MEDICA.

 unknown specific  cause;  the capriciousness of which, in
 its  migrations, its  partial subjection to temperature, and
 other habitudes, suggest the applicability to it of the ani-
 malcular hypothesis.*
   In connection with this  conclusion, I may lay down the
 following proposition,  as  of high  practical importance,
 toward  the  conservation of  the  health of communities:
 viz., that—
   All malignant epidemics are preventable, and should be
 prevented, by attention to those laws of public and domestic
 hygiene, now becoming  systematized in the form  of sanitary
 preventive measures and police.  In the protection of locali-
 ties from yellow fever, for  instance,  I believe that the only
 available and desirable quarantine is a dirt-quarantine.
 Annihilate or exclude dirt, i.e. putrefiable animal and veg-
 etable detritus, and no  migratory or  malignant morbific
 poison can  sustain its  existence,  even if  its cause  be im-
 ported to the spot.
   It is interesting to know that  this view can be shown to
 be correct, even as regards plague, which was once looked
 upon as the  very type of contagion.
   Plague has now almost  died out  in those  cities  of the
 East to which it was formerly a  frequent visitant, if not an
 endemic.  Long ago it was finally excluded from  all the
 ports  of Western  Europe;  not by  quarantine,  which has

  * In answer to the  objection of Mr.  J. Simon to this hypothesis,
 that  parasites  only produce local, and  never malignant disorder, I
 would suggest that it  is  probably not as living parasites,  but as
poisonous organic matter (animal  poison), that the microzooic cause of
 cholera acts;  an apt  illustration of this mode of  poisoning being
 Been in the toxic effects of  cantharides,  putrid meat, etc. 
ETIOLOGY.
37
always failed of its purpose, but  by improved sanitary
arrangements.
  Further  than this,  Cairo affords an illustration of the
dependence of plague upon local  conditions of malaria.
This great  oriental capital, before  the time of Mohammed
Ali Pasha, many times lost tens of thousands of its inhabit-
ants by visitations of plague.  That wise viceroy, by costly
drainage, transformed  an immense  swamp, in the heart of
the city, and the  receptacle of all its filth, into  a park or
square  (the Esbekieh);  and now Cairo  is free from
plague.

  Cholera  infantum is a disease whose causation has, un-
doubtedly,  three elements :—
  1. Intense summer heat.
  2. The atmosphere  of large cities.
  3. The peculiar susceptibility of infants.
  Of these, the second is  the most under  control, by re-
moval to the pure air of  the open country.
  Country  air, then, is the prophylactic  (preventive), and
also one of  the principal remedies for this severe and often
fatal complaint of infancy.

  Erysipelas is frequently endemic, especially in large sur-
gical hospitals.  As  to  its causation, a minority of  cases
only occur  idiopathically; i.e.  without  any local wound,
injury,  abscess, etc., to originate cutaneous inflammation.
Most cases  are traumatic; i.e.  connected with  injuries of
the surface  of  some  kind.  Yet very  many  wounds, ab-
scesses, surgical  operations, etc., may  occur  without any
erysipelas. 
38                MEMORANDA MEDICA.
   There appears, then, to be for its production required—
   1. A peculiarity of the atmosphere.
   2. A morbid tendency of the patient's system.
   3. Mostly, but not always, a lesion of the skin.
   The accumulation of the effete organic material thrown
off in connection with inflammation seems to be the source
of that contamination of the air which predisposes to ery-
sipelas.  And probably the accumulation in the blood of the
same material constitutes the cause of individual proclivity
to it;  while the presence of the very process of inflamma-
tion upon the surface is its most usual exciting cause.
   Analogy, or, more correctly, affinity, of a very  close and
important  kind, exists  between erysipelas  and puerperal
fever*  Both of these diseases occur very often at the
same time and  the same place.   Similar circumstances—
those of the crowding together of human beings, the bodies
of some of  whom  are  in  a  state of disease—will produce
erysipelas in persons of either sex who have suffered some
lesion  of the  surface,  or puerperal fever in parturient
women.
   This etiological association of these two diseases is sus-
tained by their pathological analogy or relationship.   The
traumatic state of  the uterus after childbirth,  in  which
blood, mucus, etc., may collect and become decomposed,  is
parallel  to  the condition of injury or  inflammation  which
is the usual exciting  cause of erysipelas  upon  the  skin.
The further pathological resemblance  of these  affections
may be expressed  thus:—
  * Distinguishing, of course, between this, as an epidemic or endemic
disease, and sporadic puerperal peritonitis. 
ETIOLOGY.
39
  Erysipelas is an acute fe-    Puerperal fever is an acute
brile disease, in which a pe-  febrile disease, in which a pe-
culiar diffusive inflammation  culiar diffusive inflammation
is a prominent characteristic;  is a prominent characteristic;
the seat of this inflammation  the seat of this inflammation
being the  skin, areolar tis-  being the uterine veins,peri-
sue,  etc.                     toneum,  etc.
  Lastly, many cases have occurred,  in which there was
reason  to  believe that an  obstetrician,  going  from  the
chamber of a patient with erysipelas to that of  a lying-in
woman,  has been the  means of  production of  puerperal
fever in the latter.   The most thorough disinfecting means,
with change of clothing, etc., ought certainly to be resorted
to, if, in knowledge  of this fact, the practitioner ventures
to interchange  his visits between patients under such cir-
cumstances.
   The theory of " continuous molecular changes" appears
to apply to the infection of puerperal fever and erysipelas;
but  to  expatiate  upon  this would occupy us too  long a
time.

   Diphtheria is a name recently given  to  a disease which,
although described by some ancient writers, and occurring
at intervals in different countries of Europe for  many cen-
turies, has nevertheless  increased in the frequency and ex-
tent of its epidemic visitations within  a few years.   It is
characterized by fever and debility, with  pseudo-membranous
inflammation of the fauces, tonsils, and pharynx, extending
in some cases into the larynx.
   The etiology of diphtheria remains,  as  yet, in great ob-
scurity.   The leading facts are, that it  is usually epidemic, 
40
MEMORANDA MEDICA.
and  that  its visitations are  remarkably limited; "acting
with intensity in confined centres;  as  a small village,  a
crowded school, a  numerous family;" a sort  of domestic
pestilence.
  Like other zymotic diseases, it attacks with greatest ma-
lignancy those places in which public and private hygiene
are most neglected.  The poor are therefore the greatest
sufferers.   But it is not confined to their  dwellings.   The
effeminating influences  of  luxury  and  indolence invite it
also to the homes of the affluent, where debility of constitu-
tion appears to aid or supply the place of a foul atmosphere
as a predisposing cause.
  Diphtheria  has  prevailed  under very  various circum-
stances of  situation, soil, climate, and season.   " The only
cosmic  influences which appear to exhibit any promotive
agency in  its development   are  excessive alternations of
temperature, and of the  barometric  state  of  the atmo-
sphere. "
  In the combination of a peculiar and diffusive  inflamma-
tory affection of an epithelial (mucous) surface with a con-
stitutional febrile affection,  diphtheria presents some anal-
ogy, deserving of attention,  to  erysipelas.  It is  probable
that the infection of the two diseases will be found to have
a similar  rationale, and to  be subject to the same laws of
development and prevention.
  Contagion has  been urged  by Guersent, Bretonneau,
Trousseau, and others, as explaining the mode of transmis-
sion of diphtheria.  But the experiments of Trousseau him-
self, and those of Harley, failed entirely to verify this view;
and  the apparently self-determining manner of migration
of the disease (e.g. in  England from the  southeast to the 
ETIOLOGY.
41
northwest in 1857-9) presents difficulties in the way of this
theory of personal transmission, analogous to  those con-
nected with the history of cholera.  So that even those who
insist most strongly upon its contagiousness are obliged to
admit, that the movements and  invasions of diphtheria  are
by no means dependent upon such a mode of conveyance.
o 
42
MEMORANDA MEDICA.
                 ZP.A.IFIT  II-

                    SEMEIOLOGY.

             I. RATIONAL SYMPTOMATOLOGY.
            II. PHYSICAL DIAGNOSIS.

  Rational symptoms and physical signs are distinguished
(somewhat arbitrarily) thus: a rational symptom is a sign
of disease which is obvious to the patient himself or to the
practitioner without close inspection.  A physical sign is
one determined  by  examination into  the  properties and
material conditions  of the organs of the body; as by pal-
pation,  auscultation, percussion, etc.   Symptoms guide us,
generally, by physiological inference; physical signs, by
anatomical necessity.
  Symptoms and  physical  signs  together contribute  to
diagnosis; i.e. the knowledge of the character of the mor-
bid process or state in given cases; the answer to the ques-
tion, " what is the matter V
  Prognosis is the anticipation  of the progress and results
or terminations of disease. 
SEMEIOLOGY.
43
                     SECTION I.
                SYMPTOMATOLOGY.

  Symptoms, or rational signs, are—
       Local, or constitutional;
       Idiopathic (primary), or secondary ;
       Premonitory (prodromata) ;
       Critical;
       Pathognomonic (characteristic).
  We examine the  symptoms  of disease as connected with
the digestive,  circulatory, respiratory,  tegumentary, secre-
tory, motor, sensory, and psychical apparatus.

                  DIGESTIVE SYSTEM.
  The tongue may be natural, pale,  cold, red, furred, brown,
black, cracked, or fissured.
  It is pale, in anaemia.
   Cold, in collapse, as of cholera, etc.
  Red, in scarlatina, stomatitis, sometimes in gastritis.
  Furred, in indigestion, gastro-hepatic catarrh, fever, etc.
  Brown or black,  cracked or fissured, in  low fevers: as
typhus or typhoid.
  The manner of cleaning of  the tongue during convalesc-
ence should also be noticed, as affording prognostic indica-
tions.
  The teeth are covered with  sordes in low  febrile states.
  They are loosened by severe salivation.
  Their  rapid decay  shows  impairment  of constitution.;
but this is unfortunately very  common. 
44
MEMORANDA MEDICA.
  The gums are swollen,  soft, and  spongy, and prone to
bleed, in scurvy.
  A blue line along the gums is observed in lead poisoning.
  A red line  along  their edge is  sometimes  noticed in
phthisis.
  Swelling  and soreness of the gums, with tenderness oi
the teeth, and a coppery taste, occur in salivation.
  Increased flow  of saliva gives  name to this effect of
mercury on  the mouth.
  Deficiency and thickness or viscidity of the saliva occurs
generally during fever; and  often also in chronic diseases,
especially of the throat or stomach.
   The taste is morbidly
     Bitter, in hepatic derangements, dyspepsia, etc.;
     Sour, in gastric  indigestion;
     Saltish, in phthisis pulmonalis,  haemoptysis, etc.;
     Putrid, in gangrene of the lungs.
  Appetite   is generally deficient  (anorexia)  in  disease,
especially of an acute character.
  Excessive appetite (bulimia) is  not often  important;
sometimes  it occurs in nervous affections, in diabetes, and
in persons having tape-worm in  the alimentary canal.
  Perverted appetite is one of  the  symptoms of chlorosis,
hysteria, etc.
  Thirst is  excessive in two very opposite conditions: high
fever and loxv collapse.
  Difficulty of swallowing (dysphagia) may result from—
     Inflammation  of the fauces, tonsils, or pharynx ;
     Spasmodic constriction  of  the throat;
     Stricture of the pharynx or oesophagus ;
     Obstruction by a foreign body, tumor, etc. ;
     General debility, as in the moribund state. 
SEMEIOLOGY.
45
  Nausea and vomiting may occur from—
     Indigestion:  egesta,* partly digested food, mucus,
       etc.;
     Colic:  eg., ditto, bile,  etc.;
     Pregnancy:  eg., mucus, food, etc.;
     Gastritis: eg., abundant and altered mucus, etc.;
     Hysteria: eg., gastric  and biliary secretions, more  or
       less altered;
     Cholera  morbus: eg.,  gastric  and biliary secretions,
       diluted ;
     Cholera  maligna: eg., copious  watery fluid  (rice-
       water) ;
     Ulcer of stomach : eg., mucus, lymph, blood ;
     Cancer of stomach: eg., ditto, with cancer-cells, fibres,
       etc. ;
     Disease of  the brain : eg., not peculiar in character.
     Bright's disease of kidney: eg., not peculiar ;
     Strangulated hernia: eg., stercoraceous  (faecal).
  Sarcinse,  or microscopic,  wool-sack like vegetable  para-
sites, are occasionally found in matters vomited, in cases of
disease of the stomach.   Epithelial  cells, starch granules,
torulae (also vegetable) and vibriones  (animalcular) are
often discovered by the microscope.

SYMPTOMS CONNECTED WITH THE CIRCULATORY SYSTEM.
  Palpitation or disturbed action of the heart may depend
upon—
       Pericarditis or endocarditis ;
       Hypertrophy of the  heart;

                * Egesta, matters thrown out.
                            5* 
46
MEMORANDA MEDICA.
       Chronic valvular disease;
       Anaemia;
       Nervous irritability (nervousness);
       Dyspepsia.
  The pulse should be examined when the mind and body
of the patient are as tranquil as possible. It is most rapid
in the  standing posture, less so when sitting, slowest in the
recumbent position.  Dr. Guy asserts it to be most rapid in
the morning.  It is increased in force and frequency by ex-
ercise, food, and  emotional excitement.  The pulse of the
female is slightly more rapid, as a rule, than that of the
male sex.  It diminishes in rapidity from birth to old age;
but in very aged  people it again becomes somewhat  acceler-
ated.
  In  obscure  cases  we  should examine the  pulsation of
other arteries  besides those at the wrist; and should espe-
cially observe  the character of the impulse of the heart.
  In adults, the average number of beats in health is, for
the male, 70 ;  for the female, 75.
         At birth, 120 to 140.
         Infancy, 120 to 100.
         Childhood, 100 to 90.
         Youth,  90 to 80.
         Middle  life, 75 to 65.
         Old age, 70 to 60.
         Decrepit age, 75 to 80.
  We judge by the pulse (inferentially) of the force of the
heart's action, of the force of the arterial impulse, of the
excitability of the  nervous system, of the fullness of the
blood-vessels, and of the tone and physical condition of the
arteries. 
SEMEIOLOGY.
47
   The pulse in disease  may be natural, or  strong, weak,
firm, yielding, full, small, bounding, compressible, rapid,
slow, quick, jerking,  hard,  soft, tense,  gaseous, corded,
wiry, thready, imperceptible, regular, irregular, intermit-
tent, dicrotous.
   Not considering it necessary here to define each of these
terms, it may be remarked that  an important difference
exists between a rapid pulse and a quick pulse, and between
one that is merely full and large and one that is strong.
   The pulse of fever is characterized by moderate accelera-
tion,, with variable increase of  force in the beat.
   The pulse  of inflammation (with  constitutional excite-
ment) is not only accelerated, but hard or tense. Whatever
may be said to the contrary, this character of the pulse is, in
acute inflammations, of great  consequence as an indication
of treatment; although, of course, it must not be depended
on alone.
   The pulse  of  nervous irritation  is usually quick, and
variable  in rapidity and force, under  excitement or  re-
pose.
   The pulse of extreme debility is nearly always (as in the
dying state) very rapid and very small, or "thready."
   Irregularity of the  pulse  is  occasionally  congenital;
sometimes it comes on with old age.  It  may be a transient
symptom, accidental, as it were, during the progress of an
acute malady; or at the commencement of  convalescence,
as from remittent fever.  It is directly related to the nature
of the disease, in certain cases of  disease of the heart, and
in meningitis (inflammation of the membranes of the brain)
during the stage  of effusion.
   The dicrotous or  double  pulse is observed 'especially 
48
MEMORANDA MEDICA.
 during continued fevers, either typhous or typhoid.   It is
 explained by a loss of muscular tone in the arteries, so that
 the arterial impulse is separated from that of the ventricles
 by a perceptible (though slight) interval.
   The state of  the capillary and venous circulation often
 affords signs of  disease.   Torpor of  the  circulation  is
 marked by slowness in the return of the blood after it has
 been displaced by pressure;  for instance, upon the cheek or
 the back  of the hand.   The veins of the hand or arm may
 be similarly examined with advantage ; as  in cholera, per-
 nicious intermittent, low continued fever, etc.  The venous
 circulation  is affected  not unfrequently in heart-disease:
 e.g. pulsation of  the jugular veins,  from valvular disease
 involving the right side of the heart; cyanosis, or blueness,
 from  imperfect  separation of the  arterial from the venous
 blood, etc.
   Pulsation of the veins does not, however (notwithstand-
 ing the dictum of authorities), always depend upon disorder
 of the heart.   The  author has seen  three cases in*which
jugular pulsation was evidently the result of  local irritation,
 exaggerating the  muscular activity resident in the organic
 muscle-fibres of the  vein.
   The blood itself is perhaps  the  most important of all
 subjects of inquiry in  connection  with disease.  Little,
however,  as  yet, is known  of  its morbid  changes.  The
principal facts are, that—
  In ansemia, there is a deficiency of the red  corpuscles ;
  In plethora, an excess of the red corpuscles ;
  In leucocytliemia, an excess of the colorless corpuscles;
  In inflammation, and in chlorosis,  excess of fibrin ;
  In gout', excess of uric acid ; 
SEMEIOLOGY.
49
  In BrighVs disease, excess of urea, etc. (uraemia) ;
  In diabetes, excess of sugar;
  In malignant  cholera, deficiency of water, albumen, and
salts.
  These  peculiarities require minute inspection, with  the
aid of the microscope or of chemical reagents.   To the eye,
differences  sometimes exist which may be instructive : e.g.
as to  the bright  red or very dark color of the blood;  as to
the magnitude, form, and firmness of the clot, and the ra-
pidity of coagulation, etc.
  In  cases of lingering prostration,  clots may form in the
heart or large arteries before death.  After very rapid malig-
nant diseases, the blood is sometimes found  uncoagulable.
  Hemorrhage  from different parts of the body is  often
important  as a  symptom, but requires to be  interpreted
with care.   Its  consequence varies  much with its quantity,
and the source of the blood thrown out.
  Thus, in epistaxis, or bleeding at the nose, the flow may
result from—
       Mechanical injury ;
       Congestion of the Schneiderian membrane;
       Congestion of the brain;
       Typhoid fever;
       Hemorrhagic diathesis;
       Suppressed menstruation.
  This  variety  of hemorrhage  is, however, most frequent
during childhood and early adolescence.
   In  haemoptysis, or  spitting of the blood, the  source of
the hemorrhage  may be the—
       Gums;
       Posterior nares; 
50
MEMORANDA MEDICA.
       Throat (e.g. ulcerations, etc.);
       Bronchial mucous membrane;
       Lungs;
       Stomach.
  In the last case, being vomited into the mouth, it is pro-
perly called haematemesis.   Sometimes it requires care to
determine  what is the source of blood coming from the
mouth.  We must notice what are the symptoms preceding
the hemorrhage ; and the manner of its ejection, whether
by coughing  or  vomiting, etc., as well  as  the  appearance
of the  blood,  whether mixed with food, gastric fluid, etc.
  True pulmonary haemoptysis may arise from—
       Active congestion of the lungs;
       Passive congestion, from heart-disease;
       Tubercular phthisis ;
       Hemorrhagic diathesis;
       Vicarious monthly flow, in the female;
       Mechanical injury, as fractured rib, etc.;
       Rupture of aortic aneurism.
  Haematemesis, or vomiting of  blood, may be—
       Hysterical;
       Ulcerative;
       Cancerous;
       Vicarious; etc.
  Uterine hemorrhage, other than  the normal  menses,
may  be—
       Congestive ;
       Ulcerative ;
       Cancerous; as well as, in the pregnant female, pla-
        cental,  technically  called "unavoidable  hemor-
        rhage." 
SEMEIOLOGY.
51
  Hemorrhage from the bowels may be connected with—
      Hemorrhoids, or piles;
      Dysentery;             y
       Ulceration of the bowel;
       Cancer of rectum, etc.;
      Rupture of aneurism;
      Hemorrhagic diathesis;
       Vicarious menstruation.
  Haematuria, or bloody urine, may result from—
       Mechanical injury of the bladder, prostate  gland,
         or urethra;
       Renal inflammation;
       Calculus;
      Hemorrhagic diathesis;
      Passive senile congestion of the kidneys;
      Scarlatina.

SYMPTOMS CONNECTED WITH THE RESPIRATORY ORGANS.
  The normal, average rate of breathing in the adult, while
at rest, is sixteen or eighteen respirations in the minute.
In fever it  is much accelerated.   In extreme narcotism
it becomes slower than natural.  In some cases of fatty de-
generation of the heart it is sighing and interrupted.
  Dyspnoea, or difficulty of breathing, when great, is called
orthopncea,  from the erect posture required by the patient.
Cervical respiration occurs  in cases of great exhaustion*
or of obstruction of the respiratory function by disease.
  Dyspnoea may be caused by—
       Chlorine or other irrespirable gases in the air;
      Morbid change of the blood, as in cholera ;
      Laryngeal or tracheal obstruction, as in croup, etc. 
52
MEMORANDA MEDICA.
        Bronchial spasmodic constriction, as in asthma;
        Bronchitis;  pneumonia; pleurisy; phthisis;
        Heart disease;  aneurism of thoracic aorta ;
        Cancer within the chest; hydrothorax ; ascites.
   Coughing may depend upon a variety of causes, the na-
 ture of which may often be concluded upon from its char-
 acter.  Thus, usually,
        Cough is dry and hollow, or hacking, when nervous
          or sympathetic;
        Dry and tight, in early bronchitis ;
        Soft, deep, and  loose, in advanced bronchitis;
        Hacking, in incipient phthisis pulmonalis ;
        Deep and distressing, in confirmed consumption;
        Short and sharp, in pneumonia ;
        Barking and hoarse, in early or  spasmodic croup ;
        Whistling, in advanced  membranous croup ;
        Paroxysmal, and whooping, in pertussis.
   Expectoration is—
        Mucous, in catarrh, and early bronchitis ;
        Purulent, in severe and protracted bronchitis;
        Rusty, in the early and middle stages of pneumonia;
        Bloody and muco-purulent, in phthisis ;
        Nummular and  heavy, etc., in advanced phthisis;*
        Putrid, in gangrene of  the lung.
   The temperature  of the breath is increased during the
febrile state.   It is lowered, sensibly, only in aggravated
prostration; as in the collapse  of cholera.  Coldness of
the breath is an almost  certain  prognostic of dissolution.
   The odor of the breath is  rarely perfectly agreeable ex-
  * Microscopic  examination  has  discovered  (Schrceder von der
Kolk) portions of  disintegrated lung-tissue in the  expectoration of
phthisical patients. 
SEME10L0GY.
53
cept in the healthy  infant or child.   It is very heavy at
the commencement of fever; sour during indigestion;  of-
fensive, often, from decayed teeth; rotten, in  gangrene of
the lung.
   Hiccough (singultus) is produced by a spasm of the dia-
phragm.   It may depend upon indigestion, nervous disor-
der, or exhaustion.   It  is serious  in prognosis only when
the latter is present  or is anticipated.
   Stertorous respiration, from  relaxation of the velum
palati, results from cerebral oppression;  the  cause of
which may be apoplexy, fracture of the skull, dead drunk-
enness, or narcotism by  opium, etc.

    SYMPTOMS CONNECTED WITH THE TEGUMENTARY
                      APPARATUS.
   The skin is hot and dry during the presence of  fever.
   Moisture is almost always a favorable sign.
   The exceptions are, the  profuse colliquative sweats of
phthisis,  etc., and the cold and clammy perspiration of
extreme prostration.  Coldness  of the skin, or inequality
of temperature, is always more or less unfavorable.
   Emaciation is often  an important sign.   It  generally
 occurs in severe chronic  diseases, but  is  sometimes rapidly
brought on in acute affections: e.g., diarrhoea or dysentery.
 The changes which  occur in the  adipose tissue, and in the
 plumpness and  roundness, or  flabbiness and  shrunken  ap-
 pearance  of the surface of the  body, are often extremely
 rapid in children.
   The color of the  skin varies much in disease.  Thus, the
 face is
     Pale, in anaemia, syncope, etc.;
                            6 
 54               MEMORANDA MEDICA.

     Flushed, in fever, congestion of brain, etc.;
     Cheeks brightly flushed, in  hectic fever;
     Forehead and eyes flushed, in early stage of yellow
       fever;
     Purple or livid, in low continued fever;
     Yellow, in jaundice, bilious fever,  yellow fever;
     Sallow, in chlorosis, dyspepsia, cancer;
     Blue, in the collapse of cholera, and in cyanosis;
     Black, almost, in asphyxia.
   Eruptions upon the skin are characteristic of certain dis-
 eases.    Their description belongs to the departments of
 Nosology and Special Pathology.

     SYMPTOMS CONNECTED WITH THE  SECRETIONS.
   These must  always be considered  along with  other ex-
 planatory symptoms ;  and the character of the discharges
 should never be overlooked.   Thus,
   Constipation may denote—
       Torpor of the muscular coat of the bowels ;
       Deficient secretion of the liver,  or intestinal glands;
       Defective  innervation, from spinal  or encephalic
         disease;
       Stricture of rectum, colon, etc., or cancer;
       Intussusception, strangulated hernia, etc.;
       Sympathetic disturbance from fever, etc.
   Diarrhoea and  dysentery will  be considered under an-
 other department.   It may be  mentioned,  however,  that
 in dysentery the  discharges contain blood, mucus, lymph
 (in small quantity), and, when ulceration  has occurred,
pus.  In diarrhoea they are either faecal, mucous, bilious,
or serous—the  latter being of  importance especially in the
diagnosis of cholera. 
SEMEIOLOGY.
55
         SYMPTOMS  CONNECTED WITH URINATION.

   Dysuria, or difficult urination (strangury).
   Ischuria, retention of urine.
   Enuresis, incontinence.
   Diuresis (diabetes), excessive discharge of urine.
   Morbid character of the urine itself.
   The average quantity of urine passed by a healthy adult
 in twenty-four hours, is from thirty to forty ounces—greatest
 in the winter.
   In reaction to test-paper, the urine is  normally acid;
 reddening litmus, or restoring  to turmeric its yellow after
 it had been made brownish red by an alkali.
   The color of healthy urine is that of amber.
   The average specific  gravity  of human  urine  (water
 being  1000) is 1017-20; containing about twenty grains
 of solid matter to the ounce.
  Deviation, to a certain extent, from  any or all  of  the
 above standards as to  quantity, reaction, color, and weight,
 is quite compatible  with ordinary health;  but a very de-
 cided and persistent deviation is a proof of disease.
  Retention of urine may be caused by—
       Spasmodic constriction of the vesico-urethral mus-
         cular fibres;
       True stricture of the urethra;
       Enlargement of the prostate gland;
       Calculus in the bladder or urethra.
  Percussion  and palpation,  as well as catheterism,  arc
sometimes necessary to determine the fact  of retention of
urine. 
56
MEMORANDA MEDICA.
   Suppression of urine, from inaction  of the kidneys, is a
most serious  symptom under  all circumstances.   If long
continued, it becomes fatal by ursemic poisoning—coma, and
often convulsions, preceding  death.   Partial suppression
of urine  occurs, sometimes transiently, in  cholera, scarlet
fever, etc.
   Excessive urination is frequently present in hysterical
cases—the water being pellucid, and of low specific gravity
(diabetes insipidus).  The influence of cold and of diuretic
medicines produces a similar watery excess, with little in-
crease in the solids of the urine.
   Diabetes mellitus is, however, a more important affec-
tion ; in which the urine is not only excessive in quantity,
but heavy, and loaded with sugar.
   For the accurate estimation of the changes occurring in
the urine in disease, some scientific skill is requisite.  To
pursue original investigations upon  the subject, consider-
able practical knowledge of analytical chemisti-y, and of the
use of the microscope, is indispensable.  But for the appli-
cation of the conclusions of pathological chemists and mi-
crologists to diagnosis, a much more moderate amount of
skill will  suffice.   There is wisdom in  the  remark of Dr.
Todd (Clin. Leet. on  Urinary Organs, etc., p. 73), that,
"while it is clearly a duty not to neglect any means of ob-
servation and investigation,  it is desirable that you should
be as little  as  possible dependent on means which are not
always at hand, and which  it does not fall to the lot of
every eye and  hand to use with equal readiness and skill."
  I shall state, on this principle, only  the most important
and available points in urinary pathology and diagnosis.
  Allowance must always be made,  or correction obtained, 
SEMEIOLOGY.
57
 for the variation the urine undergoes in the course of the
 same day.  It is divided technically into the urina sangui-
 nis, urina chyli, and urina potus; the first being that after
 a night's  rest, the second that after dinner, the third after a
 very light meal with fluid, as tea.   All of these should in
 each case be examined and compared.
   The questions in regard to any given specimen of urine
 are (see Barclay's Medical  Diagnosis), as to its general
 appearance, specific  gravity,  acidity  or alkalinity,  the
 chemical  or microscopical character of its  sediments, and
 the effect of reagents upon the clear fluid.
   General  appearance.   If clear,  after  standing a  few
 hours, note the color.   Deep-colored transparent urine, of
 high  specific  gravity, indicates  excessive  metamorphosis
 of tissue.  In jaundice, the urine is generally very yellow,
 and sometimes as dark as porter.
   If the urine be opaque, it is either white or dark.  White
 opaque urine contains either  mucus, or pus, or undissolved
 earthy salts, or all of these together.  Mucus  floats more
 distinctly  in a separate cloud than pus ; purulent urine is
 generally  opaque throughout, and of a creamy yellow color
 at bottom.
  Dark-colored  opaque urine is most  frequently tinged
 with blood, giving it a pinkish or brownish hue.  The latter
color  prevails  especially in cases of passive hemorrhage
from the kidney—the former, in fresh hemorrhage from  the
bladder, or in acute renal hemorrhage.  Urine may also be
dark from the presence of bile  (as  in jaundice);  in that
case it will become green on the addition of nitric acid.
  The specific gravity  of urine is easily ascertained  by
means of  the urinometer.
                          6* 
58               MEMORANDA  MEDICA.
  Excessive weight of the urine is caused by its containing
an unusual quantity of salts, or of  urea, or by sugar.  The
quantity passed in twenty-four hours  must always be con-
sidered in connection with its specific gravity, so as to judge
of the actual quantity of solids passed, as well  as their de-
gree of  dilution.
  The heaviest urine is  that  of diabetes  mellitus (glyco-
suria) ;  sometimes reaching  1060.  The lightest is observed
in hysteria, and in Bright's disease;  running down  some-
times to 1005 or lower.
  The degree of acidity of urine may be approximately
estimated by the more or less decided redness  given by it
to litmus-paper.   If it be alkaline, it  will, of course, make
turmeric brown, and restore the blue to litmus reddened by
an acid.
  Alkalinity is uncommon.  It depends upon either fixed
or volatile alkali.  If the former, it is commonly associated
with nervous debility or general depression of vital power;
unless accounted for by the medicinal  use of some prepara-
tion of  potassa, soda, or lithia.  Excess of the phosphatic
salts, and of  oxalate  of lime (oxaluria), often accom-
panies  alkalinity of the urine.    The importance  of the
presence of oxalate of lime has probably been overrated.
  Carbonate of ammonia, when present in the urine, causes
it to effervesce on the addition of  an  acid, from the escape
of carbonic acid  gas.  The change of color produced by
ammonia in turmeric-paper will, also, disappear when it is
heated.
  Ammoniated urine becomes so  by the decomposition of
urea, and its conversion into carbonate of ammonia.  When
the bladder is  inflamed, and contains  unhealthy mucus, 
SEMEIOLOGY.
59
this decomposition occurs either in the bladder, or in the
urine shortly after it is passed ;  making it alkaline in reac-
tion, and effervescent when acid is applied.  Urine will, in
cases of much less  frequency, effervesce on the addition of
acid, from the presence of carbonate of lime.
  Sediments occur in the urine, either when first passed or
after standing, from its containing substances insoluble in
the fluid, or precipitated by cold, or from chemical changes
rapidly occurring in it.   Such sediments may be examined
both chemically and microscopically; but it is only in a few
instances  that  the employment of the microscope is  indis-
pensable.
  A fawn-colored deposit, entirely dissolved by heat, con-
sists of urates of ammonia and soda.
  A similarly colored deposit of cystine occurs, rarely, not
soluble by heat.
  Heavy red sand, at the bottom of the vessel, insoluble in
hydrochloric acid, but dissolved by nitric acid, and also by
alkalies (as liquor potassae), is uric (lithic) acid.
  Blood corpuscles sometimes fall to the bottom, but they
are not soluble in acids or alkalies.
  A whitish deposit, not at  all dissolved by heat, but dis-
solved by nitric acid, consists of earthy salts, phosphatic or
oxalic.  If oxalate of lime, it will not  be  dissolved by
acetic acid; if  phosphates, that acid will render the  liquid
clear.
  A creamy white, or yellow, flocculent and ropy deposit,
dissolved by liquor potassse, consists of pus.
  The microscope may detect, even in urine scarcely opaque,
       Blood corpuscles, more or less altered in shape;
       Mucus corpuscles, less numerous and smooth than 
60
MEMORANDA MEDICA.
       Pus  corpuscles, which are granular, and with sev-
         eral nuclei;
       Epithelial cells or scales, from the kidney or bladder;
       Tubular casts, from the kidney;
       Spermatozoa;
       Oxalate of lime, in transparent octohedral or dumb-
         bell crystals;
       Uric acid crystals, lozenge-shaped, or square prisms;
       Triple  phosphate (of magnesia and ammonia), in
         three-sided prisms with beveled ends;
       Phosphate  of lime,  granular, or in long  needle-
         shaped crystals.
   Urine free  from deposit should,  in suspected cases, be
tested for albumen, and for sugar.
   The test  for albumen is the  successive addition to the
urine of heat and  nitric acid.   If it become turbid or co-
agulated under their influence, it is albuminous.   We must
remember, however, that albuminuria is no longer synony-
mous with Bright's disease.   Albumen occurs, transiently,
in the urine in many acute affections, as  scarlatina, diph-
theria, and renal congestion from cold and wet. •  It is only
when its persistency is established that it becomes  patho-
gnomonic of degeneration of the  kidney. In rare instances,
moreover, this degeneration has been proved (post mortem)
to exist, without albuminuria.
   The principal tests for diabetic sugar are liquor potassse—
solution of sulphate of copper followed  by liq. potassse—
and fermentation.
   Boiled with  liq. potass., saccharine urine becomes first
yellow, then brown, then ruby red by transmitted light.
   Trommcr's test  consists of the addition of a few drops 
SEMEIOLOGY.
61
of strong solution  of sulphate  of  copper,  followed  by a
much larger quantity of liquor potassse.  A yellowish-
brown precipitate  is rapidly  thrown down  if sugar  be
present.
  Urine will not ferment with yeast unless it contain sugar,
which is not a normal ingredient of the secretion.
  The quantitative analysis of urine, to determine the pro-
portion of urea,  etc., requires  considerable chemical pro-
ficiency.
  It  has already been stated that heavy and dark-colored
urine (diabetic urine is straw  or  amber colored), with a
strong odor, may be inferred to contain  an  excess of  post-
organic solids,  among which urea is the most  important.
  Kyestein is  a greasy pellicle found on  the surface of
urine after a day  or two standing, in pregnant females, or
in those whose mammary glands are excited  by sympathy
with uterine irritation.
  Chloride  of  Sodium has been found (Redtenbacher) to
disappear from the urine in pneumonia, and (Beale) to
appear at the same time in excess in the sputa.   This may
be tested by the addition of a few drops of nitric acid,  fol-
lowed by solution of nitrate of silver—a white precipitate
of chloride of silver indicating the presence of the chloride
of sodium.*
  The secretion of  milk may be affected in quality as well
as quantity, by the physical or even  mental  state of  the
mother.
  The sudden  arrest of the formation of milk in the  mam-
  * Chloride of ammonium will produce the same reaction ; but this
salt is rare in the urine or sputa. 
 62               MEMORANDA MEDICA.

 mae, with the cessation  of the lochial discharge, is a very
 serious symptom in the  parturient  state, especially during
 the first few days after child-birth.
   The  influence of  menstruation and its disorders upon
 the health of  the female, comes properly under the depart-
 ment of Diseases of Women.
   Perspiratory changes have already been alluded to, in
 speaking of the tegumentary apparatus.   Strong odor of
 the  perspiration indicates vicarious excretion by the skin,
 and commonly accompanies insufficient action of the bowels.
 Acidity of  the perspiration is sometimes dependent on the
 presence of an excess of uric acid; which, in gout, in the
 form of urate of soda, is occasionally concreted  palpably
 upon the surface of  the body.


 SYMPTOMS CONNECTED WITH THE MOTOR APPARATUS.

   The  decubitus, or  mode  of lying  down, of a patient,
 should  be  noticed.   Inability to rise may depend upon
 general debility, paralysis of the extremities, rheumatic or
 gouty inflammation of the joints, etc., or injuries, such as
 fractures or dislocations.
   Inability to lie down is most frequently  the result of
 dyspnoea (orthopncea)—the respiratory muscles having the
 freest scope in the erect position.
   In  colic,  the patient  generally prefers to  lie upon  the
 belly.
   In peritonitis, the characteristic position is upon the back,
 with the knees drawn up, to  relax the abdominal muscles.
   Lying upon one side is often significant in disease.  In
the early stage of pleurisy, the patient prefers to lie upon 
SEMEIOLOGY.
63
the healthy side; when effusion has taken place, this is re-
versed.   In irritative disorder of the liver, with  enlarge-
ment, the patient will often lie most comfortably upon the
right side.  When  the  heart  is enlarged or violent in its
action, the sufferer generally cannot lie upon the left side.
The exceptions are most frequent in cases of long standing.
  Muscular debility may be the result of acute disease, as
fever, or of actual exhaustion and prostration.   Total want
of  exercise will enfeeble  the  muscles;  as, when a limb is
long confined in splints on account of a fracture or other
injury.
  Spasm is of three kinds: tonic, clonic, and choreic.
   Tonic spasm is fixed  rigidity.  Clonic spasm is ordinary
convulsion: i.e. successive contractions of the muscles at
short intervals.   Choreic spasm  is a term suggested by
the author to indicate the jerking, irregular movement of
the muscles, not controllable by the will, in  cases of chorea.
  Paralysis will be alluded to presently.

SYMPTOMS CONNECTED WITH THE SENSORY APPARATUS.

  Of these, the most important is pain.  Pain may be—
       Acute, sharp, cutting, as in pleurisy;
       Shooting, darting,  as in neuralgia;
       Lancinating, in cancer;
       Gnawing, tearing,  in rheumatism;
       Dull, heavy, aching, in pneumonia;
       Griping, twisting,  in dysentery;
       Bearing down, in second stage of labor;
       Pulsating, in the formation of an abscess;
       Burning, smarting, in  erysipelas; 
64
MEMORANDA MEDICA.
        Stinging, nettling, in urticaria;
        Constant or intermittent; fixed, or wandering.
    Tenderness on pressure is generally associated with in-
 flammation; although some  affections designated as neu-
 ralgic also  present  it—possibly from inflammation of the
 sheaths of the nerves.
    Sometimes pain is relieved by pressure; as in many cases
 of colic and dysmenorrhcea.    This is a sign, certainly, of
 the absence of inflammation.
    Pain is not always at the seat of disease.   Thus, in dis-
 ease of the hip joint (morbus  coxarius),  the pain  is felt
 chiefly at the knee;  in calculus of the bladder, at the glans
 penis; in ovarian disease, sometimes, along  the limbs; in
 disorder of  the liver, often, under  the scapula;  in dyspep-
 sia, frequently, about the  sternum ;  and in  irritation of the
 uterus, on the top of the head.
   Total  loss of sensation, local or  general, is called anses-
 thesia.   Acinesia (a term seldom used) is loss of muscular
 power.
   Paralysis of one  side only, of the body,  e.g. the right
 arm  and leg, is hemiplegia.   Paralysis of both lower ex-
 tremities, paraplegia.   These terms are commonly applied
 either to loss  of  power,  loss of sensibility, or the more
 usual combination of both.
   The eye affords many indications of disease.   A promi-
 nent and turgid condition of both eyes occurs in acute oph-
 thalmia, and in congestion of the brain.  If one eye alone
 becomes prominent, local disease, e.g. a tumor behind  the
 orbit, may be suspected.  The eyes are sunken, in phthisis,
 and in other wasting  maladies.  Sinking of  one eye indi-
cates local atrophic disease. 
SEMEIOLOGY.
65
  The movements of the eyes should be noticed, especially
in children.   Rolling of the eyeballs from side to side is a
common symptom of nervous restlessness or cerebral irrita-
tion in infants.   Squinting, occurring as a symptom in dis-
ease, is  of unfavorable import.
  The color of the eyes varies in disease.   In conjunctivi-
tis, the  blood-vessels are generally enlarged, and the mem-
brane reddened.  In sclerotitis, the enlarged vessels are seen
converging toward the margin of the cornea.  In iritis,
discoloration, irregularity, and sometimes fixedness of the
pupil occur.
  The cornea in old people occasionally exhibits the  arcus
senilis — a sign of fatty  degeneration.   It is an opacity
around  the circumference of the cornea.
  The lustre of the eye is  lessened generally in depressing
acute diseases, and  especially just before death.
  The eyes are often remarkably bright during the progress
of phthisis.   They have a glare in  some cases of inflam-
mation  of the brain, and of mania.
  The pupil  is generally contracted in—
       Inflammation of the retina;
       Inflammation of the brain;
       Narcotism by opium.
  It is dilated, usually, in—
      Apoplexy;                 Amaurosis;
      Hydrocephalus;             Cataract;
      Narcotism by belladonna or stramonium.
  An immovable state of the  pupil, or a difference between
the  two  eyes under the same light, gives rise to suspicion of
ophthalmic or cerebral disorder.
  Photophobia is a dread  of  or shrinking from the light,
                           7 
66               MEMORANDA MEDICA.
 such as  occurs in ophthalmia, and  in meningitis or cere-
 britis.  Other symptoms connected with the eye are—
   Photopsia, flashes of light passing before the eyes.
   Muscee volitantes, moving spots, or spectra.
   Amblyopia, dimness of vision.
   Diplopia, double vision.
   Hemiopia, half-sight; i.e. seeing but one-half of an ob-
 ject at a time.
   Pain in the head (cephalalgia) may be specially alluded
 to as depending upon—
       Neuralgia;
       Rheumatism of the scalp;
       Congestion of the brain;
       Toxaemia (e.g. by narcotics, alcohol, etc.) ;
       Fever (remittent, yellow, typhoid, etc.) ;
       Chronic disease of the brain;
       Uterine irritation, etc.
   The distinction between these  different forms of head-
 ache is by no means always easily made out.  As a general
 statement, it may be said that neuralgic headache is mostly
 on one side (hemicrania), and extends more or  less to the
 face; it is usually accompanied, also, with sensitiveness of
 the  scalp, and  is  shooting or darting in  its  character.
 Rheumatism of the head  is attended  by stiffness  of the
 muscles which move the head from side to side.   Congest-
 ive, febrile,  and  toxesmic  headaches are accompanied by
 heat of  the head, and are throbbing or pulsating.   That of
 uterine irritation is on the top of the head.  The pain  of
 chronic cerebral disease (tumors, etc.)  is commonly con-
stant or periodic, in  one spot, and is  attended by some
functional disorder. 
SEMEIOLOGY.
67
SYMPTOMS CONNECTED WITH THE PSYCHICAL APPARATUS.
  The expression of the countenance is usually altered by
disease, especially of  an acute kind.   The  change from
anxiety or distress to serenity is always a favorable prog-
nostic, except  where gangrene, or  paralytic anaesthesia
accounts for it.
   Great anxiety  of expression is seen especially in organic
disease of the heart, and in acute disorders of the abdomi-
nal viscera.   In hypochondriasis, a sad and desponding
expression prevails.
   Terror is shown, by the countenance, in delirium tremens.
   Rage,  in hydrophobia, and sometimes in acute mania.
   Insanity and imbecility, although not characterized by
any special cast  of countenance, yet modify its expression
so as  to  enable the mental state to be  detected by one ac-
customed to the observation of deranged persons.
   The fades  Hippocratica is the countenance of extreme
exhaustion or  of  the moribund state.
   Delirium is described as being  either active or passive.
Active delirium  is present in cases of acute meningitis;
passive or low muttering delirium, in typhus fever, etc.
   Coma  presents itself in practice  chiefly in four  forms:
Alcoholic  stupefaction;  Opium  poisoning; Apoplexy;
Typhus.
   Typhous  stupor is  generally easy of recognition;  the
others may give some  trouble in the diagnosis.   Between
narcotism by opium and dead-drunkenness, we have the dis-
tinctions, that in opiate poisoning the pupil is almost always
firmly contracted, and that the breath  smells  of alcohol (or
aldebyde) in the  intoxicated subject. 
68
MEMORANDA MEDICA.
                     SECTION  II.

              PHYSICAL DIAGNOSIS.

   The  idea of  physical  exploration  for the purposes  of
 diagnosis  has been well defined  by  Piorry, in the  word
 "Organography." i.e. the determination of the actual and
 relative position, material condition, and functional action
 of the organs contained within the body.  The methods  in
 use for this purpose are modern, dating from Auenbrugger,
 of Yienna, the inventor of diagnostic percussion, in 1761,
 and Laennec, the  great originator of auscultation, about
 1818.
   The  modes of examination of  the chest, abdomen, etc.,
 are—
   Inspection; Mensuration; Palpation; Succussion; Spi-
 rometry; Percussion;  Auscultation.
   By inspection  we estimate, with the eye, the form, size,
 and movements of  the chest, etc.
   By mensuration, we obtain a more accurate knowledge
 especially of deviations and alterations of size and form.
   Palpation aids in the determination of the character of
 surfaces and of subjacent  parts, and, in the chest, detects
 changes  in the degree  or extent of the movements of res-
 piration and of the heart, and in the vibrations connected
 with the voice, cough, and breathing.
   Succussion, or shaking the chest suddenly, is  of use oc-
casionally, in establishing the presence  of fluid in the tho-
racic cavities. 
SEMEIOLOGY.
69
  Spirometry is  the  measurement of the capacity of the
lungs for air.
  By percussion  we learn much of the  physical condition
of the lungs, heart, and abdominal viscera, through the va-
riations of resonance and resistance when the walls of the
thorax or abdomen are lightly struck.
  Auscultation is  equally important, but somewhat more
difficult in its  application, on account  of the  complexity
of the signs afforded by it.  It consists in direct  listen-
ing to the sounds produced within the cavities of the body,
by placing the ear, with or without  the stethoscope, upon
the surfaces thereof.
  The Regions of the Chest, for the purposes of physical
exploration, may  be most conveniently divided into the fol-
lowing :—
                     ' ANTERIOR.
      Upper and lower sternal;
      Right and left clavicular;
      Right and left subclavian;
      Right and left mammary;
      Right and left infra-mammary.
                      POSTERIOR.
      Interscapular;
      Dorsal;
      Lower dorsal;
      Right and left acromial;
      Right and left scapular;
      Right and left infra-scapular.
                       LATERAL.
      Right and left axillary;
      Right and left lateral;
      Right and left lower lateral.
                          7* 
70
MEMORANDA MEDICA.
   The most important  peculiarities of these different re-
gions, in the normal state, are connected with percussion-
resonance.  The clearest and fullest sound, on percussion,
is given over the subclavian and lateral regions; the dullest
and smallest, over the acromial, the right infra-mammary
(hepatic), and the left mammary or praecordial region.

   For mensuration, various stethometers or chest-measurers
have been devised;  but, with care and judgment, the com-
mon tape-measure will suffice.
   The dimensions to be compared are the—
   Circular: around the chest opposite the base of the ensi-
form  cartilage.   This averages  thirty-three inches.  The
right half of the thorax is  nearly always half an inch to
an inch larger in circumference than the left.
   Transverse: from the nipple to the middle of the sternum.
   Vertical: from the clavicle to the lower margin of the ribs.
   Antero-posterior: from the clavicle anteriorly to a corre-
sponding point in the scapular region.
   General  expansion  and local bulging of the chest, and
general retraction and local depression, are the signs most
frequently determined by inspection and mensuration.
   General expansion or local bulging of the chest, usually
upon one side only,  may be caused (see Walshe on Diseases
of the Lungs)  by—
      Pleuritic effusion ;
      Pneumothorax;
      Emphysema  of the lung;
      Aneurism, cancer, etc.; or, more rarely, by
      Hydrothorax;
      Pneumonia;
      Incipient tuberculization. 
SEMEIOLOGY.
71
  Retraction or local depression of the thoracic walls may
result from—
       Absorption of pleuritic effusion ;
       Tuberculization;
       Pneumonia ;
       Pleuro-pneumonia;
       Infiltrated cancer of the lung.

  By palpation, we observe diminution of the expansion
and elevation of the ribs in breathing, in—
       Pleurisy;               Emphysema;
       Pneumonia ;             Intercostal rheumatism;
       Tuberculization ;         Paralysis;
       Pneumothorax;         Hydrothorax.
  Increased expansion and elevation of the ribs in breath-
ing occurs in—
       Asthma;
       Croup ;
       Spasm of the glottis;
       Foreign bodies in air-passages.
  Increased vibration of the walls of the chest with the
voice and cough is noticed in—
       Tuberculization;         Pulmonary apoplexy;
       Pneumonia ;             Dilatation of bronchi.
  Diminished vocal and tussive vibration occurs in—
       Pleuritic effusion;       Emphysema;
       Pneumothorax;         Cancer of the lung.
  Rhonchal vibration, occasionally, in bronchitis.
  Rubbing, or to-and-fro vibration, in—
       Pleurisy;               Pericarditis. 
72
MEMORANDA MEDICA.
   Pulsatile vibration in—
       Aneurism of aorta;
       Cancer of lung or pleura;
       Pneumonia.
   Fluctuation in—
       Large pleuritic effusion.
   Purring vibration (fremissement cataire) in—
       Aneurism of aorta;
       Valvular heart disease;
       Anaemia.
   For Spirometry, Hutchinson's, Pereira's, Coxeter's, and
 Mitchell's* spirometers have been used.
   Dr. Hutchinson  made  elaborate investigations into the
 comparative breathing power  of individuals, by which he
 proposed to conclude  upon their vital capacity.   A man
 of 5  feet 8  inches in height, and  155 pounds weight, was
 found, on the average, to expire, after a full inspiration, 230
 cubic inches.
   For every inch of height above  this, a definite increase
 in the quantity breathed was  observed.   The  proportion
 was  less  constant with weight and with age.  After fifty-
 five there was a decrease.
   In  the first stage of consumption, the average (for the
 adult of  ordinary height) was found to be  154 cubic inches;
 second stage, 131 ;  third stage, 108, etc.
  In  practice, however, spirometry is not extensively used.
  Percussion is either mediate or immediate.  In immedi-
ate percussion, we tap with the ends of the fingers at once
upon the body; in mediate percussion, a pleximeter (stroke-
measurer) is used.   The latter is almost  universal;  but a
      * Consisting of a small gas-meter, with a  mouth-piece. 
SEMEIOLOGY.
73
difference exists as to the kind of pleximeter employed.
Louis and Walshe prefer one made of caoutchouc ; Piorry
and Skoda, one of ivory; Wiinderlich uses  an ivory disk,
upon which he  strikes with a small steel hammer, the head
of which is covered with caoutchouc.
  A majority of practitioners, however, are  satisfied (with
good reason) with the use of the middle finger of the left
hand as a pleximeter.   (Percuss by movement of the hand
on  the wrist;  not by  sledge-hammer motion from the
shoulder.)
  In using percussion as a means of physical diagnosis, we
note—
  1. The clearness or dullness of the resonance produced.
  2. The duration of the resonance.
  3. Its special character.
  4. The degree of resistance felt.
  Certain terms are in  common use to describe particular
characters  of resonance: as, wooden sound, thigh sound,
stomach sound, tympanitic  or  drum-like  resonance, am-
phoric or pitcher-like sound, bruit de pot file or cracked-
pot sound, etc.
  It is indispensable, in commencing the study of percussion
(or other modes of physical diagnosis), to become familiar
with the normal and natural  sounds observed in health.
To  be anything more than a routine diagnostician, more-
over, it is necessary to understand the principle of the ex-
ploration, and, as far as  possible, the reason of the meaning
of every sign.
  Two or  three very simple  facts explain the use of per-
cussion in diagnosis.
  When any solid body  is struck, the sound elicited varies 
74
MEMORANDA MEDICA.
according to its  material, form, size, and, if hollow, the
condition of its walls, and that of its contents.
  The human thorax (or abdomen)  having a certain gen-
eral form, size, condition of  its walls, and proportion of
air, blood, and solid structure  in its contents, will give forth
a certain degree and kind of resonance.
  Whatever alters  either the state of its  walls or the pro-
portion of air, fluid,  and  solid  contained within them,
gives rise to an alteration of  percussion-resonance.
  Alteration of the state of the walls of  the thorax seldom
occurs in disease in  such a way as  to modify percussion-
resonance.   Changes in the proportion of  solid,  liquid,
and air, in the lungs  and pleural cavities, as  well as in the
similar relations  of the heart and  pericardium, aorta, etc.,
are  frequent.   The more air, and the less liquid or solid
contained within  the  part of  the chest which is  percussed,
the clearer and fuller the resonance,  and, as a general rule,
the less the resistance to the finger.   Any increase in the
relative proportion of liquid (as in pleuritic effusion), or of
solid (as in tuberculization), must cause a duller or lesser
degree of resonance, and, other things being equal, a greater
degree of resistance.
  Thus, diminution of clearness and duration of the per-
cussion-sound,  with increased resistance of the walls of
the chest, occurs  in—
     Pneumonia ;                Pulmonary apoplexy;
     Pleurisy ;                   Hydro thorax ;
     Tuberculization;            Cancer, etc.
  The extent over which dullness on percussion is observed
sometimes varies with the position of the patient.   This is 
SEMEIOLOGY.
75
practically important in the diagnosis of pleuritic effusion,
empyema, hydrothorax,  and hydropneumothorax.
  Increased  clearness  and duration of resonance, with
decrease of resistance,  occurs in—
       Pneumothorax;            Emphysema;
       Atrophy of lung  ;          Anaemia;
       Hypertrophy of lung ;      Emaciation.
  Increased  clearness  of  sound with increase  of  resist-
ance  is observed when  there is a tubercular cavity near
the surface of the chest, with its outer wall thin, hard, and
adherent to the pleura.
  Tympanitic resonance of the chest is present in—
       Pneumothorax;
       Emphysema;
       Pulmonary atrophy, etc.
  Amphoric  resonance,  when there  is a large tubercular
cavity, with solid and tense walls, near  the surface of  the
chest.
  The cracked-pot  sound  indicates an anfractuous cavity,
i.e. one whose walls are broken  or  incomplete, communi-
cating with the bronchial tubes.  It may be  imitated by
clasping the  hands loosely and then striking the back of
one of them upon the knee.
  Skoda's classification  of percussion-sounds has the merit
of great simplicity.  He distinguishes them as
       Full;  empty ; (large and small resonance) ;
       Clear; dull;
       Tympanitic ; non-tympanitic;
       High ; low; (pitch).
  A sound may be at the same time full  and dull, or clear
and empty  (small). 
76
MEMORANDA MEDICA.
   Skoda  does not value very highly the information ob-
 tained from  differences in the pitch of percussion sounds.
 Other authorities differ from him, however, upon this point.

   In auscultation,  as well as  in  percussion  and other
 modes of physical exploration, a comparison is made not
 only with the normal standard, but between the two sides
 of the chest.
   The stethoscope is, in auscultation, generally speaking, a
 superfluous instrument.   If any be used, a  simple wooden
 tube with one end slightly expanded is the best.
   The beginner must familiarize himself with the natural
 breathing sound, as heard when the ear is placed over any
 part of the lungs, and with that heard in the sternal  and
 inter-scapular regions. The latter is bronchial, the former
 is the vesicular murmur.  The tubular,  blowing character
 of the respiration, as heard in the bronchi, and its soft,
 breezy nature when  the ear is placed over the lungs, are
 essential elements in diagnosis  by auscultation.
   The pulmonary vesicular murmur is always louder in in-
fants and children.  Puerile respiration is, therefore, the
 name given to exaggerated breathing-sound  in the adult.
   In a healthy state  of the lungs, the expiratory murmur
 is very faintly heard.   A prolongation, and increase in loud-
 ness, of the sound  of expiration, is sometimes a sign of
 disease (tuberculization).
   The sounds detected by  auscultation  of the  chest  are
divided  into  respiratory  and  secretory  sounds, friction
sounds, and modifications  of vocal resonance.
                 RESPIRATORY SOUNDS.
      Normal vesicular murmur; 
SEMEIOLOGY.
77
      Puerile respiration;
      Prolonged expiratory sound;
      Harsh, tubular, blowing,
      Bronchial, and cavernous respiration ;
      Amphoric respiration.
                  SECRETORY SOUNDS.
                         Dry.
      Sibilant rhonchus (hissing or whistling) ;
      Sonorous rhonchus;
      Dry crackle.
                        Moist.
      Fine crepitation  or crepitant rale ;
      Coarse crepitant rale (mucous rale) ;
      Humid crackle or gurgling ;
      Metallic tinkling or dropping sound.
  Friction-sounds are peculiar to pleurisy and pericarditis,
at the stage of  adhesion, or, at  least, of effusion of plastic
lymph.
  Modifications of vocal resonance are—
      Bronchophony;
      Pectoriloquy;
      jEgophony.
  The above  is,  essentially, the classification  commonly
adopted by  auscultators.  That of Skoda is,  however, still
more simple.  He divides respiratory sounds into
      Yesicular;                 Amphoric;
      Bronchial;                 Indeterminate.
  Skoda denies, also, the validity of the distinction between
pectoriloquy and bronchophony;  and shows that JEgo-
phony cannot have the precision of meaning supposed  by
Laennec and others to belong to it.
                           8 
78
MEMORANDA MEDICA.
  No description of the  sounds of auscultation  can do
more than guide and assist their actual clinical study.  For
this purpose the simplest and clearest terms are, of course,
the best.
                                              r
  The normal  respiratory murmur as heard in the lungs,
is well illustrated by Skoda as resembling (during  inspira-
tion) the  sound caused by  narrowing the opening of the
mouth,  and then drawing in the air.   The  consonant  of
this  murmur is f or p.   The expiratory murmur  may be
represented as  somewhere between  f and h.   That of the
larynx, trachea, and bronchi,  by the  guttural ch, or be-
tween that and h.
   By bronchial respiration as a  sign  of disease in the
lung, we  mean a  breathing-sound  heard while listening
over the lung,  like  that normally heard when auscultating
the middle regions of the chest, over  the bronchial tube.
It occurs when the lung is solidified or condensed.  (Ex-
planation of bronchial respiration, by conduction or by
consonance.  The latter theory, that of Skoda,preferred.)
   Cavernous respiration is  that which is inferred to occur
during  the passage  of air  into or  out of a  cavity in the
lung (as in tubercular disease).  Notwithstanding the truth
of the statement urged by Skoda, that it is often impossi-
ble to draw a certain demarcation between bronchial and
cavernous respiration, yet, in a  sufficient  number  of
cases this can  be done, and the term  cavernous, therefore,
should be retained.
   Of the secretory  sounds, the  sibilant and sonorous
rhonchi are the results of narrowing  and obstruction, by
congestion,  mucus,  etc.  of the bronchial ramules;  the
smallest, in the case  of the sibilant  or whistling rhonchus ; 
SEMEIOLOGY.
79
those somewhat larger, so that  the  air passes through in
irregular and varying bubbles, in the  sonorous (snoring or
roaring) rhonchus.  Both of these sounds are characteristic
of bronchitis.   The use of the term dry sounds, as applied
to them, is  not strictly correct; but it is  convenient, as
designating the impression  which they convey to  the  ear
as compared with those technically called moist sounds.
   The dry crackle is associated with incipient  or infiltrated
tubercle.
   Among the moist sounds, the finest or most delicate is
the crepitant  rale, or  fine crepitation,  of pneumonia.   It
is very well imitated by rubbing a few hairs of one's head
between the thumb and finger, near the ear.   Its cause is,
probably, the penetration of the air into the air-cells of the
lung at a time when their walls  are rendered slightly ad-
hesive by effusion of coagulable  lymph.  The  gentle forc-
ing  apart  of  these  adherent walls, or of portions of the
viscid lymph itself, produces the  fine crackling sound, as a
modification of the natural vesicular murmur.
   Coarse crepitant or  " mucous" rales are heard whenever
any fluid exists in the lungs  in quantity sufficient to modify
respiration without arresting it,  whether that  fluid be mu-
cus, pus, blood, or serous effusion.
   The humid crackle or gurgling is pathognomonic of ad-
vanced tuberculization.  It is heard during the later stages
of nearly all cases of consumption.
   Friction or to-and-fro sounds  are produced by the rub-
bing of two surfaces, as of the pleura or pericardium, when
made adherent or slightly roughened by inflammatory lymph.
It sometimes requires an acute and practised ear to discrimi-
nate these from other sounds. 
80
MEMORANDA MEDICA.
  Bronchophony, or bronchial vocal resonance, corresponds
in its history with  bronchial respiration.   It is simply a
resonance of the voice, to the ear of  the auscultator placed
over the lung of the patient while  he speaks, loud, near,
and  clear,  as it is normally when the ear is placed over
the bronchial tube.  The same reasonings will apply to
the explanation of  this sign by the two theories of conduc-
tion and consonance, which  have been urged in regard to
bronchial respiration.  The latter theory, as in that instance,
I prefer; but, practically, all agree as to the circumstances
under which the sign occurs (solidification of the lung).
   Pectoriloquy (chest-speaking) is merely a yet nearer and
louder  resonance of the voice, heard on auscultation, than
that called  bronchophony; the sound seeming to be vocal-
ized in that part of the lung which  is immediately under
the ear.   Skoda objects that this cannot be definitely dis-
tinguished from loud bronchophony.   But,  although this is
generally true, a certain number of  cases occur in which it
may be so  distinguished, as indicative of a very different
pathological state of the lungs,  viz.,  a large cavity.
   Aegophony, bleating, or goat-like resonance of the voice,
has  been, since Laennec, supposed to be  an almost certain
sign of the existence of pleuritic effusion or hydrothorax.
Skoda's observations, and those of  others  also,  show that
it is occasionally heard in pneumonia, in phthisis, and even
in the healthy state of the thoracic organs.  It is, therefore,
not pathognomonic of the  presence of  fluid within the
pleura ; but it is among  the  signs which render that diag-
nosis probable.
  Amphoric resonance  is heard  especially in connection
with the sound produced by coughing.  A  tense condition 
SEMEIOLOGY.
81
of the walls of a large cavity will explain it, as well as the
phenomenon called metallic echo of the voice or cough.
  Metallic tinkling is usually accounted for by the drop-
ping of fluid in a large cavity (as in hydropneumothorax,
with collapsed lung) with tense walls.
  Resuming  the  consideration  of  respiratory  sounds,
puerile or exaggerated respiration occurs  in the healthy
lung, or part of the  lung,  when the other  lung or portion
of the same is obstructed, as by a foreign body, or by bron-
chitis ; condensed, as by
     Pneumonia ;                   Pleuritic effusion ;
     Tuberculization;               Tumor.
  A lung permanently expanded by emphysema, or hyper-
trophied, will  also give an exaggerated vesicular murmur;
and, transiently, this is observed  in a lung just released
from the paroxysmal obstruction of asthma.
  Feeble respiratory murmur is heard in one or both lungs
in cases of
     Croup ;                  Pulmonary apoplexy;
     Foreign bodies in air-pas-  Emphysema ;
       sages;                  Pneumothorax;
     Bronchitis;               Hydrothorax;
    Pneumonia ;              Intercostal rheumatism ;
    Pleurisy;                Paralysis;
    Asthma;                  Cancer; or other
    Infiltrated tubercle;       Tumor.
  Harsh respiratory murmur, passing by gradations  into
blowing and bronchial, in
    Dry bronchitis ;              Pneumonia;
    Incipient tubercle;          Pulmonary apoplexy ;
    Pleurisy (condensing lung);   Bronchial dilatation. 
82
MEMORANDA MEDICA.
  Cavernous respiration, in case of
      Tubercular cavity;
      Excavation from
         Abscess of lung ;     Softening of cancer ;
         Gangrene •           Large bronchial dilatation.
  Amphoric  respiratory sound is particularly associated
with the  existence  of a fistulous  opening  between the
pleural cavity and one of the bronchial tubes ; the cause of
which  fistula may  be  either  tuberculous  softening,  or
abscess, etc.
  The sibilant and sonorous rhonchi occur nearly always
in bronchitis ; occasionally in pulmonary emphysema, and
when the bronchi are pressed upon by tumors, etc.
  Dry crackling indicates the existence of hard tubercle in
the lungs.
  Humid crackling or gurgling, tubercle in the softened
state.
   The crepitant rale has already been explained as pecu-
liar to pneumonia.
   The coarse crepitant* rale, or mucous rale, is observed
frequently in
     Capillary bronchitis;      Pulmonary hemorrhage;
     Bronchorrhea;           Pulmonary oedema;
     Late stage of pneumonia;*• Pulmonary abscess.
   Friction sounds have been  already  alluded to as con-
nected with pleurisy and pericarditis.
   Resonance of the voice is feeble in
     Emphysema;  Atrophy of the lung; Pneumothorax.
  * The term sj/6-crepilant rale or rhonchus, appears to the author
to be very objectionable, as leading to confusion. 
SEMEIOLOGY.
83
  Bronchophony occurs in case of
       Tubercle ;
      Hepatization (pneumonia) ;
      Pleurisy (condensinglung); Cancer;
      Dilatation of bronchi.
  Aegophony, in *
      Pleurisy; Hydrothorax;  Pneumonia.
  Pectoriloquy,  in case of
       Tubercular cavity;
      Dilatation of bronchi;
      Excavation from
         Abscess ; Cancer ;  Gangrene.
  Metallic tinkling and echo, in
      Pneumohydrothorax;
      Large tubercular cavity.
  The sounds of the heart are heard at an unusual dis-
tance from the heart itself, in some cases  of
      Pneumonia;              Pleurisy;
      Tubercle ;                Cancer, etc.
  (This affords some argument for the conduction theory
of Laennec.)

  Displacement  of  the  heart,  diaphragm, liver, spleen,
stomach, sometimes occurs from pleuritic effusion or empy-
ema, cancer of the lung, etc.

  The physical diagnosis of diseases of the heart is con-
ducted upon exactly the same principles as that of  affec-
tions of the lungs and pleura.
  By inspection we can detect bulging or distortion in the
praecordial region, and,  in some cases, judge of the extent, 
84                MEMORANDA  MEDICA.
force, and character of the heart's impulse.  By mensura-
tion, changes in the thoracic dimensions consequent upon
diseases of the heart can be more accurately determined.
   By palpation, the impulse of the heart may always be
examined and estimated.   This is very important, not only
in actual diseases  of the heart, but also in fevers, etc.; in
the  course of which the  movements of the heart, as the
centre of the circulation,  are often seriously affected.
   In hypertrophy, this impulse is increased in force; in
dilatation, it is extended; in atrophy, it is diminished.
   Percussion aids us in detecting some very important pa-
thological changes in the heart; as hypertrophy, dilatation,
pericarditic effusion.   The percussion resonance is  un-
usually clear in atrophy of the heart.
   In auscultation of the heart there is often a convenience,
although no  necessity,  in the use of the stethoscope.  The
learner must in the first  place  make  himself familiar with
the natural sounds of  the heart.
   The first sound  is the longest and loudest; the succession
being  imitated by the syllables lubb, dupp.  If the time
from the  commencement  of one pulsation to  that of an-
other be divided into five equal parts, two of them will be
occupied by  the first sound, one by the second, and two by
the interval of repose.
   The first sound accompanies the systole  or contraction of
the ventricles ; the impulse of the heart occurs at the
same moment.   The second sound is diastolic as regards
the ventricles.
   The  causes of the first sound are believed to be  the con-
traction of the powerful ventricular muscles, the tension of
the closed auriculo-ventricular valves, the rush of blood 
SEMEIOLOGY.
85
into the great vessels, and the impulse of the heart against
the walls of the chest.
  The cause of  the second  sound has been  proved to be
the flapping together, during the diastole or dilatation of
the ventricles, of the  pocket-like, semilunar valves of the
aorta and pulmonary artery.
   The essential points in  the "medical anatomy" of the
heart are as follows :—
   The  semilunar  valves of  the  pulmonary  artery lie
behind the  junction of the cartilage of the  third rib with
the sternum.
   The semilunar valves of the aorta are just below these,
between the cartilages of the third and fourth ribs.
   The  tricuspid or  right  auriculo-ventricular valve is
behind the  sternum, on a level  with its articulation with
the fourth rib.
   The mitral or left auriculo-ventricular valve lies behind
the cartilage of the fourth rib,  a  little to the left of the
sternum.
   The heart's apex strikes, during the impulse, at a point
just below  and  outside of  the left nipple.   The point of
greatest dullness on percussion is slightly within the left
nipple.  The diameter of  the normal  region  of dullness
does  not exceed two inches.
   Using terms of convenience  merely, the valves of the
heart may  be said to be of two kinds: cavity valves and
vascular valves.  The cavity valves are both nearer to the
apex  than  to the base of the heart; the vascular  valves
 (aortic  and pulmonary arterial) nearer to its base, i.e. as
the heart is situated in the  chest, its upper part.
   By auscultation of the  heart we may detect valvular 
86
MEMORANDA MEDICA.
murmurs, anaemic murmurs, and friction  sounds.  De-
tails in  regard to these can be  best  given in  connec-
tion with the  special  pathology  of  the heart.    A few
main points only require mention here.
  The valves of the left  or systemic  portion of the heart
are much more often affected by disease than those of the
right.   Practically, in most  cases, those of the right side
may be left  out of the question of diagnosis.
  The following is Harvey's statement of the comparative
frequency of the different valvular affections :—
   1. Aortic obstructive.
  2. Mitral regurgitant.
  3. Aortic regurgitant.
  4. Aortic obstructive and  mitral regurgitant together.
  5. Aortic obstructive and  regurgitant together.
  If a murmur (not anaemic^) is systolic, i.e.  is heard with
the first sound of the heart, and is loudest at the base of
the heart, it may be inferred to be  aortic obstructive.
  If systolic, and loudest at the apex, mitral regurgitant.
  If diastolic, i.e. with the second sound, and loudest at
the base of  the heart, aortic regurgitant.
  If diastolic, and loudest at the apex, mitral obstruc-
tive.
  The rationale of these inferences  is  explained  by the
physiology  of  the heart's action,  in  connection  with the
position  of the several valves.
  Much  complexity attaches necessarily to the exact diag-
nosis of  affections of the  heart; but we have the  excellent
authority of Dr. Stokes for the principle, that the import-
ant practical questions in each case are—do the abnormal
sounds present  have origin in organic disease or lesion,  or 
SEMEIOLOGY.
87
not ? and, how far is the functional action and capacity of
the heart interfered with or impaired ?
  Upon these, as upon all other  questions in diagnosis, it
is proper never to confine our attention to physical or im-
mediate signs alone.  To rest either upon symptomatology
or physical exploration  exclusively, would be  like  hop-
ping constantly on one foot, instead of walking upon two.
   Friction sounds, in the region of the heart, are connected
with pericarditis.   Their narrow limits, and association,
in time, with the sounds  of the heart, serve usually to con-
trast them with pleuritic sounds.   It is sometimes difficult
to distinguish them from valvular murmurs.
   The signs of aneurism of the thoracic  aorta  may be
alluded to in another place. They are, chiefly: 1. A second
impulse (often with a thrill), apart from that of the heart.
2. Dullness on percussion.  3.  Bulging.  4. Symptoms of
dyspnoea, cough, and dysphagia,  from  pressure upon  the
trachea, oesophagus, etc.

   The physical diagnosis  of abdominal  affections com-
prises inspection,  mensuration, palpation,  percussion,  and
auscultation.   The belly  is divided, externally, into  the
epigastric, umbilical, hypogastric, two hypochondriac,  two
lumbar, and two iliac regions.
   By abdominal inspection we can observe the alteration
in size and shape caused  by pregnancy, hernia, tympanites,
ascites, or ovarian dropsy.  By mensuration, we can ascer-
tain the exact changes which may occur from time to time
in dropsical accumulations, etc.
   By palpation of the abdomen, we may develop the  symp-
tom of local tenderness on pressure:  as  in gastritis, he- 
88
MEMORANDA MEDICA.
jyatitis, peritonitis, cystitis, etc.   By the same method of
examination, more  forcibly employed, we detect enlarge-
ment  of the liver  or  spleen, ovarian tumor, mesenteric
disease, cancer, aneurism, faecal accumulation,  etc.;  and,
with the aid of both  hands, prove the presence of fluid
(ascites, etc.) by the sign of fluctuation.
  Percussion assists materially in the diagnosis of dis-
eases of the abdominal viscera.   The ordinary percussion-
resonance,  in health, is clear, full, and  slightly tympanitic,
all over the abdomen.   It becomes more drum-like in dis-
tention  of  the  intestines with gas (meteorism), or in tym-
panitic  distention of the peritoneum.   Dullness of reso-
nance  occurs,  with  limits  and  peculiar characters,  in
enlargement of the  liver  or  spleen, ascites, ovarian
dropsy, pregnancy, cancer, aneurism,  retention  of urine,
faecal accumulation, etc.
  Auscultation of the abdomen is especially useful in  the
diagnosis of pregnancy, by detecting the sounds  of  the
foetal heart, and the placental soufflet.
  Morbid sounds are occasionally appreciable in abdominal
affections, as in tape-worm, etc.; but they are subject to so
much uncertainty as  to be hardly available  for practical
purposes. 
SEMEIOLOGY.
89
       INSPECTION OF THE BODY AFTER DEATH.
  In conducting  post-mortem examinations, with a  view
either to pathological study or medico-legal investigation,
order and method are of great importance.
  The  three great cavities—the head, the chest, and the
abdomen—should always be examined, whether suspicion of
disease in them exist or not.  First, however (the autopsy
being made from twelve to thirty-six hours after death), we
should note the external appearance of the body; its size,
weight, conformation, color of the skin, etc.  (In cases of
suspected violence even abrasions should be  minutely de-
scribed.)
  To examine the Head, an incision should be made through
the scalp, across the top of the head, from ear to ear—the
two flaps thus formed should  be reflected, the one over the
forehead, the other over the occiput.  The nature of  the
attachment of the occipito-frontalis muscle to the bone be-
neath is  such as to  allow, very easily, the loosening of the
scalp.   The cranium  (calvaria) is now to be removed by
means of a small saw.
  For the purpose of holding  the head  firmly during  the
use of the saw, Dr. Demme has furnished, as a  substitute
for the craniotome of Mr. Lund, of London, a cranium-
holder, which enables the operator to make a section of the
skull in any direction.  It  consists simply of a bar of iron
curved like the letter U, at each* extremity of which two
drill screws are placed, which, when forced down upon the
bone, hold the bar firmly in situ, and  enable the examiner
                           9 
90
MEMORANDA MEDICA.
to control the head.   The legs of the instrument, for use,
are placed  upon the lateral portions of  the skull, over the
squamous portions of the temporal bones.
   The section of the cranium with the saw should be made
through its outer table, completely around the head—from
before, backward, from below the frontal  protuberances to
the squamous portion of the temporal  bone, and from be-
hind, forward, from  the  occipital protuberance  to the
squamous  portion of the temporal bone, meeting the line
just described.  The shape of the piece  thus cut out enables
it to be  maintained in its proper  position  when the parts
are readjusted.   It is removed by the aid of an elevator or
chisel, and hammer, fracturing the inner  table of the skull
by strokes so applied as not to pierce the brain.
   The dura  mater  is next to be cut through, on each side
 of the superior longitudinal  sinus;  after which, dividing
the falx cerebri, the brain may be raised carefully with
the hand placed under its anterior portion.  The internal
carotid artery,  and cranial nerves, etc., are now to be sev-
 ered by the knife, and, finally, the vertebral arteries and
 spinal cord.  The brain itself may then  be taken out, and
 inspected, by slicing  it, from  the  upper part downward, in
 successive horizontal layers.
    To examine  the  spinal  column, an incision  should be
 made from the occipital protuberance to the extremity of
 the os coccygis. The deep muscles of the back should then
 be loosened  from  their attachments, so  as to  expose the
 laminae and  spinous  processes of  all the vertebrae.  With
the chisel and  mallet, or saw, we must cut through the
 arches of the vertebrae on each side, close to their articular
 processes.  After thus opening  the spinal canal, the cord 
SEMEIOLOGY.
91
is  to be  exposed by dividing the dura mater through its
whole length.
   To examine the Neck, an incision should be made through
the skin, extending from above the hyoid bone to the upper
part of the sternum.   Avoiding penetration of the large
veins of  the neck, the  parts  to be examined  may be care-
fully dissected, and,  if desirable, removed from the body.
The thyroid gland, larynx  and its  appendages, tongue,
pharynx, oesophagus, blood-vessels,  and nerves of the neck,
may be thus viewed.
   To examine  the Chest, two incisions are desirable : the
one from the root of the neck, in front, to the extremity of
the ensiform cartilage ; the other  at  right angles to this,
across the middle of  the thorax.  The cartilages of the
ribs are  to be cut through at the line of junction with the
ribs.   The  ensiform cartilage, being drawn outward,  is to
be detached from the  soft parts, the knife being held  close
to  the sternum.  The sterno-clavicular articulation may
now be opened, and the sternum with the costal cartilages
raised from its position—a cautious use of the knife being
made to remove the adherent soft parts.
   The thoracic viscera are now exposed, and may be drawn
 out with care,  and inspected in detail.
   To examine the Abdomen, make a crucial incision: the
 one branch extending from  the sternum to the pubes,  pass-
 ing to the left of the umbilicus ;  the other, transversely
 across  the middle of  the abdomen.   Care must  be taken,
 in making these incisions, not to  injure  the  subjacent
 viscera.
    Before  removing the stomach or any portion of the in-
 testines, ligatures should be placed  above  and  below the
 part that is to be separated. 
92
MEMORANDA MEDICA.
  When—as is  always desirable if possible—both of the
large cavities of the  trunk are to  be opened, a single in-
cision, extending from the top of the sternum to the sym-
physis pubis, may be  made.
  In every case  incisions through the skin should be made,
as far  as practicable, only in those parts which are usually
covered by the  clothes of the deceased.   It  is  generally
advisable, when the  abdomen or thorax has  been opened,
to fill the cavities with bran or sawdust.   After the exam-
ination has been completed, the edges of the divided integ-
ument should be brought together, and retained in appo-
sition  by the common suture.
   The following is  Professor  Bennett's*  summary state-
ment of the subjects  especially claiming attention during
an autopsy:—
   I. External  Appearances.— Number of  hours  after
death.  General aspect and condition of the body; pecu-
liarities of  person; marks on the  surface; suggillation;f
amount of decomposition.  In cases of suspected death by
violence, great minuteness  in the external examination is
necessary.
  II.  Head.—Scalp; calvaria; meninges; choroid plexus;
brain,  its form and  weight; cerebellum, its weight; cortical
and medullary substance  of brain;  ventricles, exact quan-
tity  of fluid in  each — which  should  be removed with a
pipette — its character;  medulla oblongata;   nerves  and
arteries at the base of the brain; base of cranium; sinuses.
  * Clinical Medicine, Phil, ed., page 25.
  f Suggillation is discoloration, in spots, resembling those produced
by ecchymosis (extravasation of blood) during life. 
SEMEIOLOGY.
93
   III.  Spinal Column.—Integuments  over spine;  verte-
brae; meninges;  cord; nerves.
   IY. Neck.—Thyroid gland; larynx and its appendages;
trachea; tongue; tonsils;  pharynx;  oesophagus.
   Y. Chest.—Thymus gland; lining membrane of bronchi;
bronchial glands; pleurae; contents of  pleural cavity; pa-
renchyma of lungs;  large  thoracic veins;  pericardium, its
contents;  general  aspect  and  position of  the  heart, its
weight; amount of blood in its various cavities;  right
auricle; coronary veins; auricular septum; right ventricle,
size of  its cavity; thickness and degree of firmness of its
walls;  endocardium;  tricuspid valve;   pulmonary artery,
its calibre; pulmonary veins; left auricle;  mitral valve ;
left ventricle;  thickness  and condition of its muscular tis-
sue; size of its cavity; sigmoid valves;  coronary arteries;
aortic opening and arch; large  arteries of the neck; tho-
racic aorta, its structure and calibre.
   YI.  Abdomen.— Peritoneum  and  peritoneal cavity;
omentum;  position of abdominal viscera; stomach;  duo-
denum ;  small and large intestines; liver, its weight, form,
and  structure; supra-renal capsules;  kidneys, weight of
each; secreting and excreting portions; pelvis; ureters;
bladder; with the prostate and urethra  in the male; in the
female, uterus, ovaries,  Fallopian tubes,  vagina; abdominal
aorta and vena cava; large abdominal  arteries and veins;
ganglia of the sympathetic system.
   VII.  Blood.—Appearance in the cavities of the heart,
in aorta, vena cava, vena portae, etc.;  coagulated and fluid
portions, adhesions or not of the former.
   VIII. Microscopic examination of all the morbid struc-
tures and fluids, the blood, etc.
                           9* 
94
MEMORANDA MEDICA.
             IP^IELT   III-

         GENERAL  PATHOLOGY.

The seat of disease may be
  In the constitution: e.g. secondary syphilis; tubercu-
    losis.
  In special tissues: e.g. mollifies ossium.
  In particular apparatus: e.g. dyspepsia; hysteria.
  In  individual organs:   e.g. pneumonia;  cirrhosis;
    hydatids.
  In the blood:  e.g. anaemia;  scorbutus; cholera.
Morbid states of the system:—
    Over-excitement;
    Fever;
    Depression;
    Exhaustion;
    Degeneration  of organic force (cachexia);
    Toxaemia.
Morbid states of organs:—
    Over-excitement;
    Hypertrophy;
    Irritation;
    Inflammation;
    Hyperaemaesthesia or  "chronic inflammation;"
    Atony; Exhaustion;
    Atrophy;
    Degeneration  or Kakotrophy. 
GENERAL PATHOLOGY.
95
  Of the above, the  most important general or systemic
morbid states  may be included under fever, toxaemia, and
cachexia; constituting a sort of "tripod" of  systemic dis-
ease.
  A similar tripod of the most frequent and important local
disorders may be established, of irritation, inflammation,
and atrophy.

  In using the term fever, as applied to a morbid state of
the system, we must  remember  that the same word  is also
used as a part of the designation of several complex dis-
eases: as  typhus fever, yellow fever, remittent fever, etc.
This double use of  the word  is unfortunate, but cannot
now be avoided.
                 SYMPTOMS OF FEVER.
   Increased heat of the whole body;
  Dryness of the skin, mouth, etc.;
   Diminution in bulk of the excretions ;
   Muscular debility;
   Frequency  of the  pulse;
   Functional disturbance of stomach, brain,  etc.
   Heat is the most essential characteristic of the febrile
state, having given name to it in all languages.
   Notwithstanding the  scantiness in quantity of the stools,
urine,  and perspiration in  fever, it  has been shown  by
Virchow, Vogel, Bocker, Parkes,  Jenner, and Hammond,
that  the  actual amount  of solid matter  excreted,  es-
pecially by the kidneys, is increased.  Although  none of
these observers  have made  chemical  examination of the
expired air during  fever, we have, in the heavy, offensive
odor of the breath, evidence that it, too, contains an exces- 
96                MEMORANDA MEDICA.
sive amount of decomposing organic material.  It is highly
probable, also, that much excrementitious matter is, during
fever, retained in the blood.   It has been observed that if
a  local inflammation,  as  pneumonia, occurs during  the
febrile attack, the excess  of excreted solids (urea, etc.)
disappears until the inflammation has passed.
   This increase of the disintegration  of the  substance of
the body (tissue-metamorphosis) is, at present, one of the
most prominent and interesting  phenomena connected with
the  pathology of fever.   The  whole  subject, however, is
surrounded by obscurity, notwithstanding the  fact that the
symptoms and aspects of the febrile state  have been familiar
ever since man became a prey to disease.
   On the basis of the facts observed and scrutinized at the
present time, I  think we may venture to throw out a com-
prehensive theory of fever.   Thus,—its essential phenome-
non is increased heat of the body ; this being produced by
excessive tissue-metamorphosis, under an  abnormal "ten-
sion-condition" (Yirchow) of the ganglionic nerve-centres;
which abnormal condition is the result  of (Addison) either
1, corpuscular  toxaemia,  or  2, plasmic toxaemia, or 3,
(Campbell & Midler) sympathetic  irritation from local in-
flammation.
   A  pathological classification of fevers,  convenient for
some purposes,  is, into  irritative, reactive, and toxaemic
fevers.

   Toxaemia, more  properly toxicohaemia,  (from ro^ixoy, poi-
son, and aifj.a, blood,) is a term used to indicate poisoning
of the blood.
   After all the  long and reiterated disputes  between the 
GENERAL PATHOLOGY.
97
advocates of the  exclusive solidist and  humoral patholo-
gies, it has  now  become a matter of general recognition
among medical observers and reasoners, that both the fluids
and the solids  are involved in almost every disease—their
mutual interdependence making the contrary impossible.
  Certain diseases, however, more than others, are believed,
upon the strongest  evidence, to depend upon a chemical
and dynamic change in the  blood, to which the name  of
toxaemia is applied.
  Toxaemia originates in at least two  ways:—1. By the
introduction into the blood of morbid poisons from with-
out, as in the case  of syphilis, small-pox, remittent  fever,
etc.   2. By the non-excretion, and consequent accumula-
tion in the blood, of post-organic or excrementitious sub-
stances, which,  by their own properties, or by the chemical
changes they undergo, prove injurious to the system.  Ob-
structive jaundice, and uraemia, afford  the best examples
of this last occurrence.
  All of the zymotic diseases (e.g. exanthemata, cholera,
yellow fever, diphtheria, etc.) have their origin  explained
by the first of these modes of blood-poisoning.
  Yet, our  knowledge of the very existence  of  several  of
these "morbid poisons" is  inferential only.   Our idea of
their nature is conjectural; and our reasonings upon their
mode of  action upon the blood and system at large are en-
tirely speculative.
  Some facts, however (see Simon's Lectures on Pathology),
are well deserving of notice.
  1.  The effects  of these poisons, when introduced into
the body, are,  both local and constitutional  symptoms.
The  constitutional symptoms, which begin  the attack, are 
98
MEMORANDA MEDICA.
nearly alike for them all—the local symptoms are peculiar
for each one.
   2.  The small-pox virus is the most readily studied of all
of these causes.   This  material is evidently volatile, as it
acts often through considerable distances; and it is soluble,
because it infects, sometimes, the  foetus in utero, which has
no communication of fluids with the  mother, except by pla-
cental endosmosis.  The poison of primary syphilis is not
thus  transmissible, although it is directly contagious by
inoculation; that of secondary syphilis is not* contagious,
but is transmissible by descent.
   3.  One  attack  of  small-pox, scarlatina, measles, hoop-
ing-cough, usually gives immunity  for the rest of a  life-
time.   It may,  from this, be argued, that besides the mate-
ries morbi or causative matter, another material must exist
in the blood of  the susceptible person, which combines  with
the former (thus  producing the disease), aDd which is ex-
haustible.    (Illustration :  the saturation of  a  carbonated
alkali by an acid ; after a certain portion of the latter is
added, it will cease to effervesce with any subsequent addi-
tion of the same).
   Vaccination  can be best explained upon this view.   Just
as more than one acid will  neutralize potassa or soda, etc.,
so that after it has been  saturated with sulphuric acid it
will not react with nitric—so the virus  of the vaccine dis-
ease  appears capable  of saturating and exhausting that
material in the body, the presence of which constitutes the
suscejitibility to variola.
   No such immunity after a single attack is found to  exist
  * Recent experiments have occasioned some doubt  as to the entire
correctness of this commonly accepted statement. 
GENERAL PATHOLOGY.
99
in the case of the miasmatic fevers (remittent, intermit-
tent).  The element in  the  blood for which their morbid
poison has affinity is, therefore, not exhaustible.   Several
reasons exist for conjecturing this element to be  the red
corpuscles themselves.
   Of the different hypotheses propounded in regard to the
modus operandi of "zymotic"  (i.e. epidemic, endemic  or
infectious) causes upon the blood, that which has best stood
its ground is  that of catalysis, or continuous molecular
action.
   Toxaemia from non-elimination of the excretions is sel-
dom, if ever, an idiopathic affection.  It is, therefore, best
studied in connection with those disorders of which it forms
a secondary or resultant, although important part.

   Cachexia (from 7A/.0-, bad, and tctr, habit,) is usually
understood to mean a depraved habit of system;  an error
of development  and nutrition affecting the  general state of
the organs and functions with perversion or debility.
   There is,  at the same time, no reason why we should not
speak of local as well as general cachexiae.  Although not
usual, I have  introduced this mode of  employment of the
term in our department of Nosology.
   The history of the different cachexiae would not be in
place here—belonging rather to Special Pathology and
Nosography.
   A few words  must be said, however, upon the  very im-
portant subject of tuberculosis.   We shall have space only
for  the main  points concerning it.   In regard to most of
these, there is a general agreement among pathologists and
clinical observers. 
100
MEMORANDA MEDICA.
  1. Tuberculosis  and  Scrofulosis  are  identical.   The
term scrofula is generally applied to certain slow inflam-
mations, abscesses, ulcerations, and other disorders of the
skin, mucous membranes, glands  and bones, which  occur
especially in  young persons, and are characterized by the
moderate degree of vascular excitement attending  them,
with the great obstinacy or chronicity of their career.  In
many cases, also, of external scrofula, particularly in the
glands,  a deposit of curd-like or cheesy material is found,
not distinguishable from tubercle.
  2. Of the  causes apparently connected with the  produc-
tion of  the tubercular or scrofulous diathesis (to which the
general  name  tuberculosis may be applied),  the most
obvious and constant is hereditary predisposition.
  3. This diathesis may, however, undoubtedly be acquired
without  inheritance.   Change of climate, from a warm to
a cold  and  damp locality,  will often induce it.    Other
depressing influences promote it, such as  want of food,
light, or warmth, sedentary  habits, etc.   But  all of these
often fail to generate  any form of tubercular disease.
  4. Tuberculosis may be pathologically defined as a con-
stitutional tendency to the formation of blood, the plasma
of which is defective  in organizable  capacity;  so  that, in
nutrition, instead of healthy  tissue, it forms, in one, or very
often in many, of  the organs, aborted blastema,* which
accumulates as a deposit.  This deposit is called tubercle ;
the  process, tuberculization.
  5. But the tubercular diathesis (tuberculosis) may exist
without  tuberculization.   Its influence is then   shown,
especially,  in  modifying inflammatory  or other  morbid
  * From ftXaaravu), I bud; used to mean tissue-forming material. 
GENERAL PATHOLOGY.
101
processes; giving them a lower, slower, and more persist-
ent or intractable type.  Thus, many cases of what is called
tubercular meningitis in children  occur, with fatal result,
in which  (Bouchut, Hughes Wilshire, etc.)  no tubercular
deposit is found;  yet the  disease is modified by the dia-
thesis.
   6.  Tubercle is  distributed  either  in  regularly-formed
 masses (miliary  tubercles,  etc.),  or  irregularly, through
 the tissue of organs. The most amorphous  (shapeless) and
 homogeneous examples of it are called infiltrated tubercle.
 The  size of the masses of  tubercle varies from  that of a
 pin's head to that of a hen's egg.
   7.  The two essential varieties of tubercle are  the semi-
 transparent, gray, granular, and  the yellow, opaque,  ca-
 seous tubercle.
   8.  Neither of these forms ever  undergoes organization.
 They are never vascular.   They  are deposited outside of
 the  blood-vessels only,  and not in non-vascular  tissues,
 such as cartilage, etc.
   9.  The gray tubercle, when alone, is subject  (Rokitan-
 sky) to  one  change only, cornification; i.e. drying into a
 horny substance as hard as  a  shot.  When with the yellow
 tubercle, the gray may undergo softening.
   10. Yellow tubercle usually softens; sometimes it creti-
 fies ;  i.e. becomes chalk-like, by degeneration.
   11. The softening of tubercle  is spontaneous;  not  de-
 pending upon any agency of surrounding parts. In regularly
 formed tubercles it commences at  the centre; in the irreg-
 ular,  at  any part.   .Tuberculous softening must not be
 confounded with suppuration of inflamed tissue; although
 they are often mingled.
                         10 
102
MEMORANDA MEDICA.
  12. Examined with the microscope, tubercle is found to
consist essentially of: 1. An amorphous, granular material,
containing irregular solid corpuscles (tubercle-corpuscles),
considered (Virchow) to be shriveled nuclei.   2.  Elements
of disintegrated tissue of the part involved;  as  epithelial
cells, fibres, etc.   3. Results of degeneration;  e.g.  oil-
globules, pigment, calcareous particles, etc.   4. Results of
inflammation of surrounding  parts; lymph,  pus,  exuda-
tion-corpuscles.  5. Extravasated  blood-corpuscles, from
hemorrhage, the effect of obstruction or ulceration  of vas-
cular trunks.
   13.  Tubercle contains, then, no specific, heterologous
form.   All  that it holds is the consequence  of abortion
and degeneration.
   14.  The process of tuberculization or deposit of tubercle
in the organ may occur (Rokitansky)—
   a.  Insensibly, in the course  of ordinary nutrition.
   b.  With hyperaemia, or local determination of blood.
   c.  With inflammation; i.e. as  a product or concomit-
ant of the inflammatory process.
   15.  The effects of the tubercular deposit upon the part
are :  1. Obstruction, and arrest or impairment of function.
2.  Inflammation;  e.g.  in  phthisis pulmonalis (consump-
tion), which has, in its usual form, been designated (Con-
die) tubercular pneumonia, from  the common occurrence
of  inflammation of the lungs with  the deposit of tubercle.
3.  Ulcerative  destruction  of  the  tissue by the repeated
new formation and softening  of tuberculous matter, pro-
ducing cavities.
   16.  Tubercle, once thrown out, is never (as a whole) ab-
sorbed.  It can only be eliminated, cretified, or  cornified. 
GENERAL PATHOLOGY.
103
Elimination is the most common.  After this has happened,
sometimes callous cavities are formed by a process of cica-
trization.
  17. The order of frequency with which different organs
are affected with tubercle is (Rokitansky) as follows :—
     Lungs;                      Spleen;
     Intestines;                   Kidneys;
     Lymph glands;              Liver;
     Larynx;                     Bones;
     Serous membranes ;           Uterus ;
     Brain;                      Testicles.
  Except in the case of children,  in whom the lymph-
glands and the spleen stand first on the list.
   18. But the organs most frequently first invaded by tu-
bercle are, at all times of life, the lungs and lymph-glands.
   19. The parts especially preferred by tubercle  for its
deposit are, in the lungs, the  apex ; in the pia mater, about
the base of the brain; in the brain, the gray substance ; in
bones, the cancellated  structure ; in the bowels, the lowest
part of the ileum; in the  testicle, the epididymis;  in the
female  generative apparatus, the Fallopian  tubes and fun-
dus of the uterus.
   20.  The immense experience of Rokitansky gives origin
to the statement that tubercle has certain general  incom-
patibilities ; the most important  of which are, with cancer,
with typhus, with  ague, and with goitre  (bronchocele, en-
largement of  the thyroid  gland).   These  incompatibilities
are, however, general, not universal; as, for instance, a
considerable number of cases have been observed, in which
cancer  and tubercle were undeniably present in  the same
patient. 
104
MEMORANDA MEDICA.
   21. The only possible cure  of tubercular disease (e.g
of the lungs in phthisis) after the deposit has  occurred,
consists in the total elimination (or absolute quiescence by
cornification or cretification)  of  the  tuberculous matter,
and  improvement in the general haematosis  (i.e. blood-
formation),  so that no new tubercle is  formed.   The  two
great indications, therefore, in  the treatment of pulmonary
consumption (Radclyffe Hall) are, to gain time and tone:
time, by allaying or  preventing pulmonary or bronchial in-
flammation  and irritation ;  and tone, by strengthening the
patient's  system by all possible hygienic and  therapeutic
measures.


   GENERAL  PATHOLOGY OF AFFECTIONS OF ORGANS.

   Hypertrophy is, strictly, overgrowth; an increase of the
size  and weight of a part without change of tissue.   It is
only in recent times that this has been  clearly distinguished
from enlargement with alteration of tissue; which is really,
in many cases, a degenerative  change, and therefore akin
rather to atrophy than to hypertrophy.
   Hypertrophy is often, per se, physiological or natural;
although  depending  on  a  morbid  or  pathological  cause.
When the bladder, for instance, becomes hypertrophied in
consequence  of obstruction by an enlarged prostate,  al-
though the  latter is  morbid, the increase in the strength
and thickness of the muscular coat of the bladder is as
normal as is that of the uterus during gestation; in due
proportion to the necessities of its use.
  A constant law of the animal economy is, that, within
certain limits, the  growth of an organ is in proportion to 
GENERAL PATHOLOGY.
105
its exercise ; provided that this exercise is not too violent,
and is alternated with sufficient periods of repose.
  The three causes of hypertrophy, then, are (see PageVs
Surgical Pathology):—
  1. Increased exercise of a part in its healthy functions.
  2. Increased accumulation in the blood of the particular
materials  which a  part appropriates  in its  nutrition or
secretion.
  3. Increased afflux of healthy blood to the  part.
  We may illustrate the first of these  modes of causation
by  the  blacksmith's arm,  the legs  of the danseuse, the
cuticle of the  laborer's  hands, the heart in cases, of valv-
ular obstruction, etc.
  An example illustrative of the second is found in the en-
largement  of a healthy kidney, when the opposite one fails,
from disease,  to  remove from the blood its  due share of
urea, etc.
  The third is  exemplified  in  the large growth  of hairs
around  an inflamed ulcer or  osseous fracture;  by the
growth of the bones of the  limbs when their nutrition  is
increased by exercise; by hypertrophy of bones, a portion of
which has  been subject to disease with vascular excitement;
and by Hunter's interesting experiment of  the transplanta-
tion of the spur of a cock to its comb.
  Adaptative hypertrophy is remarkably seen in the changes
undergone  by the  skull in  proportion to  its  contents.
The cranium  is subject to—1, eccentric, and  2, concentric
hypertrophy.   The first occurs in cases of hydrocephalus,
the second in cerebral atrophy; the  bony case in the one
instance expanding with its contents, in the other thicken-
ing so as to fill up the abnormal void.
                          10* 
106
MEMORANDA MEDICA.
  Corns illustrate hypertrophy extremely well.
  Intermittent pressure, or attrition, causes hypertrophy;
constant pressure, atrophy or absorption.
  The formation of corns upon the  foot  illustrates  the
former of  these laws; the wasting away of vertebrae under
the incessant pressure of an aortic aneurism affords an ex-
ample of the latter.   (Chinese woman's foot, with corns,
exemplifying both.)

  Atrophy requires but a few words in this place.   Simple
atrophy is exactly the reverse of simple hypertrophy; viz.,
wasting and diminution of a part, without change of structure.
But most pathologists include also under  the  same term
such defects of nutrition as result in degenerative changes;
constituting  the two classes of—1, quantitative, and 2,
qualitative atrophy.   The latter (e.g. fatty degeneration)
is frequently attended by increase instead of  diminution
of bulk in the parts affected.
   The causes of atrophy are:—
     1.  Deficient exercise of a part;
     2.  Deficiency in the supply of blood;
     3.  Defective supply of nervous influence;
     4.  Disease (inflammation, etc.) in the part.
   Of the first of these, the atrophy of the mamma of the
old maid may afford an example.
   Of the  second, softening of a portion of  the  brain from
the obstruction of one of its arteries by a coagulum.  (Pa-
get's  examples of atrophy of the heart.)
   Of the third and first together, the muscles of a paralyzed
limb.
   Of the  last, there  are many instances familiar to the pa- 
GENERAL PATHOLOGY.
107
thologist, although obscurity often  attends their individual
history;  as, the gouty kidney, etc.
  Quantitative or qualitative atrophy may affect the heart,
arteries, brain, muscles, bones, liver, kidneys, pancreas, tes-
ticles, etc., and morbid  products, e.g. inflammatory exuda-
tions, cancer,  etc.
  Qualitative  atrophy,  or  degeneration,  will be again
alluded to presently.

  Irritation and  inflammation are at once the most fami-
liar  in their phenomena, and  the  most  obscure  in their
nature, of all pathological  processes or  occurrences.  I
shall confine myself to a broad statement of what I believe
to be the most important truths concerning them; although
a somewhat argumentative tone may be unavoidable, upon
topics  which are subject to so much controversy.
  Stimulation and irritation are often inconveniently  con-
founded.  It would be desirable to confine the former term
to excitation within physiological  (i.e. healthy or normal)
limits; applying the latter, irritation, only to such an exces-
sive action upon a part as produces morbid effects.
   With  this, which seems to me a necessary postulate—I
would define irritation as an arrest of vital movement in a
part.  This could only be elucidated, by an extended  allu-
sion, inappropriate here, to the correlation of physical
and vital forces;  life being considered as a molecular
motion.
   In regard  to the circulation, to the  old and  accepted
maxim—
               Ubi stimulus, ibi ojfiuxus—
may be added a second—
                Ubi irritatio,  ibi stasis, 
108
MEMORANDA MEDICA.
 And, anticipating the account about to be given of inflam-
 mation, a third—
                Ubi phlogosis, ibi effusio.
   The stasis of irritation may be either partial or com-
 plete ; limited to a very small surface,  or widely extended;
 and transient, or continued for a considerable time.
   If complete, extended, and  continued in a  tissue  at all
 vascular, inflammation follows.
   If the influence of the irritant be very limited and tran-
 sient, a temporary stasis and functional and sensational dis-
 turbance only follows.
   If it be extended and continued, or  repeated,  and  yet of
 power enough to produce a partial stasis only, a condition
 may result to which the name of chronic inflammation has
 (improperly) been commonly given ; of which more will be
 said hereafter.
   The effects, or symptoms, of irritation differ  according
 to the tissue or  organ affected.  When a nervous expan-
 sion or centre is  involved, pain is the most familiar result.
 Functional  disorder of the part  innervated  also occurs.
 Irritation of muscular tissue causes tonic spasm.
   Inflammation must be considered, briefly, as to its symp-
 toms, minute phenomena, products, terminations or effects,  *
 and post-mortem appearances.
   Its recognized symptoms or signs, in a part open  to in-
 spection, are redness, heat, swelling, and pain.
   In internal organs  inflammation is  detected  chiefly by
pain, increased by pressure  or motion;  obstruction or
 alteration of the functional action of the organ; and gen-
 eral (sympathetic) vascular excitement.  Certain physical
 signs also aid in the diagnosis of inflammation  of partic- 
GENERAL PATHOLOGY.
109
ular organs; these have been briefly alluded to already
(see Semeiology).
  The minute phenomena of inflammation, as  seen under
the microscope, have been variously construed by different
observers.   The use of  the term itself has been, of  late,
distorted (Virchow) from its old meaning; and  attempts
have been made by some (Andral, Eisenmann, Bennett) to
do  away with it entirely; attemp{s which  fail, because, in
proposing  other terms, a part  only is substituted for the
whole.   It is curious, that, of the three terms proposed by
three leading pathological writers, hyperaemia, stasis, and
exudation, to take the place of the old word inflammation,
each expresses a  single  part or  element  of  the process,
which can  only be defined by including them all.
  The essential minute  phenomena of inflammation  are,
as regards the circulation,—
       Central stasis ;
       Concentric hyperaemia;
       Exudation.
   Other changes,  affecting the red and white corpuscles,
etc., occur, but are of  secondary consequence.
   The nature and cause of these  phenomena  require, for
their comprehension,  a  close  consideration of  the  laws
which govern nutrition, the capillary and  arterial circula-
tion, and innervation, in their  mutual relations, under the
influence of normal stimuli and of morbid irritants.
   What are the actual causes of inflammation?  (See the
author's Essay on the Arterial Circulation.)
   Not section  of  the  nerves; nor division of the arteries
(per  se);  nor division  of the  veins;  nor  ligation of ar-
teries nor of veins; nor  (per se)  of lymphatics.  Only such 
110               MEMORANDA MEDICA.

causes as modify the molecular state of the tissue, and
arrest, for the  time,  the usual  interchange of  material
between the tissue and the blood, can induce a true inflam-
mation.
   Let us, then, revert to our  maxims.   Ubi stimulus, ibi
affluxus.    Stimulation causes active hyperaemia.   The
arteries thus exhibit reflex action;  a fact which, in spite
of the teachings of Unzer,  Hunter, and C. Bell, has been
denied or misunderstood by  nearly every other physiologist
and pathologist down to the present day.
   Next, ubi irritatio, ibi stasis.   Stimulation, carried  to
morbid excess, interrupts, by  the molecular disturbance it
induces, the normal life-movement of the part, and checks
the interchange of particles going on between the capillaries
and the tissue.   Thus the circulation in the capillaries of
the part is arrested;  stagnation ensues.
   Both of these  results, active arterial hyperaemia and ca-
pillary stasis, follow from  the  same or similar causes act-
ing in different degree.  They may and do exist together;
the one (capillary stasis) at the very point of irritation, the
other (active hyperaemia) in  the vessels surrounding it.
   What follows?  Hydraulics may answer  this question.
A quantity  of fluid,  in (minutely) porous  vessels, being
forced upon a centre whose  condition allows little or none
of it  to be  transmitted, an effusion must result,* through
the more or less  distended coats of  the vessels.
   This  is expressed  by our third maxim:  Ubi phlogosis

  * A quite different view of the inflammatory process is taken by the
distinguished Virchow, of Berlin.  But careful examination (Essay
on Irritation and Irritability;  Cellular Pathology, etc.) justifies the
rejection of his  theory,  however great the value of many of his 
GENERAL PATHOLOGY.
Ill
(inflammation), ibi  effusio.    This phenomenon, the  "ex-
udation," has attracted almost  all the attention of many
recent  pathologists,  to  the  exclusion  of  others  which
precede and  accompany it;  and  with detrimental results
(J. Hughes Bennett) as regards the practical  and  thera-
peutical deductions made therefrom.
   An example of the three stages or processes of stimula-
tion, irritation, and inflammation,  may be very well studied
in the action of a common  mustard plaster apjflied to the
skin.   Its first effect (or the only one, if the mustard be
diluted)  is stimulant merely; the skin grows warmer, and
redder, and its sensibility is moderately heightened.   Next
(if it be  strong and allowed to remain), irritation is  pro-
duced; shown by  pain, tenderness on  pressure,  and  a
deeper and more purple redness.   If the irritating matter
be now withdrawn, all of these  may subside without going
further.   But if  the  irritation be continued  up to  a cer-
tain point of duration and intensity, inflammation occurs.
Then, we have redness, heat, pain, and swelling, with  effu-
sion of  lymph, which, in the cutaneous inflammation caused
by a sinapism or cantharidal plaster, raises up the cuticle in
 the form of a blister.
   I would express, then, what I hold to be a correct theory
 of the nature of the inflammatory process, in the following
 definition: Inflammation is a  local lesion  of nutrition,
 with concentric vascular  excitement, resulting in exuda-
 tion.
 minute observations.  It. has been the misfortune of modern biology
 to be  governed too much by the leadership of a few laborious ob-
 servers,—notwithstanding the  fact that they are far from  being
 always comprehensive reasoners. 
112
MEMORANDA MEDICA.
  The products of inflammation (by exudation) are (see
Paget's Surgical  Pathology)  1. Serum.   2. Blood.   3.
Mucus.  4.  Lymph.
  The inflammatory  effusion of  non-fibrinous  serum is
rare.  The  term is often applied, however, clinically, to a
serosity which contains a small proportion of fibrin; as the
effusion which follows pleurisy, etc.
  Blood is  exuded occasionally only ; e.g. in dysentery, in
nephritis, and (dissolved) in pneumonia.
  Mucus, a certain portion  of which constantly moistens
the surface of mucous membranes in health, is altered both
in character and in amount by inflammation.  The general
statement is, that when a mucous membrane" is inflamed
(e.g.  in  bronchitis),  its  secretion  of  mucus  is  at first
arrested, then increased, and lastly perverted in character.
   Coagulable lymph is,  however, the characteristic  ingre-
dient of inflammatory exudations.
  Inflammatory lymph is divided by Paget into—1, fibrin-
ous, and 2, corpuscular  lymph; with the assertion that, as
a general fact, the more fibrin a specimen of lymph contains
(provided it be healthy fibrin), the greater the probability
of  its beiug organized  into tissue;  while the larger its
proportion  of corpuscles, the greater is the likelihood of
suppuration or some other degenerative process, and the
more tardy its development into any kind of tissue.  (Note
an apparent exception  to  this in  the case of diphtheritic
exudation ;  explained  by the fibrin of the latter not being
healthy.   See Rokitansky's Pathological Anatomy.)
  Fibrinous (coagulable or plastic) lymph is very well seen
in the autopsy of any case of acute pleurisy, peritonitis,
arachnitis, etc. 
GENERAL PATHOLOGY.
113
  It is a whitish or yellowish-gray substance, opaque or
semitranslucent after coagulation, arranged in fibrous bands,
meshes, or layers, and causing adhesions between contigu-
ous portions of the tissues affected.
   Corpuscular lymph may be studied in the fluid of the
vesicles of herpes, or of an ordinary blister; especially if
the surface of the latter have been exposed to the air for a
short time.
  The lymph- or exudation-corpuscles which it is found
(under the  microscope) to contain, are about 3J0U of an
inch in. diameter, "round or oval, pellucid, but appearing,
as if through  irregularities of surface,  dimly nebulous or
wrinkled."  Examined after a few hours,  under the action
of water, a round and pellucid nucleus is observed within
and attached to the cell-wall.  It is, however, impossible, in
a given instance, to make  a positive microscopical  diagno-
sis, between these corpuscles of inflammatory lymph, and
the normal lymph or chyle corpuscles, colorless corpuscles
of the  blood, and pus corpuscles.
  The "biography" of the lymph of exudation consists in
its resorption, or its' development into connective,  fibrous,
elastic, osseous,  cartilaginous, or vascular tissue,  or into
epithelium, etc. (rarely into muscular  or  nervous  tissue);
or its  degeneration into  pus, or granule-cells, exudation
granules, etc.
  The rapid resorption of a  moderate amount of  exuded
lymph constitutes the resolution of an inflammation.
  Its development is also a form of resolution, but with
modification of the condition, dimensions, etc. of the part.
This is, in some instances, merely restorative.
  The degeneration of the exudation results in its  being
                           11 
114
MEMORANDA MEDICA.
thrown off, as pus, or finally absorbed, in the form of mo-
lecular exudation-granules.
  Whether immediate absorption, development, or suppu-
rative or granular degeneration shall occur in any particular
case of inflammation, will depend—
       1.  On the state of the blood;
       2.  On the seat of the inflammation;
       3.  On the degree of inflammation.
  (Paget's* experiments as to the influence of the state of
 the blood on the lymph of vesication.)
  As to the seat of the attack, generally, serous and syno-
vial tissues (pleural, peritoneal,  arachnoid, articular)  are
most subject to adhesive inflammation, i.e. with the exuda-
tion of fibrinous lymph.   Mucous tissues seldom exhibit
this, being more prone to suppurative inflammation.  (Ex-
ceptions in  croup,  diphtheria, etc.)    Parenchymatous
tissues,  as  those of the  lungs, liver, etc., when inflamed,
may suppurate, or the lymph exuded  may degenerate  into
exudation granules, and be finally absorbed.
  The degree of the  inflammation exercises an  important
influence.   The greater its intensity or  severity (i.e. the
more decided and  extended the local lesion of nutrition
and concentric hypersemia), the farther will the  lymph ex-
uded be removed, in its primary character, from that trans-
uded in the natural state of the part, and the more will its
subsequent changes differ from those of normal nutrition
and development
  Degeneration may affect both the fibrinous and the  cor-
puscular portion of inflammatory lymph.
  The fibrinous part is subject to—
           * Surgical Pathology, Phil, ed., p. 1220. 
GENERAL PATHOLOGY.
115
  1. Drying into  horny concretions (as  on the valves of
the heart, from endocarditis).
  2. Fatty softening.
  3. Liquefactive degeneration.
  Both of these last contribute, no doubt,  to the process of
suppuration.   Calcareous and pigmental  degeneration are
also described  as occurring  occasionally, but they are  less
important.
  The corpuscular portion  of lymph may also undergo—
  1. Withering and drying (as in scrofulous inflammation
of glands).
  2. Conversion into granule-cells (inflammatory  globules
of Gluge), by fatty degeneration.
  3. Calcareous,
  4. Pigmental degeneration.
  5. Most commonly, degeneration of the lymph-cells into
pus-cells; the whole of the  lymph  being  transformed into
pus.
  Pus is a greenish-yellow,  creamy fluid,  consisting, under
the microscope, of the liquor puris and  pus-cells or cor-
puscles.   The  latter are definite  cell forms, larger than
blood or lymph corpuscles,  somewhat more irregular, and
often containing several nuclei. Their characters, however,
are not invariably distinctive;  as might be anticipated,
from  their  being  merely  transformed  or  degenerated
lymph or epithelial corpuscles; or, in a  wound  or ulcer,
cells of granulation.   Chemically, pus may be approxima-
tively tested by its solubility in liquor potassae.
  Suppuration is  either circumscribed  (as  in  abscess),
diffusive (in erysipelas), or superficial (in  leucorrhoea, etc.) 
116
MEMORANDA MEDICA.
   The  effects of inflammation  upon  the part  or organ
 involved are—
     Enlargement;                Degeneration;
     Induration;                  Ulceration;
     Softening;                   Mortification.
   We thus  see that very different or even opposite results
 may follow from different degrees or kinds of inflammatory
 action.

   Specific inflammations require merely to  be mentioned
 here.   They are, chiefly, scrofulous, erysipelatous, rheu-
 matic, gouty, exanthematous, syphilitic, and gonorrhoea!
 These are distinguished  from ordinary inflammation and
 from each other in that—1, each exhibits a peculiar plan of
 morbid process;  2, each depends upon a  peculiar cause;
 3, the effects of the said cause are irrespective of its quan-
 tity or extent of application; 4, they are especially diffusi-
 ble from one part of the  body to another;  5, they some-
 times exhibit definite stages of  the morbid process (e.g.
primary and  secondary syphilis);  6, they are nearly all,
 in a more  strict sense than  other inflammations,  self-
 limited; the morbid process dying out after a certain time.
 (This  last statement applies  especially, if  not only, to
 exanthematous,  rheumatic,  gouty,  and  gonorrhceal  in-
 flammations;  hardly to the  scrofulous, erysipelatous,  and
syphilitic).

  The post-mortem appearances of inflammation are im-
portant.  They can  be generalized, so as to avoid, to a
great extent, the necessity of their reiteration in connection
with the description of particular diseases.   It is, at the
same time, necessary for the student to familiarize himself 
GENERAL PATHOLOGY.
117
with them, in their local manifestations, by availing himself
of every opportunity for autopsic study.
  A part which has been inflamed will exhibit after death
some, or perhaps all, of the following signs:—
     Redness;                      Coagulable lymph;
     Enlargement of                 Pus;
         blood-vessels;              Softening;
     Tumefaction;                  Induration.
  The redness of inflammation must be distinguished with
care from—1, hypostatic injection, or cadaveric settling of
blood  in the lowest parts, by gravitation; and 2, physio-
logical redness,  as of the stomach  during digestion, the
ovaries during menstruation, etc.   Inflammatory redness is
usually more  unequal than  either of  the  above, and  is
stellated, or in streaks and patches.
  Enlargement  of the blood-vessels of a part may occur
as the  result of a chronic affection, different from  acute in-
flammation.   This sign, therefore, is  to be interpreted with
great caution.  The same is true  of tumefaction.
  Softening, if not cadaveric (as when the body has been
long defunct), may have been produced by chemical action,
as in poisoning  by corrosive sublimate, etc., by acute and
rapid inflammation, or by slow, non-inflammatory degene-
ration.
  Induration may also follow either acute inflammation or
slow, atrophic degeneration.
   The presence  of bands  or membranes  of  coagulable
lymph is indisputable evidence of  inflammation having
occurred in the  part.  But  it is not easy, in all cases, to
determine with certainty whether such  formations are old
or new.
                          11* 
118
MEMORANDA MEDICA.
   The existence of pus  is a still  stronger sign of the re-
cent  existence  of inflammation;  but,  occasionally,  in-
stances occur in which pus, produced by inflammation in
one part, is conveyed  (as in phlebitis) by the  veins, etc.,
and deposited in another.   This,  although a rare event, is
possible at least.
   Clearly, therefore, no  one of  the  above  post-mortem
signs of inflammation is sufficient alone.  Several of them
together will make the diagnosis certain.  Redness and en-
largement of blood-vessels, with lymph or pus, and soften-
ing or slight induration  of tissue, will leave little or no
doubt in any case.
   The variations in the appearance of different organs and
portions of the body, in fatal cases of inflammatory dis-
ease, are not such  as to  interfere with the correctness and
availability  of this general description.

   The term  " chronic inflammation," as commonly applied,
is a misnomer.  Although  the cases so designated exhibit
more or less redness, heat, swelling, and pain, yet they are
wanting in exudation; without which, pathologically, there
is no inflammation.   There is also, in the same cases, only
a, partial stasis or none; and the hyperaemia is less intense
and less strictly concentric than in acute inflammation.
   The characteristics of  this state, for which a new term is
wanted, are—
   1.  Enlargement of the blood-vessels of a part (chronic
hyperaemia), with  the  flow of  a  large amount of blood
through it.
   2.  Exaggeration of  the  sensibility of  the part (hyper-
esthesia) and morbid irritability. 
GENERAL PATHOLOGY.
119
  3. Deficient or irregular functional power.
  4. Unusual proneness to acute or subacute  attacks of
actual inflammation.
  For this familiar combination of pathological elements I
propose the name hyperaemaesthesia.
  It has, lately, been  usual  to  designate it  by the term
"irritable," in connection with the name of the particular
part affected;  thus—
       Irritable uterus;
       Spinal irritation;
to which I would add—
       Irritable eye (chronic  ophthalmia) ;
       Irritable stomach (chronic gastritis) ;
       Irritable brain,  etc.

  Degeneration has already been defined as qualitative
atrophy; i.e. a  substitution, under decline of the organic
force incessantly active in nutrition and repair, of abnormal
for normal structure and material.
   The forms under which  this occurs are—
       Fatty degeneration ;
       Calcification;
       Pigmental degeneration;
       Thickening of  primary membranes ;
       Fibroid degeneration  ;*
       Liquefactive and corpuscular degeneration.
  * Amyloid degeneration has also been described by Virchow and
others, as occurring in the brain, spleen,  liver, etc.  It consists  in
the conversion of tissue into a substance having physical and chemi-
cal properties resembling those of starch or cellulose. 
120
MEMORANDA MEDICA.
   In regard to all of these, except the last, it may be stated
 (see Paget's Surgical Pathology) that
   1.  They are changes such as may be observed naturally
 occurring, in one or more  parts of  the body, at  the  ap-
 proach of the natural termination of life.
   2.  The new material is of lower chemical composition
 than that normal to the part; i.e. it  is less removed from
 the inorganic state :  as fat, gelatin, calcareous matter, etc.
   3.  In structure, it is less developed; being crystalline,
 granular, simply globular, etc.
   4.  In function, it is less powerful.
   5.  In nutrition, it is less active and capacious.
   6.  Generally, although not always, constitutional debil-
 itation  precedes, and  (we may infer) institutes the local
 alteration of structure.
   7.  Inflammation or other local disease may, by impair-
 ing the nutrition of a part, cause it  to degenerate.
   The form of degenerative disease which has received the
 most  attention  from pathologists  is fatty degeneration.
 This  has been carefully studied, as it occurs  in the heart,
 arteries, brain, muscles, bones, liver, kidneys,  and  morbid
 products.  It must  be distinguished carefully from  mere
 fatty accumulation or adiposity.
   Our knowledge of the facts concerning degenerative dis-
 ease, and of the share which it  claims  in the domain of
 structural pathology, once almost entirely usurped by in-
 flammation,  is among  the most important of the acquisi-
tions of the medical science of the last quarter of a century.
  Tumors, and  morbid growths,  benign and malignant,
which may be best classified as forms of structural degener-
ation, or vitiated nutrition, I leave,—except some brief con- 
GENERAL PATHOLOGY.              121
sideration, now, of the pathology of cancer,—as more ap-
propriate to the department of Surgery.

  Cancer falls under the notice and  care of  the medical
practitioner, when it attacks parts or  organs within any of
the great cavities of the body.
  There is no essential impropriety in classing, pathologic-
ally, all malignant growths* together as cancerous; their
subdivisions being clinical or surgical.    (By  malignant,
we  mean, prone to unlimited increase  ; disastrous in effect
or result;  and difficult or impossible of arrest  or cure).
  Cancers may, then, be divided simply into
       Schirrus, or hard cancer (fibro-carcinoma) ;
       Colloid, or gelatiniform (alveolar) cancer;
       Encephaloid, or brain-like (medullary) cancer.
  Each of these contains, as its anatomical elements, fibres,
fluid, or semi-fluid jelly, and cells.
  Schirrus is composed mainly of  a fibrous or filamentous
tissue, with little fluid, and comparatively few cells.
  Colloid  cancer  has a variable amount of fibrous  tissue,
arrayed as a matrix (compared often to the structure of  an
orange), containing a jelly-like substance;  cells may  be
also found in it, but in less proportion.
  Encephaloid cancer is (so to speak) the highest develop-
ment of carcinomatous formation.  It consists of a  fibrous
matrix, containing an abundance of  abnormal, multiform
cells, and a peculiar fluid.
  When a cancer, of either type originally, is  based upon
  * Tubercle, it will be remembered, is not a growth, but an abortion
of tissue. 
122
MEMORANDA MEDICA.
and  includes bony structure, it  constitutes  osteosarcoma
If it develop itself upon the skin, or other epithelial tissue,
or, wherever occurring, display similar structure, it may be
called epithelioma.   If its location involve  especial vascu-
larity and  hemorrhage, it  assumes the form and name  of
fungus haematodes.   The pain of cancer (which is not
always present) appears to depend upon the extension of
the disease to a tissue well endowed with nerves.
   The cells, fibres and fluid* of cancer are all abnormal.
   But, are these forms heterologous; i.e.  different from
anything normal or natural to the body ?   Are they, so to
speak, implantations, or distortions ?   I believe, fully, that
the latter  is the correct view.   The "cancer-cells" are no
longer held by micrologists to  be  pathognomonically dis-
tinctive ; they are homologous with other cells found in the
body.  Yet, they are such forms as do not normally belong
to the part; being  produced  by morbid alteration or  per-
version of  its natural elements.
   The most rational theory  of cancer, then, is dynamic.
The disease consists in a morbid tendency; a  tendency to
enormous and unhealthy growth of a formation which is, at
the same time, vascular and sensitive, showing subserviency,
although under perversion, to the physiological laws of the
organization.
   The origin of cancer, in most, if not in all cases, is  con-
stitutional ; it is not unfrequently hereditary.
   Genuine cancer may always be expected  to  return after
removal—although exceptions occur, and it has occasion-
ally been known to undergo spontaneous degeneration.

  * The milky or creamy "cancer-juice,"  which emulsifies  with
water, is considered highly characteristic by  many  observers. 
GENERAL PATHOLOGY.
123
  The order of choice which cancer exhibits, as to the parts
it attacks, is (Rokitansky) as follows :—
       Uterus;                    Skin;
       Mamma;                   Brain;
       Stomach;                   Eye ;
       Rectum ;                   Testicle ;
       Lymph-glands ;             Ovary;
       Liver;                     Tongue;
       Bones;                    CEsophagus.

   Colloid cancer, in particular, prefers the
       Stomach, rectum, peritoneum.
  Schirrus, the
       Mamma, stomach, intestines.
  Encephaloid may occur in any organ; it alone attacks
the
       Liver, kidney, lung, testicle, eye, lymph-glands.

  The pathology of the nervous  system (neuropathology)
is, itself, an extensive field, of which the  merest coup d'ceuil
is possible here.
  For the purposes of pathological study, we must remem-
ber that the anatomical elements  of the nervous apparatus
are—1, gray, vesicular; and 2,  white, tubular nervous sub-
stance ; the former  being arranged in ganglia, the latter in
nerves and commissures.
  Physiologically, the  functions of the ganglia (nerve-crn-
tres, and, probably, impressible peripheral ganglionic ex-
pansions also) are,  to  receive, reflect, accumulate,  (gen-
erate ?) and distribute  nerve-force.  The sole  function of
nerves and commissures is,  to transmit or conduct it. 
124
MEMORANDA MEDICA.
  As a whole, we may state the offices of the nervous ap-
paratus to be as follows :—
      Excito-motor;
      Excito-secretory;
      Sensory;
      Voluntary motor;
      Internuncial,  i.e.
         Sympathetic and
         Synurgic (co-ordinative);
      Psychical, i.e.
         Intellectual;
         Emotional.
  The primary disorders to which this apparatus is  liable,
are (see Simon's Lectures  on Pathology),—
  1. Anaesthesia; i.e. that condition  in which the patient
remains without cognizance of impressions  made on a sur-
face which is  normally  sentient.  This may result, a, from
disease  of the nervous expansion at the surface; 6, from
disease or  injury of  the conducting nerve, somewhere on
its  track;  c,  from  disease  of the  cerebral sub-centre  of
sensation (sensorium).   The thalami (miscalled optic) are
believed by physiologists generally to  be  the aggregative
centres  of sensation ;   and local lesion (apoplectic  clots,
tumors, softening, etc.) in or near them is  frequently asso-
ciated with hemiplegia, etc.   The paralysis  is  commonly
observed (from decussation of the  nerve fibres in the me-
dulla oblongata) on the side opposite  to that on which the
lesion has occurred.
   2.  Subjective  impressions  and  sensations;  i.e.  those
which affect the consciousness of the individual without the
action of any external or peripheral  cause.  These sub- 
GENERAL PATHOLOGY.
125
jective impressions may be divided into—a, those which are
central in their origin, as when disease of the optic thala-
mus causes neuralgia of  the  fifth  pair  of  nerves;  and  b,
those whose origin is intermediate; as, when inflammation
of the sheath of  a nerve, or disease of the spinal  axis,
gives rise to pain referred by the patient to the termination
of the nerve.
   Subjective hyperaesthesia, or perversion  of sensibility or
psychical impressibility, may be, in its causation (as regards
the nervous apparatus), either functional* or organic; and
the difference between these is often practically important.
   3.  Muscular paralysis;  or  that  condition  in  which a
central volition (or  the  excitation equivalent  to it) fails
to produce its normal effect of muscular contraction.  Of
this defect, also, the  pathological  origin may be, as  to its
seat,  either peripheral, intermediate, sub-central  (in the
corpora striata or cerebellum), or central (in the convolutions
of the cerebrum).    Muscular as well as sensational paraly-
sis, dependent on  an affection of  the brain, occurs on the
opposite side  to that of the encephalic lesion.  Hemiplegia
and paraplegia have already been defined (see Semeiology).
Scarcely ever are  either of these varieties  of palsy confined
exclusively to sensation or to voluntary motion—although
the  proportion of impairment of the  two functions may
vary considerably in particular cases.
   4.  Involuntary contraction of voluntary muscles, or con-
vulsion.   Only very  local, and usually transitory spasmodic
affections are peripheral in their origin.   Usually, convul-
  * Functional nervous disorder results generally (Todd) from an
abnormal state of the blood.
                           12 
126
MEMORANDA MEDICA.
sive affections are accounted for by excessive functional ex-
citement of the (spinal) motor centres; the causation of
which is made up of three elements, in variable proportion,
viz.: a, morbid irritability of the spinal excito-motor appa-
ratus itself; b, imperfect control over the subordinate ner-
vous centres  by the brain, from an abnormal condition of
the latter; c, the disturbing influence of a peripheral irri-
tant—as, the tension of the gums in teething, worms in the
bowels, undigested  food  in the stomach, etc.
   The three forms of spasmodic disturbance to which the
muscles are liable under a morbid alteration of innervation,
viz.: the tonic, choreic, and clonic, are illustrated respect-
ively in tetanus, chorea, and epilepsy.
   A farther important pathological subdivision exists as to
the method of origination of those functional disturbances
of the nervous system to which we have been alluding.
   The source of any of the  above forms of  nervous dis-
order,  hyperaesthesia, anaesthesia, muscular paralysis,   or
convulsion, may be (when not purely local) either
       1.  Central organic disease  ;
       2.  Blood-perversion, or defective nutrition;
       3.  Purely sympathetic disturbance.
   It is far from easy, in many cases, to mark the diagnosis
between these different modes of  causation  of nervous
symptoms ;  but, when the decision has been made, in any
instance, the prognosis  is most favorable in the last case;
less so in the second; and most unfavorable in  theirs/, i.e.
when  the symptoms have their origin in an actual organic
lesion of an important nerve-centre. 
NOSOLOGY.
127
                     NOSOLOGY.

  Diseases were  by Cullen classified as locales (phleg-
masiae), pyroses, cachexiae, and neuroses (local inflamma-
tions, fevers, cachectic diseases, and nervous affections).
  The advances made in pathology since Cullen's time re-
quire some modification of this arrangement, while retaining
its principle.  I propose, therefore, that diseases be subdi-
vided as—
       Phlegmasiae:  inflammations.
       Zymoses:* zymotic diseases.
       Cachexiae:  cachectic affections.
       Neuroses:  nervous disorders.
       Ataxiae: unclassifiable diseases.
  The following list  is intended to present  only the most
important diseases of each class.
  Phlegmasiae:
       Laryngitis;                  Pericarditis;
       Tracheitis;                   Stomatitis;
       Bronchitis;                  Pharyngitis;
       Pneumonia;                  Gastritis;
       Pleurisy;                     Enteritis;
       Endocarditis;                Dysentery;
* From £u/xoa>, to ferment. 
128
MEMORANDA MEDICA.
Peritonitis;
Hepatitis;
Nephritis;
Meningitis:
Cerebritis.
Myelitis.
  Zymoses (diseases produced  by a morbid poison intro-
duced from without) :
    Not usually included as zymotic diseases—
         1. Syphilis;      "]
         2. Gonorrhoea;     t Contagious.
         3. Hydrophobia.
    Eruptive—contagious—
         1. Variola;
         2. Varioloid;
         3. Vaccinia;
         4. Varicella;
         5. Scarlatina;
         6. Rubeola.
     Contagious—not eruptive—
         1. Parotitis contagiosa (mumps);
         2. Pertussis.
     Generally epidemic or  endemic—
         1. Typhoid fever  (?);*
         2. Typhus;
         3. Puerperal  fever;
         4. Erysipelas;
         5. Plague;
         6. Cholera;
Occurring
 usually
but once.
  * The question here is intended to apply to the mode of causation of
typhoid fever;  not to its existence or distinction from typhus. 
NOSOLOGY.
       7.  Epidemic dysentery;
       8.  Influenza;
       9.  Diphtheria.
  Endemic—
       1.  Yellow fever;
       2.  Dengue.
  " Miasmatic ;" endemic—
       3.  Intermittent;
          Remittent;
          Pernicious fever.

Cachexiae:
  1.  Diatheses (general cachexiae) :
       Always chronic—
           a.  Spanaemia (anaemia);
           6. Chlorosis;
           c. Leucocythaemia;*
           d.  General dropsy;
           e. Hemorrhagic diathesis;
          /. Tuberculosis;
           g. Diabetes;
           h.  Lithiasis.
       Acute or subacute—
           a.  Scurvy;
           b. Gout;
           c. Rheumatism;
           d. Ichoraemia (pyaemia).
  * Literally, white-cell-blood;  i.e. excess of colorless corpuscles in
the blood.
                           12* 
130
MEMORANDA MEDICA.
  2.  Local cachexiae (degenerations):
           Cancer;
           Various tumors, cysts, etc.;
           Goitre ;
           Cirrhosis (of the liver);
           Bright's disease (of the kidney);
           Addison's disease (of the supra-renal capsules,
             etc.);
           Other organic degenerations.
       Skin diseases; viz.—
           Exanthemata (erythema, urticaria, roseola) ;
           Papulae (lichen, etc.) ;
           Vesiculae (eczema, etc.) ;
           Bullae (pemphigus, etc.);
           Pustulae (impetigo, etc.)  ;
           Squamae (psoriasis, etc.);
           Maculae (fuscedo, etc.);
           Hypertrophiae (elephantiasis, etc.) ;
           Tubercula (molluscum, etc.);
           Parasitici (scabies, etc.);
           Haemorrhagiae (purpura);
           Syphilid a.

Neuroses:
    Apoplexy;               Neuralgia;
    Paralysis ;               Delirium tremens ;
    Epilepsy ;                Insanity ; viz.—
    Catalepsy;                   Acute mania;
    Hysteria;                    Chronic mania ;
    Chorea;                     Monomania;
    Tetanus;                    Dementia. 
NOSOLOGY.
131
Ataxiae (unclassifiable diseases):
  Hemorrhages;                  Jaundice;
  Local dropsies (ascites, etc.);    Cholera morbus ;
  Asthma;                       Colic;
  Angina pectoris;               Diarrhoea ;
  Dyspepsia;                    Worms. 
132
MEMORANDA MEDICA.
                  ^J^JEIT  "V-

           GENERAL THERAPEUTICS.

  Remedies  have been classified, for the study of  Materia
Medica, in a  manner (see Wood's Therapeutics and Phar-
macology) which is perfectly well adapted to  the present
state of that  science.
  I propose  the following classification, from the stand-
point of the practitioner; i.e. according to the indications
of treatment, or objects proposed.
  Thus regarded, remedies may be studied as—
  Anodyne and calmative:  e.g. opium;  ether;  chloro-
form.
  Protective: e.g. demulcents;  surgical dressings.
  Balancive: e.g. cold  to an over-vascular  part;  pedi-
luvia;  blood-letting.
  Eliminative: e.g. colchicum in gout; purgatives; iodide
of potassium, etc.
  Antidotive: e.g. hydr. ox. of iron for arsenical poison-
ing ; antacids ; quininization in  intermittent.
  Alterative: e.g. nitrate of silver in scarlatinal sore throat;
arsenic in  skin diseases.
  Economic: rest; astringents;  retarders of tissue-meta-
morphosis.
  Recuperative: stimulants;  tonics;  chalybeates; oleum
aselli; travelling.
/ 
GENERAL THERAPEUTICS.
133
  An elaborate work might, of course, be written upon the
topics included in this table.  It is appropriate to our pur-
pose, only to state them;  and to dwell, for a few moments,
upon another yet more brief classification, of  the modes of
treatment most frequently called for, in the management
especially of acute and subacute affections.
   These may be designated as—
       The  antiphlogistic;
       The  febrifuge;
       The  supporting;
       The  antidotive;
       The  alterative treatment.
   Under the first head, the  antiphlogistic (i.e. the treat-
 ment of inflammation), we place—
     Rest;—position ;             Ipecacuanha ;
      Cold applications;            Veratrum viride ;
      Venesection;                 Aconite;
      Local  depletion ;              Digitalis ;
      Purgation;   .              Ergot;
      Diet;                        Mercury;
      Tartar emetic ;               Opium ;
      Nitrate of  potassa;           Counter-irritation.
   The necessity of rest during active inflammation of any
 organ is a rule without exception.
   A choice of position is often dictated by the sensations
 of the patient.  When one of the extremities is inflamed
 its  elevation is  advised, in order to allow the blood  to
 return from the overloaded vessels.
   Cold  applications  are very important in  the treatment
 not  only of  inflammation, but of  active hyperaemia  or
 congestion (e.g.  "determination of blood" to the  head). 
134
MEMORANDA MEDICA.
The two precautions most  necessary in their  use  are, that
the cold be not excessive,  and that it be not ill timed, so
as to arrest desirable perspiration.
  Blood-letting, by venesection,' leeching, and cupping, is
one of the oldest, and has  been  one of the most universal
of remedies  for inflammation.  Although " auj.o<poj[3oi," or
"blood-fearers," have  occasionally appeared  in  all  ages
and nations, yet the aggregate testimony of the profession,
from Hippocrates  down  to the  present time, has  been in
favor of the use of the lancet and of local blood-letting in
the treatment of violent inflammations and congestions.
  Now, however, it must be admitted that blood-letting has
more opponents and fewer defenders than at any previous
period in medical history.  Why is this ?   By reason of—
  1.  Reaction  from  previously existing abuse  of  the
remedy.
  2.  A change in  the average human constitution, occur-
ring under the artificial habits of civilized life.
  3.  False  construction  and misapplication of recent
science.
  4.  Leadership and fashion.
  I must briefly remark,  that  the reaction alluded to has
proceeded too far,  going from one extreme to another.
  The  change occurring especially in large cities, in the
average human constitution, affords good  reason for limit-
ing the use of  the lancet to a smaller number  of cases than
was once thought necessary ; and for using especial caution
as to the amount of blood  abstracted ;  but not for aban-
doning the remedy altogether.
  The improved condition of the sciences of semeiology
and pathology  gives us the power to discriminate more nar- 
GENERAL THERAPEUTICS.
135
rowly in our use of blood-letting, as well as of other reme-
dies.   But, we should not, for this, throw aside as  useless
all the experience of  our predecessors ; as if every new fact
was  necessarily the heir of some dead old one.  All facts,
old and new, should be retained.
   In the  physiological  and  pathological  science which
bears upon the question, I hold that false construction and
misapplication of observed facts have been operative.  An
important threefold error has been committed ; viz.—
   1.  In physiology, the denial or depreciation of the active
part taken by the arteries in the circulation;  and of the great
fact, without recognition of which  no theory of inflamma-
tion can stand, that the arteries are subject to reflex ex-
citement,__the most normal form of which constitutes active
hyperaemia, the most abnormal and exceptional, tonic con-
striction of the vessels.
   2.  The  error  of Prof. J.  H. Bennett,  of giving atten-
 tion, in regard to the  pathology of the inflammatory pro-
 cess, to the exudation alone.
   3. That of Prof. Virchow, in considering that no import-
 ant difference in  kind exists between morbid  lesions  of
 nutrition  in vascular and in non-vascular tissues ;  and that
 stimulation,  irritation, and  inflammation  are, essentially
 and practically, as  well as causatively, only degrees  of the
 same vital impression.
    The  theory of inflammation which has been already laid
 down,* as entirely consistent with the observations (what-
 ever  may have been the reasonings) of the most  accurate
 pathologists  (e.g.  Rokitansky, Paget, Wharton Jones),
* See General Pathology, Tart III. 
136              MEMORANDA MEDICA.
inculcates, that the determination  of blood toward  an in-
flamed part conspires with the central stasis in causing the
exudation ; and that a constant proportion exists between
the degree of this active turgescence and the amount of the
exudation, and the character of the changes  which  it sub-
sequently undergoes.
   Now, of the cardinal elements of the inflammatory pro-
cess, the local arrest of nutrition and capillary stasis can-
not  be directly affected by treatment.   Nor, when  the
exudation has  occurred, can any  but palliative or expect-
ant measures be applied to the management of its changes.
But, the active concentric determination of blood—the ar-
terial excitement—cannot  this be essentially modified by
treatment?  Yes.
   By abstraction of blood, we lessen (for a time at least)—
       1. The fullness  of the vessels ;
       2. The  number of red corpuscles;
       3. The  force of  the heart's impulse;
       4. The force of  the arterial impulse ;
       5. The  excitement of nerve-centres.
   And by each and all  of these influences, we diminish the
vascular excitement connected with an  inflammation;  and
thus (I repeat) lessen the amount of the  resultant exudation,
and  (Paget)  render  its  "biography" more normal, its
changes less degenerative and destructive.*
  * It may be hoped that the time has gone by when any question
in therapeutics can be decided by leadership.  But the "blood-letting
controversy" has shown, that the medical mind is not yet absolutely
free from its influence.  As to authorities, old and new, it may in-
terest the student to remember, that, of ancient opponents to the 
GENERAL THERAPEUTICS.
137
   If  this be true, it is altogether an erroneous assumption,
of  Professor  Bennett, and others, that  inflammation is  a
" self-limited  process which cannot be cut short nor  inter-
fered with  to advantage."   If there  be  anything positive
in medical experience, I  believe the contrary of  this to
have  been established.
   Thus much, perhaps, must be allowed  to the influence of
recent ratiocinations and experimentations in medical prac-
tice without the  lancet;  that  local  blood-letting may be
lancet, Chrysippus and Erasistratus were the most noted; of the
modern European schools, Van  Helmont,  Dietl, and  Skoda, in
Germany; Grisolle, in France;  Bennett and Todd, in Great  Brit-
ain.   Exemplification of Sangrado's practice, on  the contrary, has
been especially accredited to  Cullen  in England, Rasori in Italy,
Chomel and Bouillaud in France, and  Rush (the father of American
medicine) in this country.  We should place in the class of moderate
bleeders, of  antiquity, Hippocrates, Celsus,  Galen,  Avicenna, and
"J: itoXXot;" of earlier English and French teachers, Sydenham, Hux-
ham, Gregory, Laennec, etc.; of the present date, the recently deceased
Professor Alison, with Watson, Christison, Chambers, Parkes, and
others in Great Britain; Wunderlich in  Germany; and, in this country,
as a representative of American medical conservatism, Professor Wood.
As statistics  have been especially  appealed to by the opponents of
blood-letting, it may be proper to quote here the conclusion of an able
analysis of  all the evidence of this kind made public (Brit, and For.
Medico-Chirurg. Rev., July, 1858).  It is as follows:—
  "While the non-bleeding plan has a demonstrable advantage over
that of indiscriminate and repeated bleedings, we maintain that the
discriminating practice of moderate and early bleeding,  general or
local,  in cases of more or less sthenic inflammation, and  of refrain-
ing from it altogether in asthenic cases, whether  as regards the
character of the disease or the constitution of the  patient, is pressed
upon us both by experience and science."
                              13 
138
MEMORANDA MEDICA.
admitted, in almost every case, to have all the advantages
which can be claimed for venesection, except convenience;
and that, in doubtful cases, the smaller quantity abstracted
ought always  to  be an argument in favor of local rather
than general depletion.  This admission may be made with-
out surrendering, in the least degree, the principle of the-
rapeutics upon which blood-letting is scientifically justified,
and  according to which, if we are to interfere  at all with
disease, it is often one of the mildest, most beneficent, and
least hazardous of remedies.
  How, then,  it  is  proper to ask, do we define or classify
the remedial action of blood-letting ?
  It is  balancive.   What do we mean by reducing  treat-
ment f  The answer to this question is important.
  / do not  know of a single case of any kind  of disease,
in which the indication or object of medical treatment is to
reduce  the  strength, or lower the vital power of the pa-
tient's system.
  What we aim  to reduce is, disproportionate  vascular
excitement, or congestion; to restore the balance of the
circulation.   It  is a mere imagination that abstraction of
a small quantity of blood must always lower the patient's
strength.   Under  some circumstances, it actually increases
it.   At the same time, there are  many persons who will
never bear bleeding, from an actual deficiency of blood.
  Taking these  propositions as  established, we  may draw
blood, locally  or generally, for
       1.  High,  sthenic inflammation;
      2. Active congestion, threatening  inflammation or
             hemorrhage ;
      3. General plethora, ditto ; 
GENERAL THERAPEUTICS.
139
       4.  Sthenic spasm;
       5.  Sudden  passive congestion (not  toxaemic)  in
             robust persons.
  It must be remembered that, at the present time, no one
thinks of bleeding for fever, as such.
  Repeated venesections are seldom  now resorted to ;  the
time for the lancet, if at all, is always in the early stage of
a phlegmasia.
  It would  be  instructive, if compatible with our plan, to
allude farther, especially, to the use of blood-letting in cer-
tain cases of pregnancy, and of convulsions;  and to the
caution necessary in its  application to the treatment of
senile apoplexy.  We might illustrate, also, the principles
above laid  down,  by the examples  of—1, erysipelas; 2,
pneumonia; and 3, meningitis; giving reasons why bleed-
ing is seldom called for in the first, more frequently in the
second, and still more often in the last.
  As to the quantity of blood taken by venesection, f ^xij
may be stated  as a, full, though not  large, bleeding for an
adult man; f§x for a woman.  For  infants  and children,
one ounce under one year, two ounces  under three  years,
three ounces under five years, four ounces under ten  years,
would be a full average.   The practitioner should  judge
for himself  of the effect upon the pulse, etc.
   Cut cups and leeches both act alike as to the abstraction
of blood; but the former have a more revulsive or counter-
irritant effect.
   Leeching, being somewhat less violent, is more applicable
than cupping to parts which are  very tender;  as, the  side
in acute pleurisy; the abdomen in peritonitis ; a much in-
flamed joint, etc. 
140
MEMORANDA MEDICA.
   Leeches are usually, for the same reason, applied as near
 as possible to the part inflamed; cups, sometimes, at a short
 distance from it.
   In bronchitis, it is ordinarily best to apply leeches or
 cups to the upper sternal region.
   In pneumonia, they  may be preferably applied between
 the  shoulders, as a  general rule, thus leaving room for
 counter-irritation in front.
   In pleurisy, it  is desirable to use  leeches immediately
 over the inflamed part.
   Purgation, especially by saline cathartics, is a frequently
 useful part of antiphlogistic treatment.
   Cathartics are to be avoided in enteritis and peritonitis-;
 for obvious reasons.
   Diet, in cases  of  sthenic inflammation, should be non-
 stimulant; but it may be sufficiently nourishing  (vegetable,
 farinaceous)  at  the  same time.   Starving patients  is  not
 now thought of, unless they are fearfully plethoric.  In the
 later stages of inflammatory disorders—in fact,  as soon as
 the exudation has all  been thrown  out, generous diet is
 usually required.  Some patients  will never bear a purely
 vegetable diet under any circumstances; and some cases,
 even of inflammation, require stimulation from the first.
  The most powerful of antiphlogistic (arterial sedative)
 medicines is tartar emetic.
  The "contro-stimulant" plan, of giving very large doses
 of this drug in  pneumonia, pleurisy, etc., has been aban-
 doned as excessive and injurious.   We  need never give
more  than 1 of  a grain of tartar emetic  at a dose to an
adult—oftener $, J2, etc.   Children  require especial cau-
tion in its use, on account of the sensitiveness of their  ali- 
GENERAL THERAPEUTICS.
141
mentary canal.  I have  known severe  vomiting to be in-
duced in an  infant by g^ of a grain.   No other medicine
as yet discovered, however, is so useful in violent inflamma-
tions of the pleura, lungs, bronchial tubes, etc.
   Tartar  emetic (of course) must never  be given  in gas-
tritis or enteritis.
   Nitrate of potassa is a very valuable  adjunct to, or in
some cases substitute for, the antimouial tartrate.  It  is
often given in too small  doses; ten grains may be a mini-
mum for an adult, if the stomach is in an  ordinary state.
   Ipecacuanha is especially valuable in bronchial, tracheal,
and laryngeal inflammations, and in dysentery.
   Veratrum viride is, lately, assuming an important place
as a cardiac and arterial  sedative, and promoter of the se-
cretions.
   Aconite is, likewise, a favorite medicine with some prac-
titioners, in the management of pleurisy, pneumonia, etc.
   The power digitalis possesses, to reduce the action of
the heart, has induced the expectation that it  would prove
a reliable  antiphlogistic remedy; but this expectation has
been  disappointed.   It is, however, occasionally useful in
bronchitis, etc.
   Ergot has been employed with the same view, rather as
a direct sedative to the smaller arteries.  It is quite possi-
ble that its powers have not as yet been sufficiently tested.
   The place of mercury had appeared, until  within a few
years, to be  settled.  Twenty-five years  ago, nothing was
more common than intentional mercurial salivation in the
treatment of  almost all violent acute and  even chronic dis-
eases.   In the management of inflammation, in addition to
its powerful alterative influence, tending tq displace, by its
                          13* 
142
MEMORANDA MEDICA.
own impression,  morbid  actions  and  conditions, it was
believed to exert a peculiar control over the blood, lessen-
ing the tendency to the effusion of coagulable lymph.
  In  recent times, the " salivating" practice has been al-
most  entirely  abandoned, as disproportionately violent, as
well as uncertain.  A reaction, somewhat similar to that
occurring in the case of blood-letting, has even shaken the
confidence of many practitioners in the value of mercury as
an antiphlogistic.
  My own opinion, very decidedly, is this.   That experi-
ence fully warrants the inference that mercury is a general
stimulant  to all those functions of organic  life which are
performed under innervation from the ganglia of the (so-
called) sympathetic system.   It is probable that its  action
is directly upon these ganglia.  Thus, mercury tends to
diffuse and equalize secretion,* and the circulation  of the
blood, aiding, in this way, to break up local congestions
and inflammations.
   I believe  that calomel and  blue mass, etc.  have been
shown to be useful in the treatment of several of the acute
phlegmasiae.  I  do not think  that a due regard for the
principles of evidence in therapeutical science can  allow
us to put aside the proof of this, deduced from actual expe-
rience.
   Moderate doses, at the same time, are capable of  doing
 all that we can safely aim to effect with the use of mercu-
rials.   I do not  know of any variety or form of disease in
  * Very few points in practice are, for instance, so well sustained
by experience, as the familiar use of small doses of blue pill, in the
treatment of indigestion with torpor of the liver and bowels, etc. 
GENERAL THERAPEUTICS.
143
which I should, at the present moment, feel justified in in-
tentionally causing full  salivation as  a  means of medical
treatment.
  Mercury is especially contra-indicated  in the presence of
the tubercular diathesis.
  Opium, always the most reliable and potent of anodyne
medicines, has, in latter  times, assumed a more  important
position as a  remedy in  the  treatment of  inflammatory
diseases.
  Experience has warranted this,  while certain theoretical
considerations have also  been urged in regard to it.
  1. The influence of the nervous centres upon inflamma-
tion (as upon  normal nutrition, circulation, etc.), and the
intimate interconnection  of the two  portions, vegetative
and sensori-motor, of the nervous apparatus, are now more
fully recognized than formerly.
  2. Opium (morphia) is believed by some to act directly,
not only upon  the cerebro-spinal,  but  also upon  the  gan-
glionic nerve-ceZZs, as a peculiar stimulant, thus affecting the
circulation, nutrition, etc., otherwise than by mere sympathy.
  Yet,  in estimating the adaptation  of preparations  of
morphia or opium  to the  treatment  of inflammations of
important organs, in different  stages,  we must remember,
that
  Opium  is an arterial  stimulant, and  is, therefore (as a
general rule), inappropriate in the early  stage of an active
sthenic phlegmasia.
  Opium  first excites, and then oppresses the brain; in a
word, promotes determination of blood to the head, and is,
therefore, contra-indicated by an already  existing tendency
to cerebral congestion. 
144
MEMORANDA MEDICA.
  Opium  also constipates  the bowels—a fact of less im-
portance than either of the two preceding, as the consti-
pating tendency can be counteracted, if desirable, by other
medicines; while, in certain cases, it aids in the  treatment
(as in dysentery).
  In peritonitis, where the extent and visceral connections
of the tissue affected induce more rapid prostration, and
more  serious nervous irritation than in any other  phleg-
masia, opium has become  the main dependence with very
many practitioners, even from the beginning of the attack.
The same reasoning will  apply, to a somewhat less extent,
to its use in se vere cases of pleurisy and pericarditis.
  Counter-irritation is a  measure of  treatment often  of
great service, especially in  the later stages  of inflammation
(after  local or general depletion, etc.), or  in cases  unat-
tended with much vascular excitement.  In the very incipi-
ency, or rather incubation, of an inflammatory attack, i.e.
in the stage of mere irritation or congestion, counter-irri-
tation (e.g. by a sinapism) may prevent the further prog-
ress of the inflammatory process.   But, if the  stasis and
concentric hyperaemia be already developed, all  powerful
counter-irritants should be avoided (lest they prove co-irri-
tants) until the vascular disturbance has subsided.
   Counter-irritation is, usually, the most important part of
the treatment  of hyperaemaesthesia, or "chronic inflam-
mation."
   To recapitulate  the order of time, in which long recog-
nized  experience has  prescribed the  use  of the different
means now included under the term "antiphlogistic" treat-
ment :— 
GENERAL THERAPEUTICS.
145
  Supposing all* of the main remedies of this class to be
called for in a given case, we would resort first to venesec-
tion ; or,  if this  be undesirable, to cupping  or  leeching;
next, to saline purgation; then, to tartar emetic, nitrate of
potassa, ipecacuanha, veratrum viride or aconite  ; mercury
at the same time, or immediately following these  sedatives;
opium sometimes with it or them,—oftener, a little later ;
counter-irritation  by blisters, etc., last.   The  subsequent
debility, especially in  cases  of  suppurative inflammation,
may call for tonics or even stimulants, with generous diet,
etc.; while  certain cases will even require such treatment
from the first.
  The treatment of subacute or chronic  inflammation, in
external or accessible  parts, by astringents or stimulants
(e.g., nitrate of silver), does not require, in this place, ex-
tended discussion; as it usually comes under the domain
of Surgery.   One example, however, of its medical utility,
may be named—viz., the administration of nitrate of silver
(gr. £—| ter die) in chronic gastritis.   The change which
it undergoes in the intestines, when given by the  mouth,
explains the fact that the same  medicine  fails to exhibit a
similar  beneficial  influence in  chronic enteritis.   In pro-
longed dysentery, however, enemata containing this or some
analogous mineral salt, as sulphate of zinc, sulphate of cop-
per, or acetate of lead, are often very valuable remedies.
  We cannot leave the subject of the management of inflam-
matory disease without reminding  the  student of the  im-
  * Of course, this supposition, of the successive use of all of the
remedies named in this paragraph, does not, in very many cases,
need to be realized. 
146
MEMORANDA MEDICA.
portant practical difference between sthenic and  asthenic
inflammations.*
  This difference is constituted—
     1. By the  state of system of the patient affected;
     2. By the  nature of the producing cause.
  One whose constitution has been prostrated  by previous
disease, or recent excess, will have, when exposed  to the
ordinary causes of inflammation, an asthenic  attack;  i.e.
one in which, with all the local symptoms of phlogosis, the
general organic functions  are sympathetically affected
rather with depression than with excitement.
  Again,  certain  morbid poisons induce, with toxaemia,
local inflammation;  and  blood-disease (dyscrasia), arising
from various  causes, may have local inflammation  as  a
secondary effect.  In these cases the type of the inflamma-
tion is generally asthenic, and the treatment must  be modi-
fied  accordingly — depletion being avoided, or used  with
the  greatest caution, and full diet and  even stimulation
being not unfrequently called for.
  As examples of inflammations which may be either sthenic
or asthenic, I may mention erysipelas, dysentery, peritoni-
tis, pneumonia, gout.
  The first threef of these are at times epidemic;  and then
it is that the greatest number of asthenic cases is observed.
The following maxim may be considered as fully established:
  Whenever any  local  affection, as dysentery, peritonitis,

.  * Granting that all disease is debilitating (Inman), the distinction
is still valid and  important, as to the different degree of depression
produced by its different forms or types.
  f Pneumonia is also sometimes endemic or epidemic, in the form
of typhoid pneumonia.        * 
GENERAL THERAPEUTICS.
147
 catarrh or pneumonia, occurs sometimes sporadically (i.e.
 in altogether separate or independent cases) and sometimes
 endemically or epidemically (i.e. a number of cases at the
 same place and time, under a common  local or temporary
 cause), the latter cases exhibit, as a rule, the greatest ten-
 dency to  depression in their  symptoms, the  largest mor-
 tality, the least tolerance of depletory treatment, and the
 most frequent need of stimulation or support.

   By febrifuge treatment is meant, that which is proper
 during the existence of  the febrile state.    It comprises
 no violent measures of any kind.
   Remembering that the  essential phenomena of fever are,
 increased heat, especially  of the exterior of the body, dry-
 ness of its surfaces, scantiness of fluid in all the discharges,
 with actual increase in their solids, from accelerated tissue-
 metamorphosis,—our therapeutics must  be adapted to these
 conditions.  Apart from  the necessity of removing or an-
 tagonizing, if  possible, the cause of the  febrile disturbance,
 the indications are, to allay the heat and dryness of the
 surfaces of the body, tegumentary and  mucous,  and,  to
favor  the  removal of excreta, accumulated in  unusual
 amount in the blood and organs.
  For these purposes, we  may use
       Moderate laxatives;
       Saline diaphoretics;
       Cold drinks;
       Tepid ablutions.
  Of these  measures, I have no doubt of the  propriety of
the  designation of water  as  the heroic remedy, to which
the others are  merely adjuvants.  Diaphoretics will scarcely 
148
MEMORANDA MEDICA.
act at all without free imbibition of water, and the opera-
tion of laxatives is much promoted by it.  Water alone is
diaphoretic, diuretic, and laxative;  but it may be aided, to
an important degree,  in alleviating the symptoms of fever,
by the addition to it of citrate of potassa, acetate  of am-
monia, etc.
  I have already laid emphasis upon the statement, that no
one now thinks of bleeding for fever, as such.   In a much
more strict sense, pathologically speaking, than  inflamma-
tion, the febrile nisus  is self-limited, although variable in
its duration according to the cause  inducing it.  The ob-
ject of the physician is not to cut it short (jugulare), but
to conduct it safely to a critical termination.  In an equally
important practical manner, this principle applies, not only
to the management of a brief or ephemeral exacerbation
or paroxysm  of irritative  or reactive fever,  but  also to
those of longer  duration, under toxaemic (zymotic) causa-
tion : as exanthematous  (rubeolar, scarlatinal, variolous)
or continued  (typhus, typhoid) fevers.   An exception is
believed by many to  exist,  in the case of autumnal, mias-
matic, periodical  fevers:  i.e. intermittent, remittent,  and
pernicious  (congestive);  in which, interference,  by the
antidotal remedy, cinchona or its alkaloids, is considered
safe at  all times, and sometimes necessary before the sub-
sidence of fever.  But I believe this exception to be only
partial, since  the most  careful recorded  experience has
given rise  to the conclusion* that quinine is never  neces-
sary during the height of the exacerbation  of either type
of miasmatic fever, and  that  in large doses at that period

     * See Medical Statistics of United States Army, 1839-54. 
GENERAL THERAPEUTICS.
149
it  may do harm.  It is, I consider, the best practice al-
ways, in  the  treatment of autumnal remittent  (bilious)
fever, to  wait, until the febrile stage has passed its climax,
and  its symptoms have begun to decline—the urgency of
the case, and all its circumstances, then, guiding  the prac-
titioner as to how soon, as well as how largely, the special
remedy, whose interference is called for, must be introduced.
   It is a matter of general remark, that patients scarcely
ever die during the hot stage of any kind of fever.   In
the most intense form of miasmatic poisoning, called per-
nicious fever, the danger exists in the extreme depression
of the cold stage;  if fever comes  on, the patient  is com-
paratively safe for the time.

   The supporting  treatment  is that adapted to states of
prostration or debility.
   General weakness of the body (when not a congenital
defect) occurs under three forms :—
       Exhaustion;
       Depression;
       Oppression.
   We are familiar with the first, exhaustion, as  the  effect
of over-exertion, loss of sleep, deficiency of food, excessive
discharges, etc., and as following acute, or  constituting a
part of chronic disease.
   The second,  depression, is to be discriminated from ex-
haustion, as resulting, not from expenditure or waste of the
material  or forces of the body, but  from interference with
their normal activity by some disturbing cause.   To use a
mechanical illustration, exhaustion  is the running down of
                           14 
150
MEMORANDA MEDICA.
the clock; depression, the arrest of the impelling move-
ment of the weights, by which its wheels are kept in motion.
  Oppression, then, may be  compared to the obstruction of
the machinery by some foreign body, or by some mechan-
ical  disarrangement  among  the wheels, which  clogs their
action until it is removed or  corrected.
  Exhaustion and depression have their chief seat in the
nerve-central sources of dynamic force; oppression, in the
circulation of the blood, or  in some subordinate organs or
functions.
  This  distinction, however recondite  in theory it may
appear to be, is of high practical importance.   This will
be seen on consideration of the remedies used and required
in the different forms of debility.
  Supporting measures may be classified as—
       1.  Stimulant;
       2.  Analeptic (recuperative, restorative).
  Under the first head we rank the preparations of ammo-
nia and alcohol, etc., as usually employed.
  Under  the  second are included generous  diet, tonics,
chalybeates, cod-liver oil, change of air, etc.
  Now the first  of these (stimulants) are adapted espe-
cially to acute prostration or dejiression; the  second class
(analeptics), to chronic prostration or  exhaustion.  Op-
pression or counterfeit debility, generally requires neither,
being benefited by very different treatment.  A mingling or
blending of  these states is of course possible ; and then a
union of measures is  right,  to  meet  the conjoined indica-
tions.
   Oppression (simulating depression)  is every day illus-
trated  by the condition of a patient in  the early stage of 
GENERAL THERAPEUTICS.
151
any  of  even the mildest acute disorders;  as, catarrh or
bronchitis, indigestion, tonsillitis, measles, etc.   In all of
these cases, especially where fever is developing, the patient
is very weak; not only as to his muscular apparatus, but in
the performance of all the animal and  organic functions.
But  stimulation, for such a condition, in persons of ordin-
ary constitutional vigor and soundness, would be generally
inappropriate, often injurious, sometimes dangerous.
  A more serious  degree of  oppression  occurs in some
cases of visceral congestion,  particularly of the lungs or
brain ; and in violent spasmodic affections of the alimentary
canal, with constipation of the bowels.   Uraemia, from in-
action of the kidneys, presents another case of oppression,
in which even a fatal result may occur.
  Counterfeit debility or oppression, then, to recapitulate,
may occur in—
       The first stage of all acute diseases;
       The febrile state ;
       Indigestion  or dyspepsia;
       Congestion of the brain, lungs, etc.
       Obstruction of the bowels ;
       Uraemia.
  The first of these instances is  to be  treated usually by
measures which promote reaction in  the mildest manner.
More  doubt  exists,  however,  if  the cold  stage itself be
intense or profound—as  in pernicious intermittent—consti-
tuting a depression, under toxaemic influence.   Of this,  a
word or two presently.
  The febrile oppression is to be managed simply by those
palliative measures mentioned already under  the  head of
febrifuge treatment. 
152
MEMORANDA MEDICA.
   That of indigestion is usually temporary or occasional
only;  and gives way under  the use  of  antacids, carmina-
tives, blue pill, etc.
   Violent congestion of  the brain or lungs, occurring in a
person of previously good constitutional strength (although
it may produce the most absolute debility, which, especially
in the case of pulmonary congestion, masks the cause of
the disorder), calls, if the diagnosis  be  clear, for counter-
irritation and the local  or general abstraction of  blood.
In doubtful cases a  tentative  plan may be pursued:  ab-
stracting but a minimum  quantity at first, being encouraged
to repeat and enlarge the depletion only if the result  be
favorable.
   Constipation, producing oppressive debility, is of course
to be met by agents calculated to unload the bowels; anti-
spasmodics, anodynes, etc. being  also  indicated, if colic
exist, and be not relieved by laxatives alone.  In absolute
(mechanical) obstruction of the bowels, causing or endan-
gering enteritis  or strangulation, the treatment, now gene-
rally adopted, is, to depend upon opium and rest, avoiding
purgatives.
   Uraemia demands all the means within our power to re-
store  the action of the kidneys; and to aid them in their
eliminating duty by favoring the  cutaneous transpiration
and secretion.
   I have already said  that mixed cases of  oppression and
depression occur, in which the indications of treatment are,
to a certain extent, obscure and  doubtful.   Such are, the
cold stage of pernicious (congestive)  intermittent, the inci-
piency of the algid or collapsed stage of epidemic cholera,
etc. 
GENERAL THERAPEUTICS.
153
  It is clear  that  reaction is here to be brought  about, if
possible ;  and that external stimulation, by powerful rube-
facients,  frictions,  etc.,  is  altogether  appropriate;  but,
however  authoritatively rules may have been laid down, it
is not so  certain, in every case, whether alcoholic stimula-
tion or venesection would  afford the better result, or whe-
ther some cases might not be benefited by both combined.
The incompatibility supposed to exist between blood-letting
and stimulation is in fact not intrinsic,  but circumstantial.
Holding distinctly in our minds the principle that the object
of blood-letting is to balance the quantity, consistency, and
distribution of the blood, and not to reduce the strength of
the patient, it is far from impossible that the balancive ac ■
tion especially of local blood-letting may be called for in a
case in which the forces require to be sustained at the same
time by "supporting treatment."
  Personal experience, however, is indispensable to the ap-
plication of these, or any analogous principles, to cases, in
regard to the management of which the  profession has been,
but we may hope will not always be, divided.
  Depression is exemplified in the state produced by—
     Severe injuries;  e.g. railroad accidents;  extensive
         burns, etc.
     Mental shocks;  e.g. terror or great grief.
     Withdrawal of accustomed stimulation; e.g. delirium
         cum tremore.*
     Intense  toxaemia;  e.g.  cholera  collapse, etc. (see
         above).
     Gouty spasm, of  the heart or stomach, etc.

  * It is not intended, of course, to indicate that all cases of delirium
tremens are referable to this cause.
                           14* 
154
MEMORANDA MEDICA.
   Stimulation by alcohol, ammonia, ether, opium, camphor,
turpentine, capsicum, etc.  is needed, with greater or  less
urgency, and in larger or smaller doses, in all of these con-
ditions ;  always bearing in mind the probability of reac-
tion, and avoiding, as far  as possible, the exaggeration of
this reaction into fever.
   The prostration of typhus fever, in a  majority of cases
(not in  all), and  that  of  typhoid fever, in  a minority of
cases, requires, especially after the height of the fever has
passed, alcoholic stimulation, as well as support by concen-
trated liquid nutriment at short intervals.
   The instance of these fevers affords us a sort of inter-
mediate  gradation  between what I have  called  acute  and
chronic debility.
   In  regard to the latter (the  debility  of  convalescence,
chronic disease, etc.), certain principles  are agreed upon
by all  physicians, on the ground of experience, confirmed
by the deductions of physiological science.   We shall first
briefly consider some of these, and then  one or two debat-
able points akin to those already alluded  to.
   The two most important and familiar  results of clinical
experience in  the  treatment  of debility, are,  the superi-
ority  of  the pure  vegetable  bitters  in stomachic  and
digestive  weakness,  and of iron in anaemia (spanaemia).
The influence of quinia  and  cinchonia in nervous  debility
is  almost as  assured.  The confidence of many physicians
is  strong in the utility of the mineral tonics (zinc, copper,
arsenic, and silver salts)* in debility with nervous symp-
  * Bromide of potassium promises to assume a somewhat import-
ant place in this list. 
GENERAL THERAPEUTICS.
155
toms;  e.g. chorea, hysteria, etc.   I  believe this confidence
to be deserved, to a considerable extent; but, some of the
diseases in which these medicines are given (e.g. epilepsy)
will, in many instances, baffle all treatment.  The use of
strychnia in certain cases of paralysis is also well estab-
lished; although requiring much care and discrimination.
  Cod-liver oil holds, at the  present time, a very high place
in the  list of analeptics.  All medical observers are not of
one opinion in regard to its value; but most of them believe
it (on the basis of experience in practice) to be the best and
most reliable (where  it is tolerated) of  all  recuperative
medicines;  not only in consumption, but in all other wast-
ing diseases.
  The theory of the mode of action of cod-liver oil as an
analeptic  is an interesting subject.   Dr.  Bennett's view of
phthisis is, that the error of haematosis, from which tubercle
results, consists in an excess  of albumen in the blood, with
a deficiency of oil; so that, in the process of cell-forma-
tion, the first step of  which  is believed (Ascherson) to be
the investment of oil globules in  albuminous envelopes, an
imperfection exists, fatal to the subsequent development of
the cell and obliging  it to abort.   But, the debilitation of
the digestive and assimilative functions in phthisis renders
it impossible, by ordinary food, to supply the desiderated
oleaginous matter to the blood.  Cod-liver oil is fatty mat-
ter which, by the assimilating action of the liver, following
the  process of digestion, is  prepared for immediate ab-
sorption and appropriation  by  the  blood, for purposes of
nutrition.   This rationale of its  influence is, although not
demonstrable, much more probably correct than that which 
156
MEMORANDA MEDICA.
 refers it to the  presence  of  iodine, phosphorus, or  any
 other special ingredient which it may contain.
   The  phosphates and hypophosphites have  of  late at-
 tracted a great  deal  of attention.   I do not consider the
 question at all settled, as yet, as to their value ; and do not
 feel competent to pronounce  an opinion  upon  them.   My
 impression, however, is, that the phosphate of iron is the
 best of them all, and that they will be found secondary and
 inferior to cod-liver oil.  Allusion to the newly introduced
 dog-fish oil, shark  oil, etc., would  be  more proper in con-
 nection with the  subject of materia medica than here.
   What is the proper place of alcoholic beverages or prep-
 arations in the treatment of chronic debility, such  as that
 of phthisis, etc.?
   This  important  question opens  a discussion, only  the
 main  elements of which can be noticed in this work.
   In  the first place, the theory of the action of agents called
 stimulants  is almost universally  mis-stated in authoritative
 treatises.   It is commonly laid down that " one  of the laws
 of all stimulation, whatever may be its degree, is, that it is
 followed by a depression  proportionate, at least approxi-
 mately, to  the previous exaltation of the function  or func-
 tions  excited."
   The true law is this : that all stimulation which is exces-
 sive  is followed  by a depression corresponding to  the
 excess ;  while all that merely excites any function up to
par (to use a familiar expression), i.e. to or toward  its nor-
 mal activity,  does, so  far, only good, with no resulting
 debilitation, however  it may fail, from want of other condi-
 tions, to sustain the organ  or system at the point desired.
 To deny this, would be to ignore some of the most  obvious 
GENERAL THERAPEUTICS.
157
of physiological facts. Heat is a stimulant in the life force;
oxygen to all the active  functions ; blood is an excitant as
well as food to all the tissues it reaches ; and all  those  im-
pressions upon the exterior of the body which give rise to
instinctive and automatic actions are stimulant, without any
necessary ulterior  depression.  Nor do I see how the use of
stimulants in  any supposable case of disease could  be ra-
tionally justified, if we practically admitted the force of the
law as commonly stated; since if, after every dose of an ex-
citant, the patient sinks as  far below the condition for which
he was treated, as the intended remedy raised him for the
moment above it,  of  course a mere oscillation, and no ad-
vantage, must be the  result.
   This, however, is theory; which has not governed  prac-
tice  on this  subject.    Another  interesting  physiological
question—" does alcohol contribute to the material, or to
the force of the economy, or only excite some of its organs
to exhaustive  action?"—has been the  topic of able and
learned disquisitions.   I venture merely the opinion that it
may do either of the three, or neither, according to  the
circumstances  and  the quantity of its administration.
When there is scarcity of food, or difficulty of  digestion,
alcohol may contribute to the needed material;  its carbon,
hydrogen, and oxygen going to repair the adipose tissue at
least.  When  there is excessive exertion, alcohol may sus-
tain the  flagging  forces of the system.   When given in
mere excess,  as with the intemperate,  it excites to  ex-
haustive  action,  organic if not motor;  even  when  the
bloated body  shows  increase in quantity of material, its
quality being  more or less  degenerate.
   In a word, then, the phrase " accessory food" is a happy 
158
MEMORANDA MEDICA.
one.  When  unnecessary,  as  in full  health, alcohol is
injurious precisely in proportion to the quantity used ;  and
the same is true in disease, when  the quantity given is  dis-
proportionate.
  This is the important practical  precept.  Alcoholic stim-
ulus should never be taken in quantities which produce cir-
culatory or cerebro-nervous disturbance or swper-excitation.
If this rule be observed, not only will it be a valuable sup-
porting agent  in phthisis and other  complaints,  but no
dipsomania (methomania) or morbid thirst for it will arise;
that terrible disease always growing out of excess.   Upon
this principle, in the use of  alcoholic beverages in cases of
ordinary debility, the common table  doses are, medically
speaking, too large.
  Alcohol, in advanced or advancing consumption, in low
fever, and in other analogous cases, when used in due pro-
portion, is useful—
  1. By its direct excitant and supporting power.
  2. By aiding the  enfeebled  stomach  to digest a larger
supply of food.
  3. By tending to retard tissue-metamorphosis.
  This  last action is one which  alcohol has been shown
(Bocker, Hammond) to have, in common with other agents,
used as medicines or luxuries;  coffee, tea, morphia, quinia,
etc.  I  have alluded to it in our  classification of remedies,
under the head "economic medicines."
  We  must  not dismiss  the  subject of the  treatment of
chronic debility without one further remark,  upon the im-
portance of rest in cases of exhaustion from over-exertion.
The popular  truism, that exercise is beneficial to health, 
GENERAL THERAPEUTICS.
159
has been often abused by applying it almost universally to
invalids or valetudinarians.
   The one remedy for the immediate effects of over-exer-
tion is absolute and prolonged repose.
   The time required for recuperation, after cerebral over-
fatigue, may  be counted rather by months than weeks or
days ;  and it is quite possible for  irreparable mischief to
be done to the brain or spinal marrow by neglecting too
long the demand of nature  for rest. With many others, the
author must  acknowledge indebtedness  to Professor Jack-
son, of the University of  Pennsylvania, for the  judicious
emphasis of his teaching upon this point.
   It is an important hygienic and  therapeutic law, that ex-
ercise, to be beneficial, must be proportioned to the strength
of the individual; and must  never be carried to the extent
of actual fatigue or temporary exhaustion.

   Antidotal  treatment is a topic of great interest.  Its idea
is probably the oldest in medicine.  Specifics always have
been  looked upon as the magna bona  of therapeutical
science.   Unfortunately, however, their number, instead of
increasing, has diminished under the inexorable scrutiny of
modern investigation.   Yet, there is room for  hope that
they may again positively increase, with the diligent appli-
cation of the same means of  observation and discovery.
   In the largest extension  of the term, antidotive remedies
may be classified thus :—
   Positive antidotes:
       Chemical palliatives;
              Antacids;
              Antilithics. 
160
MEMORANDA MEDICA.
       Chemical antidotes;
              Antitoxics.
       Anthelmintics;
       Antipsorics.
   Constructive antidotes:
       Anti-periodics ;
       Anti-syphilitic s ;
       Anti-scorbutics.
   Tentative antidotal remedies:
       Anti-arthritic s;
       Anti-rheumatics;
       Anti-zymotics.
   The familiar use of antacids as palliatives in dyspepsia,
etc., needs no remark.
   Nor have we occasion  to dwell, here, upon anti-lithics;
i.e. solvents for urinary solids, prescribed on chemical prin-
ciples;  as, alkalies for excess of uric  acid  or the  urates,
mineral acids for excess of phosphates  or oxalates.
   The subject  of chemical antidotes for poisons belongs to
Toxicology.
   Anthelmintics are best treated  of in the department of
Special  Therapeutics.
   Anti-psorics, or specific remedies for scabies (itch), are
represented generally  by sulphur;  which, although  not at
all the  only agent capable  of  destroying the  morbific
acarus, is the most convenient.   Other cutaneous  parasites
(nosophyta) are also destroyed, but with less certainty, by
preparations of mercury, etc.
   Of "constructive antidotes," the most important are the
alkaloids of cinchona, applied  to the  treatment  of mias-
matic affections (anti-periodics).  Medical men are divided 
GENERAL THERAPEUTICS.
161
upon the question whether quinia arrests intermittent fever,
etc., by antagonizing  (chemically)  the miasmatic  poison
itself in the system, or (physiologically) by causing such
an opposite impression upon the nervous centres as is capa-
ble of subverting the condition on which the periodical or
paroxysmal affection depends.   The last is the prevailing
view.   But, in  either aspect, the cure of autumnal fevers
and  allied  affections  occurring under miasmatic influence
(neuralgias, etc.) by cinchonization,  is properly called spe-
cific treatment;  as—
   1. No other  remedies  (yet  discovered) have the same
power.
   2. These remedies have no such control over any other
diseases (e.g. typhus and typhoid fever, yellow fever).
   The  second proposition  is  asserted with positiveness,
notwithstanding the experimental use of quinine in full
doses, by a few practitioners, in typhus and typhoid fever,
and its frequent  administration in yellow fever.
   In stating  that no other medicines, yet discovered, have
the same power,  I mean, to a degree or with a certainty at all
comparable to that of the cinchonic alkaloids.  The nearest
approach to this is  afforded by arsenic.
   It is, however, a remarkable and  important  fact, that,
when the recurrence of the paroxysms of intermittent fever
has been allowed for a long period (chronic intermittent),
and the system of the patient has become debilitated and
anaemic, quinine will only interrupt, but will not cure the
disease.   Iron is, then, the remedy.
   Opinion  is  divided as to the value or necessity of mer-
cury as an  anti-syphilitic.  In the primary disease, I am a
                           15 
162
MEMORANDA MEDICA.
full believer in its importance;  against which its frequent
abuse furnishes  no  argument.   In  secondary  syphilitic
affections, especially syphilitic  rheumatism, iodide of po-
tassium exhibits decidedly specific powers.
  Anti-scorbutics  are most valuable as preventives  of
scurvy;  but will promptly relieve it, also, when it  has oc-
curred.   All fresh vegetables belong prominently to this
class ; certain plants not so used, as the cactus opuntia, are
included in  it; the juice of lemons, limes, etc , is of service
for the same end, and the neutral salts of  potassa have been
largely  employed, with variable results.
  Tentative antidotal treatment,—for diseases  in which
there  is  evidently (as a part at  least, if not the primary
part  of the  malady)  humoral  disorder,  such  as gout,
rheumatism, the exanthemata, etc.,—affords a large field for
study and ratiocination.   The  positive facts,  so far,  are
few ;  the hypotheses, legion.
   In  gout, colchicum  has long  held, deservedly,  the
first place, as either  an eliminative  or antidotal remedy.
Most  observers have  given it the first title;* Dr. Garrod's
experiments induce him to prefer the  idea, if not the phrase
of the latter.  Alkaline  salts of organic acids, as bicar-
bonate of soda, or bicarbonate  of potassa,  or tartrate of
potassa and soda, and the alkaline earth, magnesia, have
also a large  share of confidence in the treatment of gout.
After all, however, so incomplete is any curative plan as
  * Colchicum has been shown, by Krahmer and Hammond, (Pro-
ceedings of Biological Department of Acad, of JYat. Sciences of Philadel-
phia, Nov. 1st, 1858,) to increase the amount of the solids of the urine,
more decidedly than any other vegetable diuretic. 
GENERAL  THERAPEUTICS.
163
yet devised, that  a large margin is left for  patience and
opium.
   The same is true of rheumatism; especially in its dis-
tinctive form, of acute articular rheumatism,  or rheumatic
fever.  Colchicum is here also much  given ;  but in the ab-
sence of the gouty diathesis* hereditary or acquired, it will
generally disappoint.   Alkaline salts  are, at the  present
moment,  the favorite  tentative  anti-rheumatics.   Lemon-
juice has been freely employed  by some  practitioners.
Phosphate of  ammonia  was  for  a  brief time in vogue.
Calomel  and opium are the reliance of many.  Certain en-
feebled cases,  with free  perspiration,  will recover speedily
under quininization.   But  in all these modes of treatment
 there is  no specific certainty.  The  attack  will  last from
 one  or two to six or eight weeks with all.  In  chronic
 rheumatism we resort, with the  same hope, to guaiacum,
 spirits of turpentine, iodide  of potassium,  cod-liver  oil;
 but  often our hope is much lengthened out.  Of propy-
 lamin, a remedy for  rheumatism imported not long since,
 I have had no experience, and have no basis  for an opinion.
  * Garrod insists on the diagnostic importance of the uric acid test
for  gout.  It is easily applied, as follows: Take about f^jss of the
serum from a blister,  or from the blood drawn by venesection or
cupping, and place it  in a flat dish or watch-glass.  Add to this
fifteen drops of acetic acid, and place in it two or three threads of
cotton.  Allow the  glass to stand in a warm room  for  one or two
days, to evaporate.  If the cotton-fibres be then removed and ex-
amined microscopically with an inch object-glass, they will be found,
if the serum contained uric acid, to be covered  with its crystals,
arranged somewhat as the crystals of sugar-candy form on a string. 
164
MEMORANDA MEDICA.
The search for  and trial of such remedies is, however, cer-
tainly altogether legitimate.
  In the management of the zymotic affections, the only
great triumph of  medical art has  been one  of prevention.
Vaccination affords an instance of effectual control over one
of the most destructive and loathsome of pestilences, by the
interference of  the physician.   As to the treatment, even
of  small-pox itself, when it has  occurred,  and of scarlet
fever, measles, chicken-pox, hooping-cough, and mumps, we
are forced to confess  our powerlessness, except to conduct
the case, by the aid of palliative measures, to its  natural
and spontaneous termination.
  This  is equally true of yellow fever.   There is  no spe-
cific yet known for this terrible disease.  Quinine, mercury,
etc. have failed in the hour of need too  often to be relied
upon.   It is to be palliated, as it cannot be cut short.
  Nor have we any specific for epidemic cholera.   Anti-
spasmodics, at  very  short intervals of administration, and
ice, with free external stimulation, will conduct many cases
to a successful  close; but this is not  antidotal treatment.
I am fully satisfied that  calomel, in true epidemic cholera,
is altogether useless.
  In the medication of zymotic affections having, as a local
symptom, inflammation of the mucous membranes, with un-
usual tendency to (septic) decomposition or disorganiza-
tion,—e.g. scarlatina and diphtheria,—chlorate of potassa
and other preparations of chlorine, as tincture of chloride
of iron, have achieved recently a very wide-spread  reputa-
tion.
  The last-named of these medicines, the tincture  of the 
GENERAL  THERAPEUTICS.             165
chloride  of iron, appears  also to have  an excellent effect
(although we  can hardly call it antidotal) in asthenic ery-
sipelas.
  En resume, we may say that  all endemic, epidemic, in-
fectious, and contagious diseases  are naturally self-limited;
and that, so far, we have only reached a curative treatment
for one class,—viz. intermittent, remittent, and pernicious
(classed together as miasmatic) fevers; and a preventive
treatment for another, small-pox.
  While,  therefore, for yellow fever, scarlatina, pertussis,
etc., we are without the possession of any specific or anti-
dotal treatment, the  palliative  plan is the one for us to
pursue.  All  attempts,  by violent measures, to cut short
either of these diseases, while they fail to attain that object,
will endanger the patient,  by lowering his forces, and thus
promoting the victory of the depressive toxaemic cause.
  Yet, I repeat,  we are not to abandon or reject the hope
that observation  and  cautious  experiment, guided by the
lights of advancing science, will enable us hereafter to dis-
cover remedies as potent in the management and control of
scarlet fever,  yellow fever,  and cholera,  as  quinine is in
that of ague, or vaccination in the prevention or  salutary
modification of small-pox.

  Alterative treatment is distinguished, in our classification,
it may seem arbitrarily, from the antidotive.  All antidotes
may be said to be alterative,  but  all alterative medicines
are not antidotal; as the latter expression implies at least
the probable, if not the  known existence  of a material
cause, against which the antidote  is to  act.  Yet  the dis- 
166
MEMORANDA MEDICA.
tinction is not one upon which we can insist, although it
appears convenient.
  The term alterative is by no  means a mere  apology for
ignorance; it involves an important therapeutical principle;
viz., the supplanting or displacing of a morbid impression,
condition, or process in the body, by the  safer  impression
and counteraction of a medicinal agent.   The influence of
the latter, physiologically speaking, may be, per se, abnor-
mal; yet,  having a sanative purpose, it is therapeutic.
  This principle may be sufficiently illustrated  by allusion
to two or  three examples.  In the peculiar and often vio-
lent  inflammation of the throat in scarlatina, or in that of
diphtheria,  the  free  application of a  strong  solution  of
nitrate of silver to  the part will almost invariably arrest
(if used early)  the morbid process : converting  it, at all
events, from a specific and dangerous into  a simple and
mild phlogosis.
   So will the powerful impression of the solid nitrate of
silver, or  other caustic, upon the  surface of the penis
affected with chancre, supplant the venereal process, and
leave in its  place a benignant ulcer.
   When erysipelatous inflammation is spreading like a con-
flagration from part to part, a blister, or tincture of iodine,
etc., will  form  a cordon  sanitaire,  by inducing  its own
milder irritation in advance of the disease.
   The  most  essential  part  of the treatment  of chronic
diseases  of the skin, is  either alterative or antidotal.
Parasitic affections,  as scabies, favus, mentagra,  etc., re-
quire  the destruction of the epizoon  or epiphyte by  an
antidote.   Others, as  eczema, lichen, impetigo, lepra, etc., 
GENERAL THERAPEUTICS.
167
when at all  obstinate, are treated in the same manner
essentially, to  whichever class  the disease  may belong.
Why ?  Because the  principle is the  same in all—the
alterative principle.   The abnormal, perverted nutrition of
the cutaneous tissue, whether it be deeply or superficially
affected, is (apart from antiphlogistic or sedative treatment,
called  for in  some cases) to be subverted, by a decisive
change in all its conditions;  and, speaking boldly, it is
little matter  what  change, so it  be  considerable.   Any
means which will hurry the removal of the old, diseased skin,
and favor the  immediate construction of a new layer, will
be  curative, whether it be  only soap,  water  and frictions,
mercurial ointment, vesication, or the actual cautery.  And
the same  principle  explains and justifies the internal use
of  arsenic and mercury in the management of so many
very diverse forms of cutaneous disease—the indication for
alterative medication being the same in all.
   The administration, for long periods, of minute doses of
powerful  alterative medicines, in the treatment of chronic
affections which resist other management, is. less common
now than formerly, on account of the explosion of  some
old hypotheses connected with it.   It  is very possible that
in this, as in some other medical reforms, we may have gone
too far.
   Agents which  tend with any degree of constancy to in-
crease the rate of metamorphosis of tissue in the body, are
few.  It is well known that most of the diuretics given for
the removal  of dropsical accumulations, increase only the
fluid secretion of the kidneys, affecting little or  not at all
their solid excreta.   But there is  good  reason  to believe 
168
MEMORANDA MEDICA.
 that potassa and  soda, and  some of their compounds, as
 well as iodine and mercury, do hasten the disintegration of
 tissue.  Iodide of potassium has been  shown, by Melsens,
 to be in this way eliminative of lead, laid up in some organ
 (probably the liver), removing it in the shape of iodide of
 lead.
   If any possible  measures, beyond  attention to hygiene
 and repose, can benefit cases of organic degeneration, we
 might  hope for  advantage from the combination of tonics
 or  analeptics  with alteratives.  Dr. Chambers (on Diges-
 tion and its Derangements) remarks thus :—
   " In  Bright's disease I know of no treatment so advan-
 tageous as  that which unites alteratives (that is, liquefa-
 cients  of tissue) with those restorers of blood par excel-
 lence,  iron and animal food."
  Iodide of iron,  or iodide of potassium at the same time
 with cod-liver oil, may afford an example of this  sort of
 medication in its simplest form.  Its object is, to favor the
 rapid  removal  of  old  tissue, and the formation of good
 new structure in its place.
  At the same time, we must not encourage sanguine hopes
 in any  instance of organic degeneration, the origin of which
 is, so generally,  to be  found in a failure of systemic vital
 power.  The physician will do much for his patient, if he
 can persuade and  instruct him to adapt his living  to the
 actual  condition of his physical resources, so that, whether
 his  malady be Bright's disease of the kidney, cirrhosis of
the liver, or fatty  degeneration or other organic lesion of
the heart, he may economize both the  material and the
force of his  system, by  such a regimen of diet, exercise, and
excitement, as his state requires. 
GENERAL THERAPEUTICS.
169
  Nor need we look upon the failure of medicine to arrest
the process of organic degeneration as  a subject of very
humiliating discouragement.  As death is the natural re-
sult of life, in the human organism as in every other mate-
rial form,  this partial  death occurs, also, under physio-
logical laws ; and, if it be premature in certain instances,
we may believe  that this, too, may be traced to a near or
remote causation,  in  perfect harmony  with the highest
interests, moral as well  as physical, of man.


   The  following may,  in  recapitulation, be  stated to be
the most  general  desiderata in the  management  of  all
diseases:—

    Rest;
         a, in all acute diseases;
         b, in all cases of exhaustion.
    Balance;
         a, of the fluids, and solids;
         b, of the activity of functions.
     Normal blood-change;
         a, due removal of excretions;
         b, absence of  morbid poisons.
     Support;
         a, in all asthenic cases;
         o, in later stages of sthenic cases.
                           16 
170
CONCLUDING MAXIMS.
           CONCLUDING  MAXIMS.

  1. All pathology is but the physiology of organic per-
turbations.
  2. Never  interfere actively in disease without a distinct
object.
  3. Act only upon scientific reason, or well-defined expe-
rience.
  4. Treat the cause  of disease whenever it is possible.
  5. Watch always, and  treat when requisite,  the condi-
tion of the patient.
  6. Avoid, especially, routine treatment according to the
names of diseases.
  7. Use no violence with self-limited diseases.
  I believe that a sound "theory of medicine" may be ex-
pressed in a single paragraph, thus :—
  Physiological optimism is the aggregate tendency of all
the forces of the  living  organism, under  the controlling
influence of  the vital force.  But, the best possible result
in a given case may, from its conditions and circumstances,
fall far  short of health.  Medicine, then, is  to favor or
supply those conditions which, under natural laws, allow
or promote the best result.
  In  aiming to fulfil  this duty, the art of healing  must
always depend, in part, upon empirical observation (which
every branch of knowledge requires), and in part upon in-
ductive  science.   But in both alike, the physician is, or
should be, "naturae minister el interpres." 
GLOSSARY. 
 
GLOSSARY.
                             A

Abnormal.  Unnatural, irregular, unhealthy.
Abrasion.  Removal of a portion of skin, by violence  or ulcer-
     ation.
Acclimatize.  To inure to a new climate.
Acinesia.  Loss of muscular power.
Acne.  A pustular disease of the skin, involving the sebaceous
     follicles.
Acute.  Active, recent, of brief duration.
Addison's Disease.  Bronzing of the skin, with debility, and de-
     generation of the supra-renal capsules.
Adenoid.  Glandular, or gland-like.
Adipose.  Fatty.
Adynamic.  Prostrate; without power.
JEgophony.  Goat-like or bleating sound of the voice,  heard on
     auscultation.
Afflux.   Flow toward a part.
Albinism.  Loss of natural pigment, causing whiteness, e.g. in
     the negro.
Albuminuria.  The presence of albumen in the urine.
Algid.  Cold.
Alopecia.  Baldness; loss of hair.
Amaurosis.  Partial or  total blindness from an  affection of the
    retina, optic nerve, or brain ;  i.e. nervous blindness.
Amblyopia.  Dim, or obscure vision.
Amenorrhcea.  Absence or arrest of menstruation.
Amorphous.  Shapeless ; without definite form.
Amphoric. Pitcher-like, or  decanter-like.  Applied to sounds
    heard by auscultation or on percussion.
Amyloid.  Resembling starch.
                           16*              (173) 
174                      GLOSSARY.
Ancemia.  Deficiency of red blood.
Anceesthesia.  Absence or loss of sensation and perception.
Analeptic.   Invigorating, restorative.
Anasarca.  General dropsy of the areolar tissue.
Aneurism.  Morbid dilatation of an artery, with or without rup-
    ture of its coats.
Anfractuous.  Having an irregular, grooved, or broken surface;
    applied to a cavity in the lung.
Angina.  A choking or suffocating disease.
Angina Pectoris.   A paroxysmal affection, with great pain and
    distress about the heart, and difficulty of breathing.
Anodyne.   Tending to relieve pain.
Anorexia.  Loss of appetite.
Anthelmintic.  Destructive of, or tending  to  cause the removal
     of, worms.
Anti-arthritic.  Curative of gout.
Anti-lithic.  Solvent of stone or gravel.
Anti-phlogistic.  Tending to arrest or mitigate inflammation.
Anti-psoric.  Curative of itch.
Anti-toxic.  Antidotal to poison.
Apex.  The uppermost point.
Aphonia.   Loss of voice.
Aphtha;.  Small whitish ulcers, originating in vesicles; frequently
     found in the mouth, especially in children.
Aplastic.  Inorganizable.
Apncea.  Arrest of respiration.
Applicata.  Things applied to, or brought into contact with, the
     exterior of the body.
Apyrexia.  Intermission.
Arachnitis.   Inflammation of the arachnoid membrane.
Arcus senilis.   Opacity of the outer circle of the cornea, in old
     people, from fatty degeneration.
Arthritis.  Gout.
 Ascarides.  Round worms.
 Ascites.  Peritoneal dropsy.
 Asphyxia.  Suspension of breathing, or of the aeration or cir-
     culation of the blood.
 Asthenia.  Debility.
 Asthenic.   Without strength ; feeble ; attended by prostration.
 Ataxic.  Irregular; cut of order. 
GLOSSARY.
175
Atelectasis Pulmonum.  Imperfect expansion of the lungs.
Atheroma.  A pulp-like or pap-like formation or degeneration.
Atony.  Loss of tone.
Atrophy.   Absence or defect of nutrition.

                             B
Balancive.   Promotive or restorative of balance, proportion,
     harmony.
Biology.   The science  of life,  and of the functions of living
     beings.
Blastema.  Material out of which tissue is or may be organized.
Bleb.   See Bulla.
Borborygmus.  Intestinal gurgling.
Bright's Disease.  Fatty or other degeneration of the kidney.
Bronchocele.   See Goitre.
Bronchophony.  Resonance of  the  voice, in the lung, like that
     normally heard in the bronchial region.
Bronchorrhea. Excessive discharge of mucus from the bronchial
     tubes.
Bulimia, Boulimia.   Excessive appetite.
Bulla.   A blister; i.e. an elevation of the cuticle, containing
     serum.

                              C

 Cachexia.  A depraved or diseased habit of system.
 Cadaveric.  Belonging to the dead body.
 Calcareous.  Containing or resembling chalk or lime.
 Calculus.  Stone.
 Calvaria.  The cranium.
 Carcinoma.   Cancer.
 Cardialgia.   Heart-burn.
 Catalepsy.  A nervous affection, characterized by  paroxysmal
     rigidity of the muscles.
 Catarrh.  An affection of a mucous membrane, characterized by
     increased secretion.
 Cavernous.  Connected with or indicative of a cavity.
 Cephalalgia.  Headache.
 Cerebritis.  Inflammation of the  brain.
 Chalybeate.   Containing iron.
 Chloasma.  Liver-spot; a yellow discoloration of  the skin. 
176
GLOSSARY.
  Chlorosis.  "Green sickness;" a cachexia peculiar to young woman.
  Cholagogue.   Tending to increase the flow of bile.
  Chondroma.  A cartilaginous tumor.
  Chorea.   St. Yitus' dance.
  Chronic.  Protracted; continuing, without  much change, for a
     considerable period.
  Cinchonism.   The production of the characteristic effects of Pe-
     ruvian bark, or of its alkaloids, upon the system.
  Circumfusa.   Things surrounding  the  body:  e.g. air,  light.
     moisture, etc.
  Cirrhosis.  Waxy degeneration of the liver.
  Clavus.  A corn.
 Clonic.  Successive, interrupted, alternating.
 Colica pictonum.  Lead colic.
 Colliquative.   Copious, exhaustive.
 Colloid.  Jelly-like.
 Coma.  Completely unconscious stupor.
 Congenital.  Existing at the time of  birth.
 Congestion.  Accumulation of blood.
 Consonance.  Repetition or reduplication of sound, by the sono-
     rous vibration of a body upon which it impinges.
 Contactive.  Contagious.
 Contagious.  Conveyed by touch or actual contact.
 Contra-indicate.   To prohibit.
 Contro-stimulant.  Sedative.
 Corneitis.  Inflammation of the cornea.
 Coryza.  A cold in the head.
 Cosmic.  Belonging to the universal system or order of nature.
 Coup de soleil.   Sun-stroke.
 Coxalgia.  Disease of the hip-joint.
 Crepitant.   Crackling; applied technically to the fine crackling
    heard on auscultation in pneumonia.
 Cretify.  To convert into a chalky substance.
 Crusta lactca.  Milk crust; a cutaneous disease of infancy.
 Cutaneous.  Pertaining to  the skin.
 Cyanosis.  Blueness, from imperfect circulation or aeration of the
    blood.
Cynanche.   Angina.
Cyst.   A sac, cell, or bag,  formed of membrane, and  containing
    more or less fluid.
Cystitis.  Inflammation of the urinary bladder. 
GLOSSARY.                     177
                              D
 Decubitus.  The manner of lying down.
 Decussation.   Crossing, X-like, from side to side.
 Dementia.  Total loss of reason.
 Dengue.  " Break-bone fever" of the West Indies and Southern
     United States.
 Depletion.  Abstraction  of blood, or o"ther material, from  the
     system.
 Dermatophyte.   A vegetation upon the skin.
 Desideratum.   Something  desired  or required;  an  important
     object.
 Desquamate.  To scale or peel off.
 Detritus.  Refuse; the result of wearing or breaking down.
 Diabetes.  Excessive urination.
 Diabetes mellitus.  Excessive discharge of urine containing sugar.
 Diagnosis.   The discrimination of diseases;  the determination
     of the nature of an attack, or of the condition of the organs
     in a given case.
 Diaphoretic.   Productive of perspiration.
' Diastole.  Dilatation.
 Diathesis.  A constitutional tendency, peculiarity or habit.
 Dicrotous.  Double-beating.
 Diphtheria.   Membranous sore throat.
 Diphtheritic.   Pseudo-membranous.
 Diplopia.  Double vision.
 Dipsomania.  Insane thirst or craving for stimulants; oinomania.
 Diuretic.  Productive of increased flow of urine.
 Drastic.  Active, powerful.
 Dynamic.  Relating to power or force.
 Dynamize.   To imbue with force or power.
 Dyscrasia.   A morbid state of the blood or of nutrition.
 Dysmenorrhcea.  Difficult or painful menstruation.
 Dysphagia.   Difficulty of swallowing.
 Dysphonia.  Hoarseness.
 Dyspnoea.  Difficult respiration.
 Dysuria.  Difficult urination.

                              E
 Ecchymosis.  Effusion  of blood under the skin.
 Eclampsia.  Convulsion. 
178
GLOSSARY.
Ecthyma.  A disease of the skin, characterized by large pustules.
Ectrotic.  Abortive; productive of abortion.
Eczema.  A vesicular eruptive disease.
Effete.  Worn out;  dead.
Elephantiasis Arabum.   An enormous enlargement of the limbs,
    scrotum, neck, etc.
Elephantiasis Groecorum.  A severe cutaneous  affection, with
    purple tumors, etc.
Eliminate.  To remove or drive out from the  system.
Embolic.   Obstructive;  applied to a clot thrown as a plug into
    an arterial trunk.
Emphysema.  Distention of a cellular tissue with air.
Empirical.  The result of observation only;  as contrasted with
    rational or deductive.
Emprosthotonos.  Arching of the body forward.
Empyema.  A collection of pus in the pleural cavity.
Emulsify.   To  suspend or diffuse an  insoluble substance  in
    water by means of mucilage.
Encephaloid.  Brain-like.
Encephalon.  The brain; i.e. the whole contents of the cranium.
Endemic.  Local;  confined to certain localities.
Endermic.  Within or under the skin.
Endocarditis.    Inflammation of the lining membrane  of  the
    heart.
Endosmose.  The spontaneous interchange of fluids  through or-
    ganic membrane.
Enteritis.  Inflammation of the bowels.
Entozoon. A worm, or other parasite, within an animal body.
Enuresis.  Incontinence of urine.
Ephelis, Ephelides.  Sun-burn.
Ephemeral.  Continuing for a day.
Epidemic.  Affecting persons over an extended region ; migrat-
    ing; not limited to any locality.
Epigastric.  Over the stomach.
Epilepsy.  A disease  characterized  by recurring  convulsions,
    during which the patient is unconscious.
Epiphyte. A vegetable  parasite.
Epistaxis.  Bleeding from the nose.
Epithelioma.  An  epithelial tumor.
Epithelium.  A  thin, superficial layer of cells upon a basement
    membrane. 
GLOSSARY.
179
Epizoon.   A parasitic animal or animalcule.
Equinia.   Glanders;  a malignant disease of the horse, some-
    times conveyed to men.
Eremacausis.  Decay, or slow combustion.
Erosion.   Corrosion ;  destruction of tissue by chemical agency.
Eructation.  Belching of wind.
Erythema.  A florid inflammation of the skin; classed with the
    exanthemata.
Etiology.   The study of the causation of disease.
Exacerbation.   An increase of the symptoms;  e.g. of fever; a
    febrile paroxysm.
Exanthem. A rash, or florid eruption.
Exanthemata.   A class of diseases in which, with fever, there is
    an eruption characteristic of each.
Excito-motor.  Reflex ; relating to the production of movement
    in muscles by impressions  transmitted through nerves and
    nerve-centres.
Excito-secretory.   Reflex excitement  of secretory organs, by
    distant impressions, transmitted through the  nerves.
Excreta.   Matters thrown out as waste from the  body.
Exfolicde.  To fall  or throw off, like leaves from  a tree.
Exosmosis. See Endosmosis.
Extravasate.  To throw blood but from the vessels.
Exudation.  The throwing out of lymph from the vessels during
    a morbid process.   Also, the lymph  itself which is thrown
    out.

                             F

Favus.  Porrigo favosa;  a  contagious disease of the scalp, at-
    tended by the presence of a microscopic vegetative parasite.
Flocculent.  Resembling locks of wool.
Fomites.   Things supposed to  retain and convey contagion or
    infection ; as clothing, merchandise, etc.
Fuscedo.   Yellow staining of the skin in  patches or blotches.

                             G
Gangrene.  Mortification.
Gastralgia.  Pain in the stomach.
Gastritis.   Inflammation of the stomach.
Gastrodynia.   Stomach-ache. 
180
GLOSSARY.
Gastro-hepatic.  Affecting both the stomach and the liver.
Gesta.  Things done ; actions ; labors.
Glossitis.  Inflammation of the tongue.
Glucohaimia, Glycohaemia. Excess of sugar in the blood.
Glucosuria, Glycosuria.  The presence of sugar in the urine.
Goitre.   Bronchocele ; enlargement of  the thyroid gland.


                             H

Habitat.  The locality in which  a plant  or  other living thing
    grows or abounds.
Hcematemesis.  Yomiting of blood.
Hcematosis.   Blood formation ;  blood development.
Hematuria.  Yoiding of bloody urine.
Haemoptysis.  Spitting of blood.
Hemicrania.  Pain in one half  of the head.
Hemiopia.  Seeing only one-half of an object at a time.
Hemiplegia.  Paralysis of the arm and leg, etc., of one side.
Hemorrhoids. Piles.
Hepatitis.  Inflammation of the liver.
Hepatization. Conversion into a liver-like structure.
Herpes.  Tetter ;  a vesicular eruption.
Heterologous.  Different from anything natural to the body.
Homologous.  Parallel to or  resembling things  natural  to the
    body.  In physiology, this word has a more extended mean-
    ing.
Hydatid.  A vesicular formation, generally considered  to be an
    animal parasite,  found in various organs,  causing their dis-
    tention into cysts or tumors.
Hydremia.   A watery condition of the blood.
Hydragogue.  Causing watery discharges.
Hydraulics.  The mechanics of liquids; investigating especially
    the force and phenomena of liquid pressure and movement.
Hydrocephalus.  Dropsy of the head.
Hydro-pneumothorax.  The presence of water and air together,
    in the cavity of the pleura.
Hydrothorax. Water in the chest; thoracic dropsy.
Hygiene.  The science of health.
Hygrometry.  The  measurement of the amount  of moisture  in
    the air. 
GLOSSARY.
181
Hypercemcesthesia.   Excess of blood in a part, with irritability;
    commonly called chronic inflammation. .
Hyperemia.  Excess of blood in a part.
Hyperesthesia.   Over-sensitiveness.
Hyperinosis.  Excess of fibrin.
Hypertrophy.  Over-growth.
Hypnotic.   Promotive of sleep.
Hypochondriac.  In anatomy, the region over the liver, and the
    corresponding region on the left side.  In medicine, a person
    affected with depression of spirits from dyspeptic disease.
Hypochondriasis. Dyspepsia with lowness of spirits and imagin-
    ary complaints.
Hypogastric.  Below the stomach.
Hypostatic.  The result of settling or gravitative deposition.

                              I

lchormmia.  Contamination of the  blood ;  pyaemia.
Icterus.  Jaundice.
Icthyosis.  Fish-skin disease.
Idiopathic.  Primary;  independent.
Idiosyncrasy.  Individual peculiarity of  system.
Reus.  Iliac passion.  The most violent form of colic.
Impetigo.  A pustular eruption.
Incubation.  Development; maturation;  the period between the
    introduction  of  a morbid  cause and the appearance of the
    resulting disease.
Indication.  The pointing of  the signs of disease to the proper
    mode of treatment.
Induration.  Hardening.
Infection.  As frequently used, synonymous with contagion; still
    more commonly, including extension of disease from person
    to person, either by contact or through the air; in this work,
    restricted to atmospheric transmission, or the production of
    pestilential disease by local causes.
Infra-mammary.  Below the mamma.
Ingestive.  That  which is introduced into the body by the ali-
    mentary canal.
Innervation.  Supply of nervous influence.
Insomnia.   Sleeplessness.
                             17 
182
GLOSSARY.
Internuncial.  Communicating;  transferring mutual impressions
    or excitations.-
Interscapular.  Between the scapulae.
Intussusceptio.   Convolvulus;  the reception of one  portion of
    intestine into another.
Iritis.   Inflammation of the iris.
Ischuria.   Difficult urination.

                             K
Kalcotrophy.  Perverted nutrition.
Keloid.   An uncommon disease  of the skin,  with  elevations
    slightly resembling tortoise-shell.
Kyestein.   A greasy pellicle upon  the urine, observed especially
    during pregnancy.

                             L
Lancinating.  Lancing, piercing, darting.
Laryngitis.  Inflammation of the larynx.
Latent.  Concealed.
Lentigo.  Freckles; sunburn.
Lepra. A scaly cutaneous disease.
Lesion.  Injury;  essential change.
Leucocythcemia.  Excess of colorless or white corpuscles in the
    blood.
Lichen.  A papular disease of the skin.
Lientery.   Passage of undigested food through the bowels.
Lipoma.  A fatty tumor.
Lithieisis.  The formation of stone or gravel.
Lochia.  The sero-sanguineous discharge following delivery.
Lumbago.   Rheumatism of the  lumbar region.
Lumbricus.  A long round worm.
Lupus.  A malignant affection of the skin, either tuberculous or
    ulcerative.
Lymph.  The fluid  portion of the blood, without the corpuscles ;
    the fluid of the  lymphatic vessels; also, the fluid exuded dur-
     ing inflammation.

                             M
 Macula.  A spot or stain.
Malaria.   Bad or poisonous air.
 Mania.  Derangement, either intellectual or emotional,  or both. 
GLOSSARY.                     183
Marasmus.  Wasting away.
Matrix.  A formative or receptive structure or cavity.
Melanosis.   Morbid deposit of, or conversion of tissue into, black
    pigment.
Meningitis.  Inflammation of the membranes of the brain.
Menorrhagia.  Excessive flow of the menses.
Mentagra.  Sycosis;  a contagious  pustular eruption upon the
    chin.
3Ietamorphosis.  Transformation.
Metastasis.  The transfer of a disease or symptom from one part
    to another.
Meteorism-  Distention of the alimentary canal with gas.
Methomania.   The disease of habitual drunkenness;  mania  for
    strong drink.
Miasm.   Marsh poison;  the local cause of endemic country
    fevers.
Microphyte.  A microscopic vegetation.
Microzoon.   A microscopic animalcule.
Miliary.  Resembling millet-seed.
Modus operandi.  The manner of action or operation.
Molecule.  The minutest particle into which matter can be divided.
Molluscum.  An uncommon tubercular disease of the skin.
Monomania.   Insanity upon one subject only.
Morbilli.  Measles.
Muguet.  Thrush.
 Multiform.   Having many shapes.
Myalejia.   Pain (or soreness, tenderness) in one or more muscles.
 Myelitis.  Inflammation of the spinal cord.
 Myeloid.  Resembling the spinal marrow.
 Myocarditis.   Inflammation of the muscular tissue of the heart.
 Myopia.  Near-sightedness.

                              N
 Nebulous.  Cloudy.
 Nephralgia.   Pain in the kidney.
 Nephritis.  Inflammation of the kidney.
 Nervine.  Affecting the nervous system.
 Neuralgia.   Pain, the seat of which is principally in the  nerves.
 Neuroma.  A morbid enlargement of a nerve.
 Neurosis.  A nervous affection.
 Nisus.  Effort; attempt; active process. 
184
GLOSSARY.
 Normal.  Natural; regular; healthy.
 Nosography.  The description of diseases.
 Nosology.  The classification of diseases.
 Nosophyte.  A vegetation connected with, or causative of disease.
 Nostalgia.   Home sickness.
 Nucleolus.   A central granule or spot within a nucleus.
 Nucleus. The central body within a cell; being itself, frequently,
     hollow.
 Nummular. Coin-like; applied to dabs of expectoration, rounded
     like pieces of money.

                              0
 Ochlesis.  Crowd poison.
 Octohedral.  Eight-sided.
 Odontalgia.  Toothache.
 GZdema.   Swelling, from watery effusion into the cellular tissue.
 Oinomania.  Insane craving for alcoholic stimulation.
 Ophthalmia.   Inflammation of the eye.
 Opisthotonos.  Arching of the body backwards.
 Optimism.  Tendency to the best possible result.
 Organography.  Delineation of the  organs in their position.
 Orthopncea.  Breathing only in  the erect position; great dysp-
     noea.
 Osteosarcoma.   Cancerous tumor of bone.
 Otalgia.  Earache.
 Otitis.  Inflammation of the ear.
 Otorrhoea.  Discharge from the ear.
 Oxaluria.   Presence of oxalic acid  (as oxalate of lime)  in the
     urine.
 Ozone.  Oxygen in the nascent state, or with its chemical activity
     otherwise intensified (dynamized).

                              P

Palpation.  Examination (of the chest, etc.)  by the touch.
Papula.  A pimple.
Paracentesis.  Tapping.
Paralysis.   Loss of power or of sensibility;  palsy.
Paraplegia.  Paralysis of  the lower  half of the body
Parenchyma.   A glandular or other organic structure, formed
    chiefly of aggregated cells.
t 
GLOSSARY.                     185
Parotitis.  Inflammation of the parotid gland.
Pathognomonic.   Positively distinctive or characteristic of a
    certain disease.
Pathology.  The study of the seat, nature, and essential charac-
    ters and laws of disease.
Pectoriloquy.   Resonance of the voice in the chest, as though
    produced immediately under the ear of the auscultator.
Pellicular.  Membranous.
Pemphigus.  A bullar eruption upon the skin.
Percepta.  Things perceived; impressions upon  the senses and
    brain.
Pericarditis.   Inflammation of the pericardium.
Peripheral.  Connected with the surface or exterior.
Peritonitis.  Inflammation of the peritoneum.
Perturbation.  Disturbance, by an exterior or extrinsic cause.
Pertussis.  Hooping-cough.
Petechia;.  Small purple spots in or under the skin.
Phlebitis.  Inflammation of a vein.
Phlegmasia.   An inflammatory disease.
Phlogosis.   Inflammation.
Photophobia.   Dread of light.
Photopsia.  Flashing of light before the eyes.
Phrenitis.   Inflammation of the brain.
Phthisis.  Wasting.   Phthisis  pulmonalis, pulmonary consump-
    tion.
Pica.   Depraved appetite.
Pityriasis.  A disease of the skin,  accompanied by the exfolia-
    tion of minute scales.
Plasma.  Organizable fluid;  liquor sanguinis.
Plethora.  Redundance of red blood.
Pleuritis.  Pleurisy;  inflammation of the pleura.
Pleurodynia.   Neuralgic  pain in the region of the pleura.
Pleuro-pneumonia.  Inflammation involving both the lung and
    pleura.
Pleximeter.  An instrument  for mediate percussion; a stroke-
    measurer.
Plica Polonica.  Trichoma; a disease  of the hair, rarely met
    with out of Poland or its vicinity.
Pneumonia.   Inflammation of  the lung.
Pneumothorax.  Accumulation of air  in the cavity of the pleura.
Podagra.  Gout.
                            17* 
186                     GLOSSARY.
Polydipsia.  Excessive thirst.
Polysarcia.  Obesity.
Pompholyx.  A variety of pemphigus.
Porrigo.  A parasitic disease of the skin.
Post-organic.  Following organization ; effete ;  having been or-
    ganized, but no longer capable of vitalization.
Prcecordial.  Over or surrounding the heart.
Premonitory.  Warning; threatening.
Prodromata.   Forerunning signs or symptoms.
Prognosis.  Foreknowledge.
Prophylactic.  Preventive.
Prurigo.   An affection of the skin, characterized by great itch-
    ing, with little or no rash.
Pruritus.  Itching.
Pseudo-membrane.   False membrane; i.e. morbid  or misplaced
    coagulation or organization of lymph.
Psora.  Itch.
Psoriasis.   A scaly disease of the skin.
Psychical.   Affecting or relating to the mental or  moral  nature
    or faculties.
Ptyalitm.  Salivation.
Puerperal.   Pertaining to child-bed.
Purpura.  A hemorrhagic affection of the skin.
Pycemia.   The presence  or formation of pus in  the blood.
Pyelitis.  Inflammation of the pelvis  of the kidney.
Pyrexia.   Fever.
Pyrosis.  Water-brash.

                             a

Quininize.   To place under the influence of quinine.

                             R
Rabies canina.  Hydrophobia.
Bale.  A rattling sound.
Ramule.  A small branch.
Rationale.  Explanation of a process or occurrence.
Recuperative.  Restorative; invigorating.
Reflex.   Reflected ; occurring under the influence of a transmit-
    ted excitation, as contrasted with  a direct stimulus.
Regurgitant.  Flowing or escaping backward. 
                         GLOSSARY.                      187

Renal.  Belonging to or affecting the kidney.
Remittent.  Having remissions; i.e. periods of diminution of the
    symptoms {e.g. of fever) without their total subsidence.    '
Resorption.  Reabsorption.
R6sum£.  Summary; recapitulation.
Retinitis.  Inflammation of the retina.
Revulsion.  Derivation.
Rhonchus.  A rattling or roaring, or other abnormal sound, con-
    nected with respiration.
Roseola.  Scarlet rash.
Rubeola.   Morbilli; measles.
Rupia.  A bullar and scabbing disease of the skin.

                              S
Saccharine.   Of the nature of sugar.
Salivation.   Excessive  flow of saliva;  usually with soreness  of
    the gums, coppery taste, etc.
Sanitary.  Pertaining to the preservation of health.
Sarcina.  A microscopic vegetation, growing in square or wool-
    sack-like forms.
Sarcoma.  A fleshy tumor.
Scabies.  Itch.
Schirrus.  Hard cancer.
Sciatica.   Neuralgia of  the sciatic nerve.
Sclerotitis.  Inflammation of the sclerotic coat of the eye.
Scorbutus.  Scurvy.
Semeiology.  The study  of the signs and symptoms of disease.
Sensori-motor.  Relating to movements which are connected with
    sensations.
Sensorium.  An aggregate term, including those portions of the
    brain which are the  centres of sensation and perception.
Sentient.   Endowed with sensation.
Septic.  Putrefactive or decaying.
Serum.  The fluid portion of blood after coagulation, or after the
    removal of its fibrin;  also, the liquid transuding upon serous
    membranes; the liquid of certain dropsical effusions, etc.
Sibilant.   Hissing.
Soporific.   Promotive of sleep.
Spanoemia.  Hydremia; poverty of blood.
Spermatozoa.   Microscopic bodies found  in the generative fluid
     of the male. 
188
GLOSSARY.
Sphacelus.  Sloughing.
Spirometry.  The measurement of breathing power by the quan-
    tity of air exhaled after a forced inspiration.
Sporadic.  Separate, independent,  occasional; not endemic  or
    epidemic or contagious.
Sputum.   Anything ejected by spitting;  expectoration.
Squama.   A scale.
Stasis.  Stagnation ;  arrest of movement.
Steatomatous.  Fatty ; consisting principally of fat.
Stercoraceous.   Faecal.
Stertorous.  Loud and snoring.
Stethometer.  A chest measurer.
Stethoscope.  A tube used for mediate auscultation.
Sthenic.   Possessed of or attended  by vigor and activity.
Stomatitis.  Inflammation of the mouth.
Strabismus.  Squinting.
Strangury.  Dysuria, ischuria.
Subclavian.  Under the clavicle.
Subcrepitant.  Crackling, but not typically identical with  the
    crepitant rale ; being a coarser sound.
Subjective.  Originating  in the mind, brain, or other part of  the
    individual;  as contrasted with  objective, i.e.  of external
    origin.
Subsultus tendinum.   Jerking of the  tendons; e.g. of the wrist
    in low fever.
Succussion.  Sudden shaking.
Sudamina.  Minute transparent vesicles,  often  seen over  the
    breast or abdomen in low fevers.
Sudorific.  Promotive of perspiration.
Suggillation.  Collection  of blood in spots under the skin of  the
    dead body.
Suppuration.  The formation of  pus.
Sycosis.   Mentagra.
Syncope.   Fainting ;  suspended  animation.
Synovia.   The lubricating fluid of the joints.
Synurgic.  Co-operative ;  working together.
Syphilida, Syphilides. The eruptions  occurring under the influ-
    ence of syphilis.
Systole.  The act of contraction of the heart and arteries ; usu-
    ally applied to the contraction of the ventricles. 
GLOSSARY.
189
                             T
Tabes.  Wasting; atrophy.
Tenia-   Tape-worm.
Tegument.   Covering; skin.
Tenesmus.   Straining; bearing down.
Tentative.   Experimental.
Tetanus.  A disease characterized by muscular rigidity.
Therapeutic.   Sanative ;  medicinal;  restorative ; promotive of
    the cure of disease.
Thrush.  A disease of the mouth, with curd-like exudation.
Tinea.  Porrigo; a disease of the skin. Tinea capitis, contagious
    ring-worm.
Tonic.  In physiology and pathology, as applied to the muscles,
    tonic contraction means  fixed rigidity.   In materia medica
    and  therapeutics, a tonic is  a strengthening  medicine or
    agency.
Tormina.   Griping pains.
Torula.  A minute vegetation, found (Torula  cerevisiae) in fer-
    menting liquids.
Toxemia.   Blood-poisoning.
Toxic.  Poisonous.
Tracheitis.  Inflammation of the trachea.
Transudation.   Passage of fluid through the walls  of vessels.
Traumatic.  Resulting from a wound or injury.
Trichoma.   Plica polonica.
Trismus.   Lock-jaw.
Tuberculization.   The deposition of tubercle.
Tuberculosis.   The development of the tubercular diathesis.
Tumefaction.   SweHing.
Turgescence.  Distention with fluid, usually with blood.
Tussive.  Connected with cough.
Tympanites.  Distention of the abdomen with air.
Typical.   Representative;  characteristic.
Typhoid.   Resembling, and yet not identical with, typhus.
Typhus.  A form of low continued fever.

                             U
Uremia.   The presence in the  blood of  the constituents of the
    urine, from inaction of the kidneys.
Urina cibi vet  chyli. Urine of food or chyle; i.e. that passed
    after a full meal. 
190
GLOSSARY.
 Urina potus.   Urine of drink; i.e. that passed after a light meal
    as tea or breakfast.
 Urina sanguinis.   Urine of the blood ;  i.e. that  passed in the
    morning, after sleep.
 Urinometer.  An instrument used to estimate the specific gravity
    of urine; by the distance  to which it sinks in the latter, as
    compared with that to which it will sink in water.
 Urticaria.  Nettle-rash.

                              V
 Vaccinia.   Cow-pox; vaccination.
 Varicella.   Chicken-pox.
 Varicose.  Dilated;  enlarged.
 Variola.   Small-pox.
 Varioloid.  Mild  or modified small-pox.
 Vascular.   Well supplied with blood-vessels.
 Venesection.  Blood-letting from a vein.
 Verruca.  A wart.
 Vesical.   Pertaining to the bladder.
 Vesication.  The production of a blister.
 Vesicle.  A small blister.
 Vesicular.  Composed  of, or resembling, vesicles or small cells.
 Vibices.   Large spots of effused blood under the skin.
 Vibrio.   A minute animalcule, rarely found in  animal  tissues or
    cavities.
 Vicarious.  Substitutive.
 Vitiligo.  Partial discoloration of the skin.
 Volvulus.  Intussusception.

                              z
Zona.  Shingles; an eruptive disease, affecting only one-half of
    the body. 
 
 
 
Ill