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             PRIZE   ESSAY,            *p-.s
(To which the First Prize of One Hundred Dollars, offered by the South
     Carolina Medical Association, was awarded February, 1860.) ,/
  JlIustrationB of grease with tfa ^Ukrouoi^t
                    ------------         /•  / *
         CLINICAL INVESTIGATIONS,
aided by the microscope, and by chemical reagents ; with microscopical
    observations of  pathological specimens', medical and surgical,
                  obtained in charleston, s. c.
                A  CONTRIBUTION
INTENDED TO DISCLOSE THE MINUTE HISTORY OF THE DISEASES PREVAILING IN THIS
             LATITUDE, AND TO ASSIST FUTURE STUDENTS ;
  Wixfy upfoarbs of Jibe f| nvtbrtit Drigiital grabings from Mature,
             MADE AT THE TIME OF THE OBSERVATIONS.
         BY FRANCIS PEYRB  PORCHER, M. D.
               LECTURER ON MATERIA MEDICA AND THERAPEUTICS.
                  PART  FIRST.
WITH ONE HUNDRED AND TEN ILLUSTRATIONS ON WOOD.
" NATURA MAXIME MIRANDA IN MINIMIS."—Linnxus.
IXOWL
' Where there is an obscurity too deep for our reason, 'tis good to sit down with a description.'^—
                 Sir Thomas Browne's " Religio Medici."
            CHARLESTON, S. C, C. S. A.
PUBLISHED BY THE SOUTH CAROLINA MEDICAL ASSOCIATION.
             EVANS k COGSWELL, PRINTERS.
                       1861. 

]oyi. Med.*
\%U
 
PREFATORY.
  The microscope used was made by Nachet, in Paris—a
fourth of an  inch  object glass being generally  employed.
The wood engraving was undertaken  by Mr. Douglas E.
Jerrold,  of London,  England.  He  did  not  complete the
contract entered into with him, and much the larger portion
of the Essay was sent on to New York  to have the wood
cuts finished, which it has been found impossible to have
returned during our present difficulties.  Hence the great
delay in the appearance of  the Essay has been entirely
beyond my control, or that  of the Committee on Publica-
tion.   I  little thought that  I should have this part of the
work to do; but, seeing no  alternative  in the present con-
dition of affairs, and having procured the proper  instru-
ments, I undertook to complete the cutting of a very large
number of the blocks—seventy of the one hundred and ten
blocks, illustrating Part 1st, having been  left in  an  imper-
fect  state by Mr.  Jerrold.  This proved a  very exacting
task, and occupied leisure moments during several months,
though  the transfer of the  drawings upon the wood, and
much of the  more difficult portions of the work, had been
completed by the artist.
  Part 1st, now issued,  is scarcely one-third of  the entire
paper, it will be remembered, and  it  only embraces the
introductory portion, and one section containing the "Ap-
pearances observed in Yellow Fever."  The original draw- 
4
PREFATORY.
 ings of this having also been the first executed, are neces-
 sarily much more roughly done than those attempted when
 more experience was had.  I regret that the illustrations of
 Intermittent and Remittent Fevers could not also have been
 included  in the  present issue.  Several pages have been
 added to  the Introductory Essay, since it passed  through
 the hands of the  Committee.  It may not be amiss to state
 here that one or two of the smaller figures, among the few
 entirely executed by  myself, were done upon blocks pre-
 pared from our common swTamp Dogwood (Cornus Florida);
 and engravers in this city have also, upon my recommenda-
 tion,  used it with satisfactory  results.  I found  both the
 Persimmon and the Holly too soft  for the purpose.
  I take occasion to suggest to engravers on wood, though
 never having tried it, the Service  Tree—Amelanchier cana-
 densis, L.   Aronia botryapium, Ell.  Sk.—growing in  South
 Carolina,  as, probably, only inferior to the Boxwood.  The
 sum expended at the North for wood sufficient for  Part 1st
 of this Essay, has already amounted to no inconsiderable
 amount—which item, only, of the expense of publication
 was defrayed by myself.
  The subject, in the present aspect of our country, is an
 important one.
  I have  to thank the Committee on Publication for the
 evidences  they manifested  of the most liberal spirit  as
regards the expenditure necessary  to a publication of this
kind,  and again express  my regret that the entire work,
with all the drawings, cannot be examined at one view, as
originally  contemplated by the writer, in order that more
comprehensive  and, consequently, more satisfactory com-
parisons might be  presented.   The Introductory  Essay,
however, is based upon a review of the whole paper.
  Charleston, September 15th, 1861. 
INTRODUCTORY   ESSAY.
   I would deem it necessary to offer an apology for the
 presentation of this paper, had  it been prepared in a few
 months; but, as it contains  the results  of three years  of
 almost  daily labor (from June,  1856, to  September, 1859),
 with every sense of its imperfection, I consider such apolosw
 less necessary.  It is submitted, therefore, with the hope
 that, by means of it, not only will increased light be thrown
 upon some of the diseases met with in our  midst, their
 symptoms and phenomena; but, also, that,  by aid  of the
 drawings, future investigators will be enabled more readily
 to avoid those difficulties which  beset the author in this—a
 pioneer enterprise in  this State and city.  For, when I
 began, I could obtain scarcely any assistance, so far  as one
 entire department of research was concerned.  In Histol-
 ogy, embracing  the minute anatomy of tumors,  cancerous
 growths, the structure of vegetable cells, etc., I had enjoyed
 the benefit of several months daily instruction from M. C.
 Robin, in  Paris, 1853-4; but, in the difficult, if  not obscure,
 study of Renal Pathology and Crystallography, I was com-
 pelled to trust to my own efforts,  aided only by the Atlas of
 Plates  attached  to M.  M. Robin and Verdeil's " Traite de
 Chimic Anatomique et Physiologique" the works  of Golding,
 Bird,  Prout, Bowman, Beale,   Thudichum, Hassall,  and
 others.  These, however, were only resorted to to assist in
the identification of objects under inspection.  The matter
presented  is original, and obtained by personal observation.
  This material, to be profitable,  must necessarily be large 
 6               ILLUSTRATIONS OF DISEASE

 in bulk, because only from an extended series of minutely
 recorded  observations  can  those comparatively few  con-
 stant characters be eliminated which  are peculiar to, and
 possibly diagnostic of,  certain  diseases.    Only by accu-
 mulating the observations, noting even the most apparently
 trivial and unimportant phenomenon, if its  abundance was
 sufficient  to render it characteristic, could I hope to ascer-
 tain what belonged to  the disease by its very nature, and
 to distinguish this from  what  wras variable or only acci-
 dental.  Besides, even negative observations possess a posi-
 tive value, inasmuch as they tend to set at rest, as I hope
 the results will prove, litigious questions touching the pres-
 ence or absence of certain principles supposed to exist.
  Speaking generally, I am indebted to the advantages  of
 a residence in, and the accidencies of, a large city, and  to
 certain  hospital facilities, for the ability to make these
 imperfect researches—having been for several years Physi-
 cian to the Marine Hospital, in Charleston ; also, to the kind
 co-operation of a number of my professional brethren, both
 here and in the surrounding districts, who sent me nume-
 rous specimens for examination.  Among these, I should
 especially mention  the late Dr. P. C. Gaillard, and the
 medical gentlemen, house physicians of the Roper Hospital:
Drs. Trescott and Seabrook, Parker  and De Saussure, Jr.;
Dr. Cain, formerly Physician to  the Marine  Hospital; Drs.
Dickson,  P.  Porcher,  De Saussure,  Happoldt,  Chisolm,
 Raoul, Brims, "Westcoat, Huger, Fitch, Snowden, Petti-
grew, F. Greddings, as  well as several residing out of the
 city.
  The specimens of diseased action examined and re-exam-
 ined are quite  numerous.  The cases investigated are classi-
 fied, and number 300 (?)
  They embrace: Yellow Fever; Remittent, Intermittent
 and Continued Fevers; Black Vomit of Yellow Fever and
 for comparison, Black Vomit of Bilious Fever, of Cancer  of
 the Stomach,  of Enteritis and ordinary Vomit- Nervous
 and Hysterical Disorders; Dyspepsia and Indigestion; Jaun-
 dice; Dropsy; Pneumonia;  Rheumatism;  Scarlet  Fever 
WITH THE MICROSCOPE.
7
Albuminuria, Chylous Urine; Scrofula, Osseous Degenera-
tions, Syphilis;  Catarrh  and Inflammation of Urethra and
Bladder;  Renal Excretion of healthy individual for com-
parison ; Fluids  obtained by Trocar, Fluid from Ventricles
of the Brain; Blood Pus, Mucus, Bile; Tumors; Choleliths,
Concretions; Secretions  and  Excretions  of various kinds,
healthy and morbid.
  I  have not included  in  this  collection  the complete
account of histological and vegetable specimens in  my pos-
session, examined whilst in Paris.
  The Statistical Tables  appended are the product of much
labor,  and they  serve to  represent at a glance, numerically,
the characteristic features of certain diseases, or classes of
allied  diseases.  They required for their preparation, first
the  classification,  and next the examination, of the  entire
paper.
  Amid the conflicting duties of daily  practice, lectures,
and other demands upon my attention, I could not hope to
give that scientific  completeness desirable, to every detail
of procedure, so far as  chemical appliances are concerned.
If this had been  essential, then nothing could have been
done by me.  It pretends to be only numerous observations
of facts, and searchings,  whether successful or unsuccessful,
after characteristic  features  of disease, however roughly
made  or crudely put together.  But, in  the representation
of objects observed by  the microscope, I have endeavored
to be accurate.
  For example: Any one at all familiar with the subject,
recognizes  a typical  crystal of  the  ammoniaco-magnes.
phosphates,  of  uric  acid, of  oxalate of lime, or  a blood
corpuscle, etc.,  with  different degrees of ease.  It was not
necessary, therefore, to  represent these elaborately in every
instance.  The fact of  their presence stated, and  a few
accurately drawn, suffice for all purposes.  Accurate meas-
urements are not essential to a large proportion  of these.
The word of the observer must be taken when names  are
assigned—for he has a guarantee  in his daily observation of
numerous objects,  his  opportunities for instruction, etc. 
ILLUSTRATIONS  OF  DISEASE
 But the drawings, though executed with the pen for the
 most part, will remain for any persons coming after to iden-
 tify, interpret, or comment upon as they please.   Their
 value consists in this—that, after much trouble in  secur-
 ing them, they were executed from an inspection  of mor-
 bid  specimens that  existed  of many  diseases observed
 repeatedly.  In the  preparation of the wood cuts, I have
 caused to be retained almost every object originally  repre-
 sented from an inspection of the field of the microscope,
 because they serve  to show the  predominance of certain
 substances, and some, though apparently valueless, may
 one  day be recognized  as peculiar  or important.   Dr.
 Lionel Beale says, on this subject, in his work, the "Mi-
 croscope in Medicine" :
  "It may almost be said that all progress in our knowledge
 of minute structure, both  in healthy and diseased tissues^
 depends upon  the drawings which are made.   It is almost
 hopeless for an observer to attempt to describe what he sees
 in words, and  such descriptions, however careful they may
 be, cannot possibly be compared with those of others. . On
 the other hand, a truthful  drawing of wrhat a  man has seen
 lately, may be compared with others which may be made a
 hundred years hence, although the means  of observation
 will  be  far more perfect than they are at present.   Much
 will be  learned by such comparisons.  I am  sure  that an
honest enquirer cannot be  of greater use, in his time, than
by making good drawings of what he has seen ; they will
be of far greater help to our successors than any amount of
description we can write for them, and we may feel sure
they will look at our drawings  if  they are honest copies of
 nature, while we all know that, comparatively, very little of
what we write will be read, when  the whole aspect of this
department of science shall be changed.   *  *  *   A gr>od
knowledge  of drawing,  of the  stethoscope, of the opthal-
moscope, and,  indeed, of any other investigation accessory
to medical  research,  requires far more devotion  than is
 implied in the mere sacrifice of the money which is neces-
 sary for the purchase of books and instruments.   So it
is 
WITH  THE MICROSCOPE.
9
with the microscope; and he who has the largest means at
his disposal for obtaining the most costly instrument made,
and all the books published on the subject, with the advan-
tage of the best tuition, is hardly so  likely to  become a
useful, earnest laborer in this field of enquiry as the student
who spends his five pounds in a simple instrument, without
any unnecessary luxurious arrangements, with a conviction
that the study is  real and worthy of attention, and with a
determination to set to  wTork honestly and zealously, with
the hope of being one day able to add his work to that of
men who  worked  before  him, whose lives and labors he
respects  and honors.  Every observation  should be  care-
fully recorded  in a note book, at the time it is made, and
drawings made if necessary."
   The applications  of chemical tests, the  counterproof by
.reagents, and the search in  almost every  case for  several
important  elements, including: albumen,  bile, purpurine,
sugar,  nitrate of urea, iodine, etc., etc., are numerous, and
they must possess their own  special significance.  Besides,
the collection will, probably, for some time remain unique,
as, perhaps, few will possess the inclination to  continue, for
a length of time, investigations often so difficult, disagree-
able, and exacting.  Any subsequent investigations of like
character, whether by myself or others, may be inserted at
any time; and it is desirable that they should be extended,
that the results, when tabulated anew, may be made more
striking and conclusive.
   After most of the material had been already collected, it
has required four  months  of almost uninterrupted labor
simply to  prepare  it for presentation; indeed, the entire
period contemplated by  the Association as sufficient for a
contribution wrorthy their  attention, was thus consumed.*
The figures take up a great deal of space, and this, with
 * As much delay was caused, subsequently, during the execution of the wood
cuts, I have continued to make additions to the paper up to September, 1861, when
it was put into the hands of the printer. 
10
ILLUSTRATIONS OF DISEASE
the  unoccupied  portion  of  many pages, contributes  to
swell the bulk,  and make the length  of the paper more
apparent than real.
  Every tyro now knowTs that even the slightest muscular
contraction gives rise to a corresponding molecular change,
accompanied by waste, however  inappreciable.  It was  an
important step made in organic  chemistry applied to phy-
siology, to the fundamental thought of which the Italian,
Bufalini,* was conducted as far back as 1819.   Matteucci,
Liebig, Draper and others, only more fully developed that
thought.  So  that a sensation, we  may say, even  leads  to
fatigue, and is more closely related  to a  special chemical
phenomenon than to mere mechanical motion.  It is  as
if there was a respiration going  on  even  in the  muscles.
Whilst we remember this,  and, therefore, admit that  mat-
ters exuded, secretions and  excretions (to confine myself to
these alone, for  the  moment), infinitely vary in certain dis-
eases, and  even, perhaps, at certain stages of each disease;
yet, it is not  less true that there  are,  also, broad distinc-
tions or characteristics, founded upon the nature of the ex-
creta, which belong to each disease  almost exclusively.  It is
not pretended that the principles or elements givino- rise to
these distinctions are never  found elsewhere; but that they
are  never so marked either by their frequency or  amount.
These visible characteristics, when once established by aid
of the microscope or by chemical reagents, as distinguish-
ing, by their unusual presence, certain diseases or classes
of disease,  necessarily throw some light upon  their nature
and the rationale of their phenomena,  and even give indi-
cations for their prevention  and cure. For,  knowing  if
not  the materies morbi, at least, some of the results of dis-
 t ^nd. diPatolog. Analit. di Bufalini, 2.  Also a translation by the writer from
the <WB Medica Italiana Toscana, published among the AUtrL in CharleZ
Medical Journal, Vol. XIII.                               v,naneston 
WITH THE MICROSCOPE.
11
eased action, as shown in the excreta, we are surely in  a
better position to attempt their removal or prevention. For
we must assume that  the matters eliminated—products of
exudation and earthy or animalized deposits—bear a certain
relation to diseased organs as well as to the essence of dis-
eases themselves.  I  will now  endeavor to  substantiate
what I have just said  by the acknowledged admissions of
some of the highest  authorities in the profession,  with
respect to certain affections which I will select, before pro-
ceeding to state what additional conclusions I have arrived
at as the result of my own observations.
   It will  not be denied  that Rheumatism and  Gout are
generally characterized  by what may be called  the acid
diathesis, viz:  the prevalence of excess of acidity in the
system at large, and by the presence of lactic and uric acids
in the discharges from the kidneys, and even in the blood;
the tophi and chalky exudations  of one of these  being, for
the most part,  composed  of urate of soda and also of uric
acid.  See contributions of Todd, Johnson, Garrod, Gaird-
ner, Adams, Headland, Richardson, and others.  These are
broad and well-marked distinctive features of these two
obscurely-related affections—however they may be accom-
panied or  not  Ivy  other  peculiarities—as the individuals
suffering from  them have been subjected to varying  exter-
nal or internal conditions.  These affections become daily
less  obscure as our acquaintance w7ith the peculiarities re-
ferred to as distinguishing them is  improved.  The gen-
eral plan of treatment, also, by alkalies and renal depurants
acting on the blood, or even  applied locally to the relief of
inflamed joints, is to  remove these special materies morbi—
occasional failures in this  attempt in no way modifying the
argument.   The same  is  true of  Scarlet Fever, and the
special liability to albuminuria and anasarca, with  uric acid
in  the  renal  discharge,  accompanying  or  following its
attack, and entirely  irrespective of any views  we may
entertain regarding the complemental  action  of  the skin
and  kidney, in  a disease where true inflammation of the
capillaries  of the surface is so marked.  Can  there be 
 12              ILLUSTRATIONS  OF DISEASE

 any doubt that congestion of the kidney, with albumi-
 nuria,  are  almost characteristic of this  affection .   Ana,
 from a consideration  of this latter phenomenon,  when we
 have once  established it, we argue back to the pathology of
 the kidney, and thence to that of the blood and skin, just as
 we may legitimately reason concerning the nature of  a dis-
 ease and special condition of a diseased organ, from the uni-
 formity of the action  of certain agents in modifying them—
 which  is only realizing the truth of the Hippocratic maxim:
 " Naturam morborum curationes ostendunt."   So, also, Brights'
 Disease, with characteristic tubular casts  and albumen es-
 caping in excess! had the original observations of the  latter
 in the  urine by F. Simon,  of Berlin, nothing to do with the
 establishment of the  co-existence of desquamative nephri-
 tis?  Even the subdivision of the latter into three varieties
 has been the result of researches, by aid of the microscope,
 for the most part externally to the kidney itself; and in-
 vestigations  respecting the  structure  of the Malpighian
 tufts, and their physiological functions, only tended to cor-
 roborate the views with regard to the pathology of the dis-
 ease, previously  deduced from the escape  of the several
 varieties of tubular casts.   Are  not careful study of  these
products of diseased action (if  not of the disease itself) now
 assisting us to distinguish  between the  albuminuria of the
 Morbus Brightii,  and that occurring in women  encientes?
 and  may they not throw some light upon the eclampsia to
 which  the latter are especially liable ?
  Ursemic  poisoning  of the  blood and brain, is  a reality
 acknowledged  by the  most  competent authorities.   How
 could  any  one suspect  the cause of this  variety  of coma
 unless  from  the absence  of urea  in  the  renal excretion
 being proven, or that some obvious congestion of the kid-
 ney gave rise to a suspicion of its retention in the system ?
 However,  ursemic intoxication  is a characteristic  result of
 congestion of the kidney, of the excessive production of
 urea during the metamorphosis of the tissues in the waste
 and repair  of the system, particularly during morbid states
 of the blood, or  other  arrest of the normal escape of this 
WITH THE MICROSCOPE.
13
principle. Hematuria and Dysuria, with the escape of blood
as a  characteristic, is a form of disease common among
natives of the  Isle of Bourbon, and the detection of this
feature serves to mark the disease,  whatever other symp-
toms may accompany it;  and this is just as philosophical
as that the more obvious presence of blood in the fecal
discharges should lead us to assign a certain character and
name  to the affection of the intestinal canal (Dysentery),
the existence of which it  very  rationally leads us to sus-
pect.   It is  only that many reasons exist to prevent  as
careful and frequent a study of this excretion—though M.
Marcet has  not shrank from this,  also,  and many physi-
cians do find it to their advantage to inspect sometimes the
intestinal and other discharges.
  To proceed: The prominent fact  about Jaundice, is the
saturation of the system  by bile, with  the  usual phenom-
ena  obviously  consequent  thereto.   The most prominent
feature in osteomalacia, is the enormous  proportion of phos-
phate  of lime present; and the comparatively recent dis-
covery of the constant presence of chloride of sodium  in
the secretions from  the kidney in certain diseases and  its
absence in that of others,  is a sufficiently striking illustra-
tion.   Nervous disorders,  and those slowly wasting away
the powers  of the  system, are  for the  most part charac-
terized by great discharge of the phosphates and  urates  of
soda and ammonia,  and sometimes  by phosphate and oxlate
of lime.  So, Intermittent,  Remittent and Yellow Fevers,
as well as other diseases  not yet studied with a view  to
testing these questions, may be and, in my opinion, are
found  to  differ  in  the greater  or  less  amount in  which
certain principles are excreted from, or retained in, the
system.   By the  more  accurate  determination  of this
difference,  and  by  tracing these principles up  to their
source, we  may  also  one  day hope  to  separate  more
clearly still, the  diseases  in which they are  respectively
found to predominate.
  But, setting aside all this, of the  existence and  reality
of many of these great  distinguishing features  or char-
acteristics referred to above there is hardly a dispute. 
 14              ILLUSTRATIONS OF DISEASE

  Now, to establish the  presence or absence  of these, ana
 to add  to their number if possible,  is  only one  ot  the
 very objects  of these researches.  Indeed, the great body
 of the material contributed by writers on Renal Pathol-
 ogy, and where  the microscope  and  chemistry are em-
 ployed,  is of  this character, and their labor must be judged
 of finally by its fruits.   In such laborious,  ofttimes disa-
 greeable processes, much may be found to be useless, and
 will  be discarded accordingly; but the workers will  be
 rewarded, in my  humble opinion,  if  they  shall succeed
 in establishing as  much more as  has been  already con-
 fessedly done since the  time of Prout.  The truth is,  he
 is blind who does  not perceive that the humoral pathol-
 ogy  is  being revived under happier  auspices,   and  that
 animal chemistry is being rapidly brought to  the assistance
 of researches in anatomy, physiology  and practical medi-
 cine, including therapeutics.
  Let us  next  enquire  if researches such as these under
 consideration have not an  important bearing upon diseases
 with which they are not  often associated  by the profession
 generally.  The relative heat and  combustion noticed  in
 the bodies of those sick  with fever (however  primarily de-
pendent upon the altered state of the  nervous media and
 the capillary  system caused by the action of malarial, ani-
 mal or blood poisons, or even by atmospheric and  electrical
 vicissitudes),  occasions the burning out of the nitrogenized
 protein compounds and hydrocarbons: as seen by the abun-
 dance of what  I may call their efete representatives  in the
 intestinal and renal excretions.   These are the phosphates,
 urates, uric acid,  etc.  Or  if, from impaired integrity  of
 structures, or from morbid congestions, the  combustion
 had  not been complete,  some of the original  protein com-
 pounds, viz:  albumen, fibrine and animal matter  accumu-
 late in too great quantities, or are not rendered effete__not
 burned out—they pass out and  are recognized in  the renal
 excretion in  morbid excess, unchanged  or only  partially
 changed.  We  are thereby  led to suspect the existence of
 such over-production, or of such obstacles.  It will  be re- 
WITH  THE MICROSCOPE.
15
membered that in health the protein compounds, fat, starch,
sugar, etc., are always used or destroyed, and never excreted
as such.   However, the consideration of all these facts goes
to make up, in the opinion of the writer, an important por-
tion of our most plausible theories and speculations at the
present  day  concerning fevers, and  very justly.  For  by
them we are  often enabled to remount to the  most recon-
dite principles or  elements involved in  the causation and
progress  of fever, as  well  as  of inflammation generally.
The  fact of their presence  established  also reflects light
upon the functions and operations of the capillary  tubes,
their dilatation or contraction, as well as of the most impor-
tant of the  glands and other emunctories of the  body, so
constantly implicated as well in fevers as in other diseases.
The truth is, hardly  a problem can be constructed concern-
ing the causation and nature of fevers as well as other dis-
eases, without these products of microscopical and  chemical
research entering as important elements.
   An appreciation of the precise condition of the cutaneous,
renal and intestinal excretions must, therefore, be important;
and the  consideration of what  may be called their morphol-
ogy, a term I am not conscious of ever having seen applied
in  this way before, though seemingly forced upon me by
the progress  of  modern Physiology and Pathology, is espe-
cially important.  For it involves a knowledge of all the
changes occurring to them previously to their expulsion;
and hence includes  the history of the formation, growth,
maturation  and decay  of many of the most essential ele-
mental substances engaged in the nutrition of the human
body.  We should observe that all these are especially im-
plicated during  diseased states.   For, if we admit  that final
destruction, more  or less complete (that  is, so far  as its nu-
tritive powers are  concerned), is consequent upon the com-
plete assimilation and use of food introduced into the system,
out of which food protein compounds  are first  supplied,
together with the blood corpuscles conveying nutritive ma-
terials for the tissues, preparatory to  their downward retro-
grade course when they assume  the condition and form of 
 16              ILLUSTRATIONS  OF  DISEASE

 excretions, it  must,  of necessity ensue: that the relative
 absence of normal destruction, or the presence of abnormal
 substances exhibited in the excreta (the renal, for example)
 must be significant of morbid congestions, lesions, impaired
 functions, nervous injury, etc., which disturbed the normal
 metamorphoses.  This is demonstrable from what has been
 said above, as well as from a quotation I will make directly
 from M. E. Robin.  But first, to  include all the data, as
 there was only one other possible condition not stated, I
 add: That when, from gastric or intestinal inflammation,
 cancer of the stomach, nervous atony or impaired nervous
 energy, causing or  caused by  blood poisoning  (fever, in
 other words), there can  be absolutely no  assimilation or
 absorption  of  food  supplied  from  without; the excreta
 must, under these circumstances, represent substances de-
 stroyed, which have been robbed from the body itself, viz:
 carbonaceous matters, hydrocarbons and carbohydrates—the
derivatives of the protein compounds stored away in  the
 shape of fat; and in this way we  readily account for  the
 simple fact  of wasting  and emaciation occurring under
 such circumstances.
  M. Edward  Robin, in a paper read before the Academy
 of Medicine of Paris, and republished in the London Lan-
 cet, makes the following remarks in reference to the beha-
vior of one of the most important of the substances referred
to above:
  " In the normal state the albumen is burned in the blood,
 and the nitrogenized residue of this combustion, viz., urea
 and uric  acid, is eliminated by the urine.  M. Robin thinks
that if, during a sufficiently long time, the albumen under-
 went in the circulation a much smaller amount of combus-
tion than is  habitually the case, it might  pass unaltered in
 the  urine, instead of  being thrown  off in  the form of urea
 and  uric acid;" and  he cites, adds the Lancet, several  ex-
 amples of disease where the arrest  of combustion  exists
 and  albumen makes its appearance,  as in croup  capillary
 Bronchitis with dyspnoea; Phthisis  complicated with Pneu
 monia and marked with difficult breathing; in gestation 
WITH THE MICROSCOPE.
17
when sufficiently advanced to occasion an habitual conges-
tion  of the kidney owing to an impeded abdominal circu-
lation ;  in such  states of the system "in which a very
incomplete respiration causes a marked diminution of com-
bustion."  It is also albuminous in cyanosis, in idiopathic
or traumatic lesions of the  nervous centres, in diabetes,  a
"disease where very often a lesion of the nervous centre
seems to be the origo mali, and where the great amount of
sugar in the blood seems to be an obstacle  to  the combus-
tion of the albumen."  As a general rule, he adds,  the
urine of the common mammalia and of birds contain no
albumen.  Reptiles, on the other hand, remarkable for the
low temperature of  their animal heat, yield urine in which
albumen is always to be found.
   " When the  activity of the combustion which takes place'
in the blood is too feeble to burn the whole of the albumen,.
which in the normal state should be consumed in a given
time, the general vitality is diminished, and thus  more or
less albumen is allowed to  pass unaltered into the urine,
viz: just so much organic matter as escaped the transfor-
mation into urea or uric  acid.   The  proportion of  urea
contained in albuminous urine  should, therefore, be small-
er than it is found in normal urine, and such is found to be
the case in  the following diseases, the only ones according
to the author, in which  experiments have been made, viz:
Pulmonary Phthisis, diseases of the cerebro-spinal  axis,
extensive  and  acute  Bronchitis,  with  intense  dyspnoea
and Bright's Disease."
   We will  see farther on what bearing some of my own
conclusions, deduced from the statistical tables presented,
have upon these remarks just quoted.
   To show that the particular variety or kind  of nutrition,
or  its arrest as  by congestions, fevers, or other diseased
states, has a marked  influence  upon the excreta, we can
also  appeal  to comparative Physiology : In  herbivorous
animals (as rabbits),  whose urine is  normally clouded,
troubled, alkaline, and charged  with the carbonates, whilst
it is poor in phosphates  and urea, abstinence causes it to be
       2 
18              ILLUSTRATIONS  OF  DISEASE
            i       i          i   •    ■ *- jnnr and acid, as
rich in phosphates and urea, rendering  it cleai
in the carnivora.  This is because the phenomena of nutri-
tion must then be accomplished at  the expense of the azo-
tised princioles of the blood.   Analogous  differences have
been observed  between birds of rapid  flight and serpents
or other hybernating animals which consume the depot of
food stored in their own bodies.
  And,  even with  respect to  the  special  mode of action
of certain medicinal agents, without citing  numerous ex-
amples at his disposal to show that such examinations are
not futile, the  writer will allude  to one  substance,  con-
cerning which  he  published  his  views some  time since,
and which were based  upon researches of this character.
They tended to prove that  we  should now cease to regard
the action of the  salts  of  cinchona or quinia in malarial
fevers, as  in their nature specific—which  term was equiv-
alent to  an  acknowledgment that  we did not understand
it.  For  the researches of Dr. H. Stuart,  of this State,
and his own repeated series of observations upon Inter-
mittent and Remittent  Fevers, have convinced  him  that
it was,  perhaps,  sufficiently explained  by  their  positive
influence  as renal  depurants  of phosphates, urates,  pur-
purine, bile, and other  products of hepatic  derangement,
as  well as  of the poisoned blood.   The  discharge of all
these the salts of  quinia  and cinchonia facilitate, which,
when accomplished, is generally coexistent with recovery.
These  efficient remedial agents, probably, affect  these im-
portant results  when absorbed, by  their primary influence
upon the nervous matter—pneumogastric  or ganglionic—
upon  which  the action  of  the   glands  and  the entire
capillary  system  is dependent.  The primary influence of
sulphate  of quinine upon  the nervous matter is marked,
affecting  the nerves of  audition,  and producing a de-
cided effect in cases  of neuralgia,  and  givino- tone to the
nervous  system  even when given in small  doses,  thus
acting as a tonic.  Its  complete effect, as an eliminatory
agent, is  attained when large doses are employed,  when
its full power  as an  antiperiodic  is  secured.  Chlorate of 
WITH THE MICROSCOPE.
19
potash and other  agents  of this class, now  so largely
used, undoubtedly act  upon the glands  and upon  the
blood during the process by which they are excreted.
  The pursuit of  these investigations  has, also, enablec]
the  writer  frequently  to  detect  in  the renal excretion,
substances  which  had  been administered internally, as
iodine after iodide of potash,  etc.   And  even  after the
tincture  of iodine  had  been applied externally  over the
entire surface of a leg, he has been  able clearly  to recog-
nize it,  after  a certain  time, in  the discharges  from the
bladder.   (See examinations in the body of the Essay.)
Thus proving absorption through the skin, and  throwing
doubt upon the  conclusion deduced  from the  experiments
of Rousseau,  Dangerfield  and  others, which  taught that
the  only mode  of admission into the  system of agents
applied  externally, was by emanations  from  them re-
ceived into  the lungs.  Vice versa, I  have  detected, by
the  usual tests, the bichloride of mercury  externally in  a
discharge from a  syphilitic ulcer, after it had  been for
some time  administered internally—all of which was de-
monstrated to  students attending  the Marine  Hospital
in this city.
  It would seem  strange,  perhaps,  that  I should be re-
quired to offer further arguments for the  possible utility
of studies, microscopical or chemical, which have engaged
the  attention  of  some of the most distinguished  minds in
Europe  and in this  country; yet there exist those who
do decry their utility in any  particular.
  Certainly, this is not the place to introduce  a defence
or farther plea for such examinations;  but,  setting aside
the  convictions resulting from  my  own daily experience,
and my somewhat extended opportunities of forming an
opinion, I  would  ask one  question: Is it productive of
no   satisfaction  or advantage for the  physician  to  have
definite  and  correct  notions  concerning  excretions  and
secretions, to which his attention is  occasionally  attracted
by  their unusual  appearance;  and  when, before minute
scientific examination, he  is frequently  in doubt whether 
 20              ILLUSTRATIONS OF  DISEASK

 that appearance is owing to the presence of  blood,  pus,
 mucus, oxalate of lime,  uric-acid, albumen  in excess, or
 simply to  the existence of a large amount of the phos-
 phates  caused by an  indigestion ?  Some  of these, un-
Yloubtedly, are significant of grave organic lesions, whilst
 the others are comparatively unimportant.  I would ask
 whether the presence or  absence of any  or all  of them
 is a matter of supreme  indifference to the practitioner?
 Mialhe considers  the  escape of albumen, or albuminose,
 in  excess,  as always an indication of  some lesion of
 structure, and, of course, very  different from the mere
 deposit of crystals, thrown  down  from urine containing
salts,  previously   dissolved  by  the large  proportion of
 water present. (" Chimie appliqittc  ti la. I hysiologie ct  a la
 TJicrapculiqitcX)   So blood can  sometimes  be discovered
 only by the microscope, and, before examination, is often
 confounded with  the red urates  and uric acid stained by
bile and purpurine.   The  same is true of many other
 substances; the distinction  between mucus  and  pus, for
 example, is with  difficulty, if ever, made out after all the
 appliances  of art  are brought to bear  upon  them;  yet,
the  detection  of either, which can  readily be accomplish-
 ed,  wdll  always reward the attempt.  How often  has the
 writer been appealed to  to  determine the precise nature
 of  secretions which,  by their  appearance,  gave  rise to
 uneasiness  in the  minds of  both patient  and physician,
 and an answer, favorable or unfavorable (in some cases
 violating all  preconceived  opinions founded  on  a mere
 casual inspection), either  set at rest  all disquietude, or
 confirmed the justness  of it.   Even  a few drops of nitric,
 or  other strong  acid,  will  disclose the presence of  an
 enormous  amount of albumen which  had  escaped from
 the  blood  itself, but  held in chemical solution in a  per-
 fectly clear fluid,  not suspected,  before  the application of
 such test, to be in  any degree morbid.  I have seen a  per-
 son, for example, dying from the  excessive drain caused by
 the escape of albumen, after apparent recovery  from an
 attack of lellow Fever, with the renal excretion  seemingly 
WITH  THE MICROSCOPE.                21
perfectly natural, till  the  requisite examination 'disclosed
the enormous amount of albumen held in  solution.   He
was- dying  of  the albuminuria.   Not  to  multiply exam-
ples of this character,  we  may safely assert that every
circumstance connected with the  sick  is important.  The
pulse,  tongue,  general appearance, heat of  surface, injec-
tion of eye, contraction or dilatation of pupil, amount of
perspiration, etc., etc.;  so,  also, are the  excretions  and
secretions.  If it is entirely  useless  to examine into  the
nature of  any  unusual amount of substance  present  in
the  renal  excretion,  in  order  to assist  in ascertaining
whether  the bladder,  urethra, or kidney is  at fault, why,
then, does the  careful physician think  it worth his while
to enquire as to the physical appearance of the fecal dis-
charges—whether  watery, bloody,  purulent,  bilious  or
natural?   Why does he  seek to obtain clearer  and more
accurate  insight  into  the nature  of  any  outward  phe-
nomena,  seemingly the result of morbid processes hidden
from his view?  I do not think it complimentary to  the
Association  to  proceed  much  farther in  this  direction,
but will call to my assistance the opinions of others.
  And, first:  of the utility  or  essential  importance of the
microscope, itself, in  clinical studies.   Under article "Mi-
croscopic,"  in Nysten's  "Dictionnaire  de  Medicine,"  M.
Robin,  probably, uses  this  language: "La microscope
n'est pas  pour le biologiste et  le Medicin un  instrument
d'ont,  suivant  sa volonte, il  peut indifferemment ou se
servir  ou  se passer.   C'est un  instrument d'ont  l'employ
est parfaitement  determine.  II est  destine a. nous  faire
connaitre   un ensemble  considerable  de  parties apparte-
nant aux  etres organizes; parties d'ont  l'etude ne  peut
etre suivie a Toeil un, ni a I'aide d'un autre instrument.
II est  indispensable; etc., etc.   Mais pour  le Medicin ce
ne  sont pas la des  objets de simple  curiosite; il a en vue
lcur utilite dans tel ou  tel appafeil,  leur  role dans tel ou
tel ordre de fonctions, a l'etat normal et a l'etat morbide."
  In order to  show, to  those who will not listen  to  any
but  voices  from  abroad,  that  some  examination  is often 
22              ILLUSTRATIONS OF DISEASE

useful, I will quote, from  several authorities, the follow-
ing rather miscellaneous remarks.  "This deposit,"  when
speaking of the urates,  stained red by the coloring prin-
ciples, urrosacine, etc., "is  often taken by the naked eye
for  pus or  blood, and it is  not infrequent  to  see  the sick
treated in  consequence."   (Nysten's Dictionary, article
"Sediment")  '
  "The  condition  of the  urine in  these cases,"  whilst
referring  to  cylindrical  fibrinous  casts  of  the  urinary
tubes  appearing  in acute  desquamative  nephritis, "is
clearly indicative  of  the process going on  in  the kid-
ney."  It  is only  by  microscopic examination  that  we
could  be aware of  this coexistence.   (See article "Ben,"
by  Dr. Johnson, in  Todds' Eucyc. of An at. and Physiol.,
Part  IV,  p.  -258 ;  also, Dr.  Todd's paper  in  Medical
Gazette for June, 1847.)
  "The  microscopical and  chemical  characters combined
supply, however,  the  real  evidence  from   which  their
composition  is  ascertained."  (Walter Hayle Walshe  in
Todd's Anat.  and  Physiology  Encyc, Part IV, p. 75;
article, "Products  Adventitious.")  In same  paper, also,
it is  stated by Dr.  Walshe that:  "The rarity of oxalate
of  lime  crystals in  urinary deposits was matter  of re-
ceived  opinion, until the enquiries of  Dr.  G. Bird led
him to the inference that  in  the cases of disease  occur-
ring  in  London  *  *  *  the  oxalate  is  of far  more
frequent occurrence in  urine  than the deposit of earthy
phosphates."   (Toe. cit., p. 79.)   Certainly,  the  reverse
is strikingly  true  in the  fevers prevailing  in  this city
(Charleston), as  an  inspection of  the drawings  in this
paper will demonstrate.   See,  also,  Statistical   Tables,
Nos.  1 and  3.  So, also, greater  experience and deduc-
tions from more ample data, have  corrected the  assertion
by Berzelius:  of  a general law that uric acid  was the
chief material in  the urine.
   Dr. Walshe, also, has called  attention to the same fact
observed by others, that: "An abundant  precipitation  of
phosphates,  with, mucus and  epithelium,  will  sometimes 
WITH THE MICROSCOPE.
23
 produce an appearance most strangely like that  of pus—
 the  riiicroscope and the  addition of a little acid,  readily
 settle  the nature of the  deposit."   In the hands of the
 writer, the microscope has repeatedly corrected impres-
 sions  calculated to lead  astray,  derived  from the phos-
 phates and  urates  mistaken for pus  and blood, as well
 as a large amount of purpurine for the latter.
   In a clinical lecture, by Dr. George Johnson, published
 in the Medical Times and  Gazette, on "Albuminuria in  Ty-
 phus and Typhoid  Fevers," he says:  "It not unfrequently
 happens  that during the  progress of Typhus and Typhoid
 Fevers,  the  urine  contains  one of  the  constituents of
'blood.   The  secretion may be  simply albuminous,  in  a
 greater  or less degree, or  it may contain a notable quan-
 tity of  blood.  A  deep  blood-tinge  of  the urine is  not
 likely to escape notice; but the urine may be very scanty
 and  very albuminous,  without  any  striking  change of
 color" (as the writer has observed  in Yellow Fever, also),
 "and in such  cases, if your attention has not been  par-
 ticularly  directed  to  this circumstance  in  the  natural
 history  of fever,  a  very serious  complication   may  be
 entirely  overlooked and,  therefore, left without remedy.
 I shall, probably, have repeated opportunities of pointing
 out  to  you  the complications of Typhus  and  Typhoid
 Fevers  with  renal  congestion, a  scanty  secretion of albu-
 minous  urine, and the  early  occurrence of drowsiness
 passing into  deep coma.   In  the meantime, bear in mind
 this practical advice: During  the  progress of Typhus or
 Typhoid  Fever, make  it a point  to examine  the urine
 either daily  or every other day, and test it for albumen.
 This  can be done  with  so slight an  expenditure of  time
 and labor, that the neglect of it  is inexcusable.  If you
 find that the urine is becoming albuminous, and at the
 same time  scanty,  be  sure that  serious  head symptoms
 will  speedily  appear, and give your prognosis  accord-
 ingly:  remembering that  caleris  paribus  the  danger  is
 great in proportion to the scantiness of  the secretion  of
 urine  and the  amount  of albumen; greater,  too, when 
 24             ILLUSTRATIONS OF  DISEASE

 this complication  occurs  at an early period of the febrile
 disease than  when  the malady  is more  advanced,   etc.
 Drv cupping to loins, etc., etc., advised.
   Dr.  Anthony White (late President of  the College of
 Surgeons),  in  his paper on  "Gout," Medical Gazette,
 August, 1848, remarks:  "And the most we  can venture
 to  assert  is, that  the  renal functions, in common  with
 others,  are secondarily affected by the cause, whatever it
 be, of the gouty  diathesis.  I think  it the more neces-
 sary to insist on this point, as  it is  one ou  which so
 acute  and lucid  a  reasoner  as  Dr.  Holland  appears to
 have  fallen into  error.  "The kidneys,"  he  says,  "are
 evidently the organs  of the body,  upon the disordered or
 deficient action of which depend those  changes  in the
 circulating fluids  which  have the closest  relation to all
the phenomena  of Gout."  He would, I think, have  been
 nearer the truth if he had said that "the  kidneys are, of
all  organs, those  whose secretions afford the most faith-
ful,  and the  most  readily  discernible evidence  of the
 changes aforesaid."   (Also, Braithwaite's  Retros., p. 39,
 Vol. XVIII.)
  The  writer has only  within  the  last  few days  seen
 Golcling Bird's paper on the "Depuration  of the Blood,"
 from  which he  quotes as follows,  to corroborate his  own
 views, long  since published  in  the  Charleston Medical
 Journal and Review, on the coexistence in certain fevers
 of amelioration and recovery, with critical discharges:
   "An illustration, also,  of another fact, and a  very im-
 portant one,  to  which I have  already alluded__that  a
 direct ratio exists in certain diseases,  between the excre-
 tion of a  definite  portion of effete matter from the blood
 and  the  amelioration of  the  patient's  condition,  such
 amelioration being protanto critical."  He then relates two
 cases of Ague,  in which the  amount of solids  excreted
 in  the urine was  ascertained  at  regular intervals  durino-
 the treatment.    "It  was found   that their amount in-
 creased in the ratio of the improvement of the  patient' "
 Did space permit, I  could quote nothing  more' apropos 
WITH  THE MICROSCOPE.               25
than the continuation of Dr. Bird's views respecting the
connection between these critical discharges and the true
nature  of  the  diseases themselves.   My own  series of
observations are only confirmed by the above.  (Consult
Charleston  Journal—papers,  respectively,  on the Pathol-
ogy and Treatment of Yellow, and on Remittent and In-
termittent Fevers.)
   Bird also  says:  "That the kidneys can  depurate the
blood, not only  of matters generally  regarded as proper
to  their  function, but of  substances  which  it  is  the
normal duty  of other emunctories to separate  from the
animal organism."
   T quote, again, from Dr. Bird, Braithwaite's  Retrospect,
Vol. XXVIII,  as  confirmatory of  what I  before  stated:
"I am  anxious to announce to you  a new fact;  one which
bids fair to be  of great importance in the treatment of
disease, and  one  which, I believe,  has never  yet been
announced,  and  which  the  examination  of  the  urine
secreted under  the influence of remedies,  has led me to
discover.  It is, that we possess remedies which, when admin-
istered, remarkably  increase  the metamorphosis of  tissue, and
enable its to produce at. will the very depuratire  effects which
I hare pointed out  to  you as resulting normally in the course
 of certain  zymotic  diseases.  In  taking a practical  view  of
 the so-called diuretic agents, it  will  now  become neces-
 sary to divide  these  into two  classes: the  one  including
 those which  simply  increase the bulk of the  urine; the
 other those which act as renal alteratives  and aid the de-
 puration of  the blood."  As  I  said  before, I  have only
 read the above  for the first time since  these introductory
 remarks had been thus far already written, though I liave
 long been  a  careful  student  of Dr. Bird's larger Treatise.
 Indeed, these  pages  have only been  interpolated  here
 since  the  beginning  of  the present year (January 4th,
 1860).   (Sec  my own series  of cases  in this paper,  under
 the collection  entitled:  "Intermittent and  Remittent Fe-
 vers,"  where the  relation between the stage  of the fever
 and the matters  excreted is attempted to  be established
 by careful examinations—microscopical  and chemical.) 
 26             ILLUSTRATIONS OF  DISEASE

   I think it not inappropriate,  to  that portion of  the
 subjects of this Essay with  which I  am  at present occu-
 pied, to  quote the  following from  the late  Dr. Charles
 Frick's lecture  on "Diuretic Remedies," before the medi-
 cal class  of the University  of Maryland, February, 1860.
 It  shows the action of  certain remedies  upon the blood,
 thereby  modifying  the excretions,  and  acting  as renal
 depurants.  These and  other extracts which  follow from
 recent authorities, published since this Essay  was  accept-
 ed  by the Association,  I introduce,  as they  all  tend to
 explain doctrines which are most practical  in  their  re-
 sults, and which now  occupy the  public mind.   They
 constitute, at  least, one of the advance columns  in which
the most  recent spirit  of  research  is now pushing  for-
ward.  I  may bring up those  made in other directions,
also,  preparatory  to  a full  comprehension of the entire
field,  that as  many  elements as possible of the problem
of disease  may be seen at a view.   These  will contain
the collateral progress made in therapeutics, also.  Phy-
siological  chemistry  has  been  much reviled  even   by
those high in authority;  but, with  its  aid, the best ad-
vances  are  made in rational  practical  medicine.   It is
so  intimately  connected  with  the  latter,  a  distinguish-
ed  cultivator  in  this  country (Professor W.  A. Ham-
mond) remarks: "As  to  exercise a  very material influ-
ence  upon the views  of  those  physicians who  act  in
accordance with facts rather than  fancies,  and  as  a con-
sequence, has  modified to  a considerable extent the prac-
tical  application  of  medical principles."   Witness  the
researches of Liebig,  Koelliker, Lehman,  Yirchow, Ber-
nard; Sequard, Mialhe, Day, and  others.   Dr.  Frick says:
  "You are  aware  that the  fibrine  of the  blood—the
coagulable element—undergoes  various changes in  dis-
 ease, both  as  regards quantity  and quality.  So far as its
 quantity is concerned, a vast increase  is noted in inflam-
 matory and certain  other  morbid conditions, amono- them
 Rheumatism,  in  which  the absolute  amount  becomes
 tripled, and  even quadrupled, above  its  usual  healthy 
WITH  THE MICROSCOPE.
27
standard.   *  *  *  I  hold that this increase is rather
the result of retrograde than of formative changes. There
are others, however,  who maintain a  different  view,  and
think the large amount of this fibrine  in the blood which,
as I just  said, is one of  the characteristics of acute rheu-
matism,  is the  cause  of  many  of the phenomena of the
disease;  and as the alkaline  salts have the property to a
very  great  degree, when  given in large  and  continuous
doses, of  destroying  the  plasticity   of  the blood,  and
diminishing  the quantity  of  fibrine  it  contains, would
assume that  the benefit derived from these remedies  is
due to this  fact.   This  may  be so; but whether correct
or  otherwise, I am satisfied  that all  the  good effect ex-
erted  is  not in this mode.    Not only  do  the  alkalies
lessen the  fibrine, but,  like  mercury, they increase the
waste of tissue, as  well  as of the  elements of the blood
itself, and, when disease is  present,  the  morbific princi-
ples  that  this  fluid contains.  It  is  in  this way that  it
(bicarb,  potash) proves beneficial in  Rheumatism, and  is
preferable,  as you  have  seen,  to both the carbonate and
acetate, as it is less  irritating, and to mercury because it
is more manageable.  But, in the treatment of  this dis-
ease, it  is  necessary that it  should  be  administered  in
large  doses—at least 30 to 60 grains every two  or  three
hours, if the  stomach will bear it.   It is, of course, in-
applicable  to cases  of Rheumatism  occurring in debili-
tated  and ill-nourished individuals,  and is, therefore, not
a specific for it, as many  of its advocates would seem  to
imply.  It  will be noted, also,  that  under its use-when
it acts favorably, the quantity of urine becomes increased,
and  there is, also, an additional amount of solid material
contained in it.  It  is, therefore, in one sense  a  diuretic,
but I beg you to recollect what I have stated, more  than
once, that this increase  is not  so much owing to  stimu-
lation and increased function on  the  part of the kidneys
as because  the remedy  has  produced additional  waste,
and  has, therefore,  provided  more  material for  these
organs to  excrete."   These remarks may equally  apply 
  28              ILLUSTRATIONS OF DISEASE
  to all  remedies of this  class, viz:  chlorates, acetates, aim
  citrates of potash, carb. of lithia, etc.
   Dr. Alfred Stille, also, in his excellent  treatise on the
  Materia  Medica  and  Therapeutics,  recently published,
  very nearly, if not entirely endorses  these views, as fol-
  lows—Vol. II, 641, article "Diuretics," I quote from him,
 also, as collateral authority  to strengthen the position long
 since assumed by myself—"Formerly, a great many dis-
 eases were held to depend upon an acrimony in the blood.
 By  this term  was  understood certain particles which, by
 their shape or their chemical action,  irritated the tissues,
 and thus  gave  rise to  the local  phenomena of disease.
 However plausible  this doctrine may  have  seemed, it has
 not  the support  of the actual  observation of any  such
 morbid agents, nor of any  arguments, by  the way of ex-
 clusion, which prove the necessity of their existence.
   "The effects of miasmata  and  various  more tangible
 poisons  we  are  acquainted with,  and  the probable ex-
 planation  of their  morbific  agency, is  that  they  act
 upon the blood  catalytically, or in the manner  of a fer-
 ment.   As regards  many  diseases, it  may be  assumed
 that they  arise  from  a retention in the  blood not of sub-
 stances  essentially foreign to  it, but of  some  which  have as-
 sumed a new form, rendering their presence  in the svstem
 incompatible with health.   In other  words, they are the
 excrementitious  matters of  nutrition.  As,  next to  the
 foeces, the  urine of all  the  excretions  contains the largest
 proportion of such  substances, a diminution of the quan-
tity of it excreted necessarily  involves  a greater or less
 deterioration of the blood, and its renewed  or auo-mented
 discharge as  necessarily  tends to the purification  of the
vital fluid, provided that the  proportion of  solid effete
matters contained in  it  equals or  exceeds the  normal
quantity."
  Dr. S. fully  sustains the views of Bird and others as  to
the material value of renal depurants.
  "It  seems  probable,  therefore,"  he adds,  "that   they
decompose, destroy, and eliminate a material morbid cause 
                  WITH THE MICROSCOPE.                29

circulating in the blood, or, what is quite as probable, that
they  promote  the  elimination  of the  effete  substances
which hare  been produced by the  action of that morbid cause,
and  thus literally purge the capillary blood-vessels of the
noxious  materials with which they are loaded, and which
interfere with all  the  processes of a healthy nutrition.  It
seems to be  a  rational  opinion that every  disease, and
especially every febrile disease,  is attended  with an in-
crease of the  destructive processes proper  to  the  econ-
omy, while  the organs  destined for the  elimination  of
the  resulting substances  become  engorged, and unable
efficiently  to continue  their  function."   (The  italics  in
the above are my  own.)
   In continuation  of this subject,  and  as  Intermittent
and Remittent  Fevers form an important subdivision  of
this  Fssay, I quote here a paragraph someAvhat modified
from  my  paper (Charleston  Medical Journal)  on  ltSul-
phate of Cinchonia as a substitute for Quinine," in  refer-
ence to  their action in malarial  fever.   No  effort is  made
to show  the nature of malaria, but only some of its effects:
   " Malaria (whether dependent upon  ozone,  electricity,
ciyptogamic plants, chemical compounds,-gaseous or other,
the  product  of  decaying vegetable  substance  under the
combined influence of heat and moisture) is but remote-
ly  the cause, of  the  phosphates, urates,  bile,  purpurine,
 high color  of  urine,  increased  heat and  vascular action,
 etc., which characterize  these  fevers.   Such  phenomena
 result, I  suggest, from the influence of the cold  stage—the
 disease in action—upon the central organs,  glands, diges-
 tive  track  and capillaries, which  are  known to  be con-
 gested.  The nerves  and nervous centres, dominating all,
 are, perhaps, primarily disturbed; and  quinine only  cures
 by  its action  on  the nerves which  specially  incite the
 capillaries,  promoting  a  tonic  and  detergent  influence
 which results in  throwing  out  the products of waste  of
 tissues, the products  resulting  from alteration  or excess
 in  the  elements  of the blood,  of  combustion, etc.  By
 these means the niatcries morbi, the effects of the disease, 
  30             ILLUSTRATIONS OF DISEASE

  nay, the cause itself if it  is material, may be eliminated,
  and the disease put an  end  to.  It may accomplish  all
  this by  its sole,  direct action  on  the  nervous  mattpr.
  Thus, also, it  may anticipate and prevent the chill  when
  taken by one  exposed to malaria, by its  continued action
  on  the nervous  media; also, by keeping up an influence
  in the capillaries, resisting  or antagonizing  the  morbid
 influences produced  by the malarial poison, and eliminat-
 ing the products of the latter in  the blood  as they  are
 produced."
   To  continue from my paper:  "Quinia acts almost  in
 as purely physical a  way as narcotics or any such  agents.
 It contains, or is, a  principle capable of acting, perhaps,
 directly upon the nerves, and  also  of being  received  in
 the  circulation by absorption; of penetrating the ultimate
 arterioles and venules constituting the capillaries throuo-h-
 out  the  system,  including  the  brain,  and thus acting
 upon the cerebral  substance and  nerves  proceeding from
 it, by which they have increased energy imparted to them.
 It thus causes increased  activity of function ;  so that the
 products of waste of tissues (whether as the cause or the
 result  of  chill),  including phosphates, urates, saline   of
 coloring matters in  the blood  and liver,  are  thrown out
 of the system.   This being  accomplished  (aided, if ne-
 cessary, by  calomel,  opium  or  stimulants),  periodical
 agues and chill, caused by malaria, and giving rise to these
 accumulations, generally disappear.  They are liable  to
return  when there is  reaccumulation of  these  products
by the presence  of some of the cause still remaining—to
be removed by a repetition of the same  course.   And I
believe that sulphate of cinchonia possesses similar  pow-
ers, but,  perhaps, to  a  less  degree.   For sulphate of qui-
nine to enter the system, it  requires the intervention of
the gastric acids, as  it is a basic compound,  and hence
we very  properly add a little sulphuric acid 'to mixtures
containing it, to render it more soluble.  For it is quinine
itself,  says  Mialhe  (' Chimie  applioue'),  which   'duco*
its  dynamic  action,  from whence  results  a lowering  of 
WITH  THE MICROSCOPE.
31
the temperature, stupor of the  senses  and general pros-
tration, and not  its saline combination, as when we give
it, for example, in the form of a  salt—the acid with which
it is united only serving as a vehicle for its introduction
into the  blood.   'There it is,' adds Mialhe, 'that quinine,
placed at liberty  by means of the  alkaline carbonates, exerts
its action  as  a  modifier.'  I  may  observe  here the  gen-
eral principle: that pressure being  removed by all agents
which lessen  the heart's action, they favor excretion  and
exhalation.  Quinine, besides  this effect of large doses, is,
also, in small  doses strengthening and tonic, and contracts
capillaries; but I think that even  the  first-named result,
viz: its  power as a depuratory agent, depends rather upon
its tonic influence upon the nerves, and that this increases
capillary action.   Large  doses are  oppressive, because ap-
proaching to  the character of a poison, and morbid sensi-
bility  is manifested."
   The galvanoid and electroid influences acting upon the
capillaries  through  the  instrumentality  of the  nervous
media, the contraction and  expansion of the  capillaries,
and the sources of increased animal heat during fevers
and inflammation, dwelt upon  by  Billing and others,  I
may again refer to, as they  are particularly important in
this connection.
   Dr. Headland  thinks that "some diseases may be cured
in two ways;  either by the supply of something, or by the
neutralization of something  else,"  and he suggests  that
Ague is perhaps one  of these.   "And  it is  not repug-
nant to what we know of Ague  to suppose  that there
is in  it a want of some  natural  material which would
have,  when  present, the  effect of  checking  the  opera-
tion of  the morbid agent.  The fact of having had Ague
 once  does  not, as in the case of the eruptive fevers, pro-
tect a man from the disorder thenceforward.   So, in this
sense, all  persons may be said  to  be liable to Ague, and
 none  protected  from its assault.   But it is not the  case
with Ague as it  is with Syphilis  and Small  Pox, which
diseases most persons  inevitably  catch who are exposed 
 go              ILLUSTRATIONS OF DISEASE

 to the virus  for the first time  in  their  lives.  For,  of a
 number of persons exposed to the same malarious  influ-
 ence,  only  a  part  take  the disorder;  some  escape. ^  It is
 o-enerallv"found that those are most likely to  take it who
 have been  previously debilitated by  any cause;  so  that
 we must suppose  that the rest have in  their  blood some
 material which serves to prevent  the working  in it of the
 Ague-poison,  which apparently must enter it.   It is not
 unlikely, then, that Ague  may be cured by supplying the
 want of this material."
   He  goes  on further to  state more precisely, that there
 is in that, part of the bile which is  absorbed into  the
 blood,  a  crystalline substance bearing a resemblance,  in
 several important  points,  to  the bitter  alkaloids.   --It is
 discovered,  by  careful  experiment,   that  quinia, when
 taken  in moderate doses, is   not  excreted  from the sys-
 tem, but retained  in the blood like its  analogue taurine.
 It being  thus  shown  that quina  adds something  to the
blood, and  it  being granted   that  it cures certain disor-
 ders,  a presumption is  lastly established  that these dis-
 orders are connected with some deficiency in  the blood,
which may be supplied by  such an agent."
   The views on  this particular subject presented  by this
author contain little more than  a speculation, yet I will
quote  them here  in this  connection,  as  it may serve to
build up some more correct theory:
  "I  have already made use  of  one of the principles of
the bile, for the purpose of showing that aniona- the  nat-
ural constituents  of the blood there is a  substance which
chemically resembles a  tonic  alkaloid, like  quina.  This
similarity admits  of a further and  more  distinct applica-
tion.
   "It  is ascertained that many, if not  all, of the diseases
in which quina and its kindred  medicines are found to
be of use, are connected with  a derangement of the secre-
tory functions  of the liver.  One of these diseases is the
debility  which is  consequent upon Typhoid  and other
fevers.  In  these  fevers the  function  of the  liver i^ al 
WITH THE MICROSCOPE.
33
ways more or  less interfered with, though more obviously
in some  cases than  in others.  In strumous habits—in
which, generally, bark is of signal  service, and  was very
strongly recommended by  Cullen,  Fordyce and others—
there is  found commonly  a peculiar degeneration of the
liver, which has been  ably described  by  Dr.  G. Budd.
This state is distinct from the fatty enlargement common
in Phthisis, in the early stage of  which disease quinine
is also very serviceable.
   "Quinine is often beneficial in Gout, in which the liver
is always more or less  deranged.  (A celebrated nostrum,
the 'Portland  Powder  for  the Gout,' contained another
bitter—gentian.)
   "Turning to periodic diseases,  we  find that impaired
hepatic  functions are the rule, and the  absence of such
disorder  the  exception.  This  will  be  at once admitted
in the  case of Dysentery, and of the Remittent and Yel-
low Fevers of the Tropics.  It is also true of Ague.   It
seems even likely that the enlarged spleen may be partly
caused by an obstruction to the circulation in  the  liver.
This affection  of the  spleen  is not uncommon in  other
liver diseases.
   "In Typhus Fever, both the spleen is  disorganized and
 the  liver deranged.   It is observed in  tropical countries
 that severe forms of remittent not unfrequently pass into
 continued fever, which seems  to  point  to some analogy
 between the   two.   Ague, even, may pass into Typhoid
 Fever.  And  quina  has of late been strongly recommend-
 ed in the treatment of  continued fevers in general.
   "Dr. Watson states that  in New Zealand the  biliary
 functions suffer so much in the Intermittent which occurs
 there,  that  it is known  among  the inhabitants by  the
 name  of the  'Gall-fever.'  (Lectures on the Practice of
 Medicine, Vol. I, p.  793.)
   "Asiatic  Cholera  is  considered by  many  physicians
 to  be  a kind of  terrible  intermittent, which seldom
 lasts  beyond the second  (or cold)  stage.   The  secre-
 tion of bile is completely  arrested   during   the  con-
        3 
34              ILLUSTRATIONS OF DISEASE
tinuance of  the  rice-water purging.   Quina  has been
tried  in Cholera, and the  beneficial results  have been
sufficiently marked  to encourage us to  give  it  a more
extensive trial in  the event of another visitation.
  "Let us now  place in  conjunction  with  these facts,
the similarity which  has been pointed  out between the
bitter  vegetable  principles  and one of  the chief constit-
uents  of the  reabsorbed  bile.  Quina and others resem-
ble in many  points  a certain  principle in the bile; they
tend  to  cure certain  diseases, and these  diseases depend
on  deranged hepatic  functions.    Does not this  suggest
the possibility that they may be  of service by  actually
forming the  above principle, or by supplying its place in
the blood?   It is possible that such bodies as quina and
cinchonia may be able  to fulfil  the function  of bile in
the blood by remaining as  they  are, wuthout even chang-
ing at all.
  "It  is just possible that  the presence  in the blood of
the bile-product,  the  supply  of  which has been  cut off
by  the hepatic  disease, might have  prevented the con-
tinued action of the ague-poison.
  " There is  another fact which gives additional probabil-
ity to  such an idea.   Another remedy of  a  different kind
has been used in all  the diseases in which quina is ad-
missible, proving in   some cases  superior,  and in other
instances second  only to  it in its  beneficial action. This
is mercury;  used in  Remittent  and Yellow  Fevers; of
the first importance in Dysentery;  employed by Dr. Baillie
in Ague, and  pronounced  by him to be in  some cases
superior even to quina.   In small doses,  it is  frequently
of  use in cases  of Debility  and  Scrofula.  And mercury
is a cholagogue; i. e., an agent  which is known  to have
the effect of  promoting the  secretory function of the liver.
Thus we may conceive that  mercury, not  given in excess
or  to  salivation,  may  operate  in  a  different way  to pro-
duce  the same  end   as quina.   One explanation would
suffice for both.
   "If this connection between tonics and  the  bile were
f 
                 WITH THE MICROSCOPE.               35

actually  established,  then we should  be enabled  to  ex-
plain  a matter  which  would  otherwise  seem  difficult to
understand; how it is that  small doses  of mercury may
sometimes act as tonics, though we  know that the ulti-
mate  action of this medicine, like that of other catalytic*,
is to  deteriorate the  blood.   Even in scrofulous and en-
feebled cases, small  doses of blue pill or of calomel are
often signally useful; and not prejudicial, as  is sometimes
stated by those  who  confound their application with that
of  mercury  given  in  salivating doses.   Under such  a
course, when judiciously enforced, we  may see the  dilated
pupil  contract to its normal size, and the pale, enervated
countenance become  rosy and lively, and feel  the  weak,
compressible pulse become hard  and  firm.  Perhaps mer-
cury  in such  a  case  may be, indirectly, tonic, by restoring
to the blood the natural tonic principle of the bile."
   Alkalies, and particularly soda, which are so important
 in  fevers and other  disorders where  the biliary functions
 are deranged, it will  be remembered, enter largely  into
 the composition of  bile;  and  hence these agents may
 perform  a much  more important role than  simply the
 neutralizing the too excessive production of acids usually
 accompanying  depraved condition of the  gastro-intestinal
 surfaces  during fevers.  They  act,  in other words,  as
 succedanea for principles important  to  the  health}' econ-
 omy,  the production  or secretion of  which is  arrested by
 disease.   I may refer, in passing, to  a  valuable paper on
 the alkaline  agents, by  Dr. Andrews, published  in the
 Chicago Journal,  February, 1859, and  translate the fol-
 lowing from M. Mialhe, which is commended  to the  con-
 sideration of the reader:
    "'Alkaline agents (of which the preference is  not im-
 portant, potash being quite  as good  as  soda,) give rise to
 and  disengage  ammonia in the system.  *   *   *  The
 alkalies, by  reason  of their importance in  the  natural
 phenomena of  decomposition,   of absorption,  of oxida-
 tion   of  sugar  and  starchy  substances, of  fatty matters,
 oils and resinous substances, are  at the head  of the most 
 36              ILLUSTRATIONS OF DISEASE

 useful  and much  used  medicines.    They maintain  the
 blood in its necessary degree of viscosity, fluidify its  too
 great coagulability, increase circulation, dissolve the prin-
 cipal elements (albumen and fibrine) which constitute  the
 bases of nearly  all engorgements.  They  liquify the ele-
 ments  of  the  bile, prevent them from becoming  thick,
 from concreting together, from  forming  calculus.   They
 reanimate and regulate  intestinal digestion; facilitate the
 secretions; saturate the  acids,  which,  taking their  origin
 within  the economy, can, through  their  excess, occasion
 disease :'  Such  as Gout, Rheumatism, Diabetes, or  those
 insoluble collections constituting  chalky concretions, uri-
 nary calculi, deposits, etc."
   I  hope  to give  increased prominence,  at some future
 time, to a remark from Becquerel,  referred  to by Dr.
 Stille, on  account  of its  bearings upon  the prevention of
 some of our epidemic and  endemic zymotic diseases.  Becque-
 rel first observed  that  even in  health,  the  quantity  of
 solid food  remaining the same, the  amount of solid mat-
 ter in the  urine  is somewhat increased by increasing the
 quantity of water  used  as  a drink.*   A  statement  fully
 confirmed  by  Bird, "who explains  by its means the effi-
 cacy  of mineral  springs  famous for their curative  influ-
ence  in  chronic  disorders, and which are but little,  if  at
 all, mineralized."t   Dr.  Rush, himself, referred  to the pro-
 phylactic influence of purgatives  taken at  the inception
 of Yellow Fever, which  always begins with constipation;
 and  I am  not  only prepared to learn  that  slightly miner-
 alized artesian waters, however mildly impregnated, will
 prevent the spread of Yellow Fever and  other blood dis-
 eases by their slow, but  constant, eliminatory action  upon
 the blood through  the glands, but I have  long since pub-
 lished (Charleston Medical Journal) a suggestion, which I
 await an opportunity more fully still to test, that artificial
 saline  diuretics will  be  found  to  be  highly efficient for
the same purpose.   Their depuratory  influence  upon the
*Semeiotiques des Urines, 1841, p. 140, and Stille, Vol II 642
J Stille, loc. cit. sup.                           '
• 
WITH  THE MICROSCOPE.
37
glands may retain  the blood in a condition of health, by
eliminating  the  rna.teries  morbi of  contagious disease as
fast as they accumulate in the system  of those exposed to
the influences which  give rise to such diseases,  and thus
act as prophylactics.   A  course  of bicarbonate or citrate
of potash, appropriately combined  with quinine, perhaps,
and  an occasional laxative,  may  prevent,  in  the opinion
of the writer, the  inception  or maturation of Yellow  and
Scarlet Fevers!  No  more  remarkable than that quinine
wards off the  incursion  of  Intermittents—which  is  ad-
mitted.  Even  so  apparently  vulgar  a popular idea as
that which exists, that the  free use  of molasses  on our
plantations  prevents   the spread   of  Typhoid Fever, I
would, from  theoretical  grounds, not  be inclined to re-
ject too hastily.
   To  show  the probable mode  of action of vegetable
acids in fever, I quote from Headland ("Action  of Medi-
cines," third edition, p.  150).  It gives  some  color to
the project for preventing the depraved condition of  the
blood  in  fevers and zymotic diseases,  by certain elimina-
tory agents:
   "In many  febrile  cases it is found  that diluent drinks
containing the free  vegetable acids,  act beneficially in
lowering  the pulse  and  in moderating  the  progress of
the  disorder.*   These  should  be  distinguished  from
saline drinks, whether of mineral or  of vegetable  acid
salts;  for  salts, from   their known  effects on  the blood,
would seem  to  belong simply  to my  division of cata-
lytics.  But  the effect of these  vegetable acids  seems to
be to  restore the blood to a more  natural condition,  and
this   independently of the  faction of the  diluent with
which they  are  administered.  It would  seem that in
such  cases the free vegetable acid acts as a  restorative.
In fevers of  a low type, where there is a tendency to alka-
linity, the vegetable   acid may act directly  by neutraliz-
ing alkali in the  blood.   But in  sthenic fevers,  also, it

  "* It is ri-ht to state that this is  doubted by Dr. Maoiagan and others.  But on
the other sido are Dr. Pereira, and the majority of therapeutists." 
38              ILLUSTRATIONS  OF  DISEASE

seems possible that  this organic acid may  step  in  as a
substitute for  lactic  acid, the natural fuel of the system.
In fact, I suppose that in fevers the supply of this  natu-
ral  blood fuel is deficient;  that  the nitrogenous tissues
are  then  consumed to maintain  the heat  of the  body,
causing not only  wasting,  but tending to  keep up the
fever, by the excessive amount of oxygen demanded  for
this abnormal combustion;  that in such a case the  vege-
table  acid is well adapted to take  the place  of lactic acid,
the  material wdiich  is ordinarily  oxidized in  the system
to maintain the animal  heat.  For  though  in health the
ingestion  of such an acid is immediately  followed by  in-
creased acidity of the urine, when used in fevers it does
not pass into  the urine.   It is then disposed of, or burnt,
in the blood.  The alkaline salt of the same acid is  simi-
larly  burnt, as  it would be in health;  but  it leaves a
residue, an alkaline carbonate, which exerts upon the sys-
tem the usual  operation of an alkali.
  "It has  long been  considered  probable, but may now
be  said  to have been proved  by the researches of  M.
Becquerel, that in  febrile  disorders and inflammations
there is excreted in the urine  an excess  of urea and  of
urate of  ammonia—substances which are  formed by the
oxidation of  nitrogenous  tissues.    This  extra-oxidation
probably  arises  from  a  deficiency  of that  matter  which
is the proper food  of oxygen in the system.   This,  as
we  have  seen,  being the step between  grape-sugar and
carbonic  acid, must either  be  lactic acid,  or  something
similar  to it.   It  must  be  remembered  that no food is
usually  taken  in  fever;  tjpis  would  at length quite  cut
off  the usual source of this  lactic acid, which is the  starch
and sugar of  the  food, and render it necessary  that  the
animal tissues should continue to undergo  oxidation,  to
maintain  animal heat.  (Rheumatism and  Gout are  an
exception to  this.)   If  we compare the  commonly  re-
ceived formula  of proteiiie  with those of lactic acid and
tartaric acid, it  will at once be seen, as  was  pointed  out
some time ago by  Dr.  Murray,  that the latter contain 
WITH THE MICROSCOPE.
39
more oxygen, in proportion to their carbon  and hydro-
gen, than is found in proteine or albumen.

            Protoine    =C40 II81 N5 O,,.
            Lactic acid  =C6 II6  06.
            Tartaric acid=C8 II4 O,0 + 2 HO.

Thus,  while for  40 equivalents  of  carbon  proteine con-
tains only  12  of  oxygen, lactic  acid contains 40,  and
tartaric 50,  of  that element.   So it seems that albumin-
ous  matters, containing less oxygen,  would require much
more oxygen for their combustion;  this would produce
more  heat,  augment the  number  of  respirations,  and
keep up  the fever.  And though it  has been proved by
A\rolder  that free  vegetable acids pass  out in  the urine
without  having  undergone  oxidation, yet the  condition
of fever  wrould probably be an  exceptional case.   Lactic
acid, the natural  fuel,  being deficient, the  alkali with
which it should  combine must  be  present  in  some  ex-
cess ; so  it  seems likely that a free vegetable acid would
combine at once with this alkali as the  lactic acid would
have done,  and thus be  burnt or oxidized instead of  the
latter.  Accordingly  it has been observed, by  Dr. Rees
and others, that  the  use of these acids  in fevers  and in-
flammations is not followed  by increased acidity of  the
urine.  The action of such an acid is then simply resto-
rative.  Requiring less  oxygen than  the proteine would
need to  transform it into carbonic  acid,  it  would thus
diminish  the  number  of the  respirations, the  frequency
of the pulse, the temperature  of the body—and in this
way allay the  fever.   It  would  be  strongly  confirmatory
of this idea, if it were proved that the amount  of urea
and urates  in  the urine is actually  diminished  by  the
use  of acid drinks  and fruits  in  febrile cases.  This
hypothesis  can only  be admitted on  the supposition  that
fever (in which  there  is likely to  be  in the  blood an
excess of uncombined  alkali)  constitutes an  exception to
the  general rule that  the vegetable  acids pass  through
the blood without undergoing change.
• 
40              ILLUSTRATIONS OF DISEASE
   "Now, the salts of these acids with alkalies, which are
 often  administered  in  the form of effervescing  draughts,
 might  exert the  same  refrigerant  action.   But  there
 would  be this  difference: the alkali of the blood  would
 not be required, the acid  being already combined with.an
 alkali.   M.  \Yohler  has found  that  these vegetable-acid
 salts always  undergo oxidation in  the system—being con-
 verted  into  carbonates or bicarbonates, and  thus reacting
 on the secretions as alkalies.  And  so  in the same way
 it seems that the  natural lactate  of soda is formed into
 a carbonate—the  carbonic acid  being  afterwards  freed
 from the  base, to *be  excreted by  the  lungs.   By this
 natural process  the quantity of alkali in the blood  would
 not  be  increased,  nor  would  it  be  augmented by the
 action of a  free vegetable acid.   But the change under-
 gone by a salt  of this  acid would continually add to the
 alkaline matter  already in the system.  And as alkalies
 have a catalytic action on  the  blood, which  may  prove
 useful in some  sthenic  fevers, it  follows that these salts
 have a double action, and  are not simply  restorative.
   "Rheumatism and Gout differ considerably  from other
 fevers, both  in  their nature and  in  the remedies which
 they  require.   They  are produced  by  special morbid
 poisons  or agencies, which  we are enabled to counteract
 by certain catalytic medicines.  There is in both of them
 an excess of free acid formed in the  system.   Here  alka-
 lies are the  remedies mainly indicated,  for they  neutral-
 ize the acid.  Some  obscurity  rests  upon the subject of
 the use  of citric acid in Scurvy; but as  it seems to par-
 take rather of the nature  of a catalytic than of a restora-
 tive  action, I have  placed  antiscorbutics  in  the second
 division.   It appears likely flat  the catalytic action of
 the  vegetable acids  consists in a certain  ill-understood
 control over  the  progress  of various cachexies  and blood-
degenerations.   Among others, it  has been  asserted, ap-
 parently upon  a  reasonable amount of  evidence  that
they afford a sort of exemption from liability  to Asiatic
 Cholera. 
WITH THE  MICROSCOPE.
41
  In a paper  by Dr. J.  L.  Teed, of Mendota, 111., in the
Am. Jour.  Med. Science, April, 1860, on "Animal  Chem-
istry in its relation  to Therapeutics," and in another on
"Fever and Inflammation," in same  journal, April, 1861,
I  find a true view, I  think, of the elements of the complex
problem  involved in the causation and  nature of diseases,
and  their treatment.  I interpolate  the  following  (July,
1861), as it fully endorses what has been before advanced :
  " The  rational physician will,  therefore, use experience
as his  guide, when  he has no  better; but he will, at the
same time, endeavor to extend his knowledge of the modus
operandi of remedial agents, of the nature and  properties
of the organism, and of  the laws governing it in its whole
and  in its varied parts,  and of the variations induced by
external  or internal causes.  By these means experience,
when correct, will be confirmed ;  when erroneous,  will be
corrected."
  "The chemistry of the tissues is another and an  impor-
tant division of this subject, and one which  hardly needs
more than mention, as it  must be evident that the most
minute acquaintance with the composition of any body, in
its whole and  in its parts, is a necessary prerequisite to its
complete study.  The metamorphosis of tissue  is so inti-
mately connected with two other divisions, viz : the chemis-
try of food and the chemistry of the  excretions, and when
to these  have been  added the  chemistry of the secretions
and  of nutrition, the importance of the subject looms up
before the mind in its vastness and sublimity; the force of
the nervous system  capping the whole, and impressing the
reflective mind with its unspeakable grandeur."
  Dr. Teed gives an account of  the nature of disease and
the indications for and mode of action of stimulants, alka-
lies,  mercurials, etc., very much  in  accordance with the
views long since expressed by the writer.'  I quote the con-
cluding paragraph of his last article :
  " The present state of physiology has been attained chiefly
on the foundation of animal chemistry; for, although the
microscope has revealed  the minute structure, we have not 
42
ILLUSTRATIONS  OF DISEASE
  been able to gain thereby a definite idea of the function of
  the part; but by learning more and more fully the chemical
  characters of each secretion, and by carrying the investiga-
  tion into the  laboratory,  we  have  obtained information
  which has yielded valuable  results.  The same plan  in
  pathological physiology will add greatly to them, and when
  observers shall  take the vito-chemical stand-point, medicine
  will progress as a science and  as an art."
    I find that Dr. Teed also lays equal stress with myself on
  points upon which I had touched when this paper wras pre-
  pared.  It is all very rational, and comports  with what we
  know of the requirements  of the  system  in  disease.   He
  says, in his paper on " Animal Chemistry" :
    "In the case of the pyrexiae" (fevers), "the utmost impor-
  tance attaches  to a correct understanding of the chemical
  changes which  should occur in health, and which do happen
  in the disease, and to the  influence  of remedial agents in
  preventing, counteracting and  removing those morbid pro-
" ducts which keep up the disease, and by their presence and
  decomposing influences induce still farther disorganization.
  The treatment of fevers is essentially a chemical process.
  We use evacuants to  remove  accumulations  of  effete mat-
  ter,  and  thereby  purify the residue;  we act  on  one organ
  to relieve the system  of matters which should  have been
  discharged by  another; we adjust our supplies of nourish-
  ment to the capabilities of the system to assimilate ; we
  supply stimulants to maintain the nerve-force under depres-
  sion. * * * We  examine  the  excretions  with the  view of
  finding their chemical constitution, and the  knowledge of
  the  chemical changes  induced by remedial agents enables
  us to understand the success w^rieh follows seemingly oppo-
  site modes of treatment; the better we are acquainted with
  animal chemistry, with the  greater facility shall  we  be
  enabled  to  adjust our treatment to the exigencies of the
  case, and  the  greater will be the success  attending  our
  efforts.  The knowledge of the modus operandi of our reme-
  dies is similar to the acquaintance with reagents of the
  chemist, and the more they are understood  the less shall 
WITH THE MICROSCOPE.
43
we  be guilt}'  of 'pouring medicines of which  we know
little into a body of which we know less.'''
  This  passage was  strikingly foreshadowed  by what was
written  in the earlier portions of this Essay—and I quote it
partly to show how general these doctrines are becoming.
  My object is to suggest clues of thought to others, if I
cannot  instruct; therefore, though my interpolations since
this Essay was received may give an air of patchwork and
a desultory character to these introductory remarks, I add
still the  following  from  the Am. Jour.  Med.  Sciences,
April, 1861.   They all show the drift of thought of intelli-
gent observers in both hemispheres :
  Dr. Morland, of Boston, in his Fisk-fund Prize Essay on
Uraemia, in  referring to Dr.  Garrod's conclusions, that  in
"Blood from patients suffering from Bright's Disease and
albuminuria after scarlet fever: the kidneys are always de-
ficient in their power of throwing off urea; but with regard
to the uric acid, their excreting function may be impaired
or not," adds:
   "We thus see what serious disturbances may arise in the
system  by a perverted  condition of secretion, arrest of ex-
cretion, and attempts at vicarious elimination of a product
which must, in order to the preservation of health, be dis-
charged from the body.  The diseases thus produced come
clearly  under the head  of disordered vital chemistry.   Thus,
when the above vital  functions are weakened, or totally
disabled, there  must be not only general disturbance, but,
after a  time, some special  manifestation of  disease, and the
results of vitiated secretion, decomposition, and over-worked
and irritated organs."   I believe that in remittent fevers,
gastric  or bilious, generally ushered in by constipation and
arrest of glandular and secretory action, there is the same
production and accumulation  of effete material, which keeps
up the  fever and which must  be removed by the usual elim-
inatory agents, accompanied with or followed by the use  of
some of the products of the Cinchona barks.
   Teed, in  his  paper on  "Fever and Inflammation," also
Am.  Jour. Med. Sciences, April, 1861, says that/car, from 
44
ILLUSTRATIONS OF DISEASE
its very commencement, seems to be a general disorder  of
the whole organic functions:  "In inflammation  the pecu-
liar  product is  an  excess  of fibrin,  in addition to the
varied results arising from the affection of different organs;
in fever the tendency is  to a diminution of the fibrin and
of the red corpuscles, the results of a general derangement
of the secreting functions being added."
  I procure from this author, also, at second  hand, these
definitions:
  Copland writes "that the morbid impression (producing
fever) is first made upon the organic or ganglionic nervous
system, and  owing  to  the circumstances of this system
actuating the circulating, secreting and  excreting viscera,
is  manifested  in  an especial  manner  by the changes ob-
served in the state of vascular action, in the animal tem-
perature, in  the functions of secretion and excretion, in the
circulating fluids, and in the  other functions which are
more or less intimately dependent  upon  the  ganglial
system."
  Virchow says "that fever consists essentially in elevation
of temperature, which must arise from  increased consump-
tion of tissue, and appears to  have its immediate cause in
alterations of the  nervous system."  He adds: "Every dis-
ease may become  febrile;  every disturbance may  form
itself into a  fever if it  extends itself to  the centres which
regulate the waste of the tissues, and the proper moderat-
ing power of the  tissue metamorphosis is suspended."
  South wood Smith remarks: " that the order  in which
the morbid  actions which  constitute fever  occur is, first,
derangement in  the nervous and sensorial functions—this
is the invariable antecedent; secondly,  derangement in the
circulating function—this is  the  invariable sequent;  and,
thirdly, derangement in secreting and excreting functions__
this is the last result in  the succession  of morbid changes.
Derangement in  the function of  secretion  and excretion
never comes first in the series; derangement  in the ner-
vous and sensorial functions never comes last in the series-
derangement in  the function of circulation never comes 
WITH  THE MICROSCOPE.
45
either first or last in the series, but always the second in
succession."
  Dr. Lilling (Principles  of Medicine) traces fevers  "to a
loss  of  the  functions  of  the  nervous centres, and, subse-
quently, of the organs depending  on  them."  We  may
observe how many agree  in the nervous system  being impli-
cated in the causation or progress of fever; and this con-
sideration  may enable us  to account  for  the beneficial
influence of certain agents,  salts  of potash,  stimulants,
opium  and quinine among the  number,  which I had al-
luded  to when the  earlier  portions of this paper were
written, and which act specially on the nerves which gov-
ern  and direct so many functions  of the  organism,  and
thus ultimately tend to cause  the excretion of morbid accu-
mulations.  Dr. Billing says:
   " The animal heat  has been  accounted for  in different
ways by several ingenious physiologists; from the aggre-
gate of their opinions and experiments, I deduce that heat
is extricated all  over  the frame ; in  the capillaries, by the action
of* the  nerves during  the change of  the blood from  scarlet
arterial to purple venous; and also whilst  it is changing in
the lungs from purple to scarlet.
   "  There is a perpetual deposition, by the  capillary system,
of new  matter,  and decomposition  of the  old, all over the
frame, influenced by the nerves; in other words, the  gal-
vanoid  or electroid influence of the nerves, which occasions
these  depositions  and decompositions, keeps up a slow
combustion.  In this decomposition there  is  a  continual
disengagement of carbon, which mixes  with the  blood
returning to the heart at the time it changes  from scarlet
to purple; this decomposition being effected by the agency of
the nerves, produces constant extrication of  caloric ;  again,
in the lungs that carbon is thrown off and united with  oxy-
gen, during which  caloric is again set free; so  that we have
in the  lungs a charcoal fire constantly burning, and  in
the  OTHER PARTS a FIRE  of VEGETABLE OF  ANIMAL fuel, the
one  producing carbonic acid gas, the other carbon; the  food
supph/ing, through  the circulation, the vegetable or animal 
46
ILLUSTRATIONS OF DISEASE
matter from which the charcoal is prepared that is burned in
the lungs.
  "It is thus that the animal heat is kept up ;  on the other
hand, the evaporation of perspiration keeps the surface
cool ; but in inflammatory fevers, where this is deficient, the
body gets too  hot; and  in  low fevers, when  the nervous
influence is not sufficient to keep up the full  fire, the sur-
face gets cooler than  the natural standard.  This is pecu-
liarly evident in  the beginning  of eruptive fevers, as scar-
latina, where there is strong heat, with the arterial color of
the  skin; but  if the same  becomes malignant  and low,
with deficient  arterialization, the temperature sinks, and
the diminution  of the charcoal  combustion in the lungs is
evinced by the dusky color of the  skin, shewing that the
carbon is not thrown  off as  it ought  to be: and the same
phenomena takes place in typhoid cases, and still more so
in malignant cholera.
  "Whatever nervous influence may be, or however gene-
rated, we know  that the energy of parts depends upon a
something that is communicated to them by  the nerves in
conjunction with the  ganglia, brain and spinal cord ; that
while parts are  supplied with this nervous influence, they
retain their power of action, and not  longer ;  that arteries
become less susceptible of impression from external agents
when the nervous energy is  low; that when the vital pow-
ers  are sunk, the capillary arteries cease to secrete ; that
various phenomena in the  healing  of inflammation are  the
effects of healthy action of the heart  and arteries.  We find
likewise,  when  nervous energy is deficient, that  parts  which
had advanced to a certain stage  of healing  become flabby,
as in stumps after operation when the patient sinks ;  and
that when the power of the  constitution, the nervous ener-
gy,  fails,  nitrate of silver  will have no effect  upon  ulcers
except chemical decomposition—not that astringent effect
which is  the result of contractility depending  on  vitality."
  The following  is the rationale, according to Dr. Jones
of Ga., of the phenomena which constitute a  paroxysm of
malarial fever as exhibited in its most common and regular 
WITH  THE MICROSCOPE.
47
form, that of  an intermittent:   (See  Rev. Am. Journ.
Med. Sci., April, 1860.)
  "The  poison,  as we have demonstrated in  the chapter
on the blood, first alters the constitution of the blood, and
interferes with the actions  and secretions of those organs
which elaborate the blood, before producing any percepti-
ble changes in  the phenomena of either the sympathetic or
cerebro-spinal  systems; this  alteration of the  blood pro-
gresses,  until  a point is reached where either such com-
pounds  are generated in the cycle of chemical changes,
induced  by the malarial  poison, or  the constituents of the
blood, especially the  colored  blood-corpuscles and fibrin,
become  so altered  that disturbances  are produced in the
chemical changes  by  which  the  capillary circulation is
maintained, and as a  necessary consequence, the action of
the heart, which depends, as all other muscular actions do,
upon the chemical changes in the  capillaries, is impeded,
and the blood generally stagnates  in the capillaries, and
accumulates in the large  bloodvessels of the trunk  and
internal  organs, and  the temperature  of the extremities,
due to the chemical changes of the  blood  in the capillaries
and the surrounding  tissues,  sinks far below  the normal
standard; this arrest  of the  capillary circulation in the
extremities, and probably also in the lungs, is attended by
the retention of the products of excretion as carbonic acid,
and the matters thrown off from  the  skin and kidneys;
these excrementitious offending matters, together with the
products resulting from the  perverted chemical changes,
due  in  part  to the  reduction of the  temperature  of the
extremities many degrees below the normal  standard, stim-
ulate the sympathetic and cerebro-spinal nervous system;
the sensation  of cold is felt, attended by  twitching and
jumping of the muscles, entirely beyond the control of the
will, because  they are due to aberrated muscular and ner-
vous action, arising from disturbances  in the  capillary cir-
culation ; and from the action of the perverted elements 01
the blood the  respiration is aroused, more oxygen is intro-
 duced, and the temperature of the trunk elevated, provided 
48
ILLUSTRATIONS of disease
the alterations in the constitution  of the blood have not
proceeded  too far, or the nervous S3rstem been so over-
whelmed, either by the action of the altered products or
of the malarial poison, that they  cannot respond to the
excitation produced  by the( altered and  retained produc-
tions ; the  elevation  of the  temperature of the trunk  is
attended by more rapid circulation of the blood in the cap-
illaries of the heart and of the nervous centres, and conse-
quently by a more rapid and powerful action of the heart
and generation of nervous force, the oxygen is introduced
and distributed with greater rapidity, the chemical changes
in the capillaries are again excited, the capillary circulation
is first restored in the trunk, and then in the extremities,
the elevation of temperature becomes general, and we have
the phenomena called fever.'
  "During the active  chemical changes of fever,  the mala-
rial poison and the altered products of the blood are drawn
into the round of chemical chauge, physically and  chemi-
cally  altered, and  are  finally  thrown off from the lungs,
skin, kidneys, and intestinal  canal.  After the removal of
these  offending products,  the excitants of the  sympathetic
and cerebro-spinal system, after the system has been puri-
fied, as if by fire, then the nervous system returns back to
the normal  exercise of its functions; the  force and fre-
quency of the heart diminish ; the panting, full respiration
subsides  into the calm regularity of health ; the  tempera-
ture, both in the trunk and in  the extremities, returns to
the normal standard, and we have what is called the remis-
sion of fever.
  " 'If remedies have  been applied which  effect the perma-
nent alteration and destruction  and removal of the mala-
rial poison,  there  is no return  of the chill, succeeded by
fever.  If, on the other hand, the poison has not thus been
removed, the same round of phenomena  is repeated; the
blood is  again altered, the  capillary circulation is  again
retarded, and the whole round of phenomena are repeated.'
  "The changes that take place in the color  of the  liver
during malarial fever  is referred, by Dr. J., to changes in 
WITH THE  MICROSCOPE.
49
the amount and physical  and chemical constitution of the
blood in the capillaries of the organ, and to the physical
and chemical  changes in  the bile, and the contents of the
secretory apparatus.
   "Alterations  of the spleen  are laid down by Dr. J.  as
among  the very  first of the  pathological  effects of the
malarial poison,  and previously to  the development  of
the  phenomena constituting the febrile  paroxysm.  The
alterations consist chiefly  in the engorgement of the spleen
with blood, the softening  of its texture, and rupture,  in
many places, of the trabeculse."
   It  seems to  the writer both plausible and natural, that
when all the data are obtained by the clinician, the micro-
scopist and chemist,  to make up a complete history of each
disease—when  a  knowledge of all the excreta peculiar  to
or characteristic  of  each one  shall be  acquired,  then the
processes going on in each will  be  better understood, and
the rationale of their inception, progress  and effects more
thoroughly appreciated.*
   For example  : when we have fully  ascertained, from the
researches of the student of clinical  medicine, that there
are  marked distinctive features in Scarlet Fever,  viz : that
there is true inflammation of the skin  exhibited by its sub-
sequent desquamation, and in  some instance by its pealing
off in large flakes, forming an entire cast of a limb ; that
this never occurs in either Yellow Fever or in fevers marked
by periodicity, because   the inflammation  of the skin  in
these latter is not so intense ;  that in Scarlet Fever uric acid
in the renal discharge and in  the blood is  more constant
 * The writers and lecturers on the Practice of Physic should not adhere so rigid-
ly to the stereotyped subdivisions into prognosis, diagnosis, etc., usual with them—
their descriptions being often little more than a mere catalogue of symptoms, etc.,
as if each disease was a well-defined  unit.  They may not  be species of extensive
genera, linked together under orders and classes as by a natural system of classi-
fication, but they are often closely related one with the other.  The  difficulty con-
stantly met with during epidemics of determining the true character of milder cases
prevailing at the same time, or on their outskirts, show by what insensible grada-
tion, different types of disease shade into each  other.  Frequently no distinct lines
of demarcation  can be drawn, and at the conclusion of such visitation some preva-
lent forms of disease are left undecided. 
50
ILLUSTRATIONS OF DISEASE
and more abundant than  in the diseases just mentioned ;
whilst under increased metamorphosis of tissue, albumen also
more frequently escapes, because, perhaps, the functions of
the kidneys are compelled to  serve vicariously for those
of the  injured cutaneous  surface, and congestion results;
that this escape of albumen is much less common in other
cutaneous diseases (or diseases of the blood with eruptions,
such as Measles for example); less frequent also in Yellow
Fever,  and less still in Intermittent and Remittent.  These
facts,  with  others, being successively  determined,  will
surely  aid us in making  comprehensive comparisons, and
place us in a  better position to argue with respect  to such
phenomena, to classify them,  to make further deductions
and establish general principles.  In a word, we thus com-
plete the natural history of diseases, and perform the legiti-
mate functions of intelligent pathologists seeking to obtain
enlarged views, befitting the scientific  requirements of the
age.  I suppose I shall be  accused by the nil admirari set of
anticipating a general medical millennium.   However this
may be, let such  always remember "c'est le premier pas qui
c-oate."
  Again.   Yellow Fever and those caused by marsh mias-
mata, on the other hand, will  be  found, after minute in-
spection, to have other features distinguishing them to an
equally marked degree—other  tissues  and  organs in those
suffering  from  them  being more prominently affected.
Thus, to be very brief, we establish with  respect to Yellow
Fever:  that it is a disease arising in hot seasons, in cities
near to and not much above the level of the sea; that there
is more rapid and fatal combustion of the blood than in
intermittents ; the fever—the  vital  heat  and the  burning
sensation  of  the  skin being  more  intense  and  uninter-
rupted—produces engorgement of the kidneys, accompanied
by manifest impairment of its excretory functions, with the
morbid results upon the  blood, etc., following thereupon.
Malarious paludal fevers  are characterized  by their  more
distinct and  frequent apyrexise, or by remissions  and by
more perspiration ; consequently, they are  attended with 
WITH THE  MICROSCOPE.
51
less  heat and less combustion, with a greater tendency to
congestion of the  glandular  system,  engorgements, etc.,
particularly of the  liver, spleen and  mesenteric glands.*
  So,  also, the  peculiarities  of Typhoid Fever may be
compared.  It may be defined: a  non-malarious  or non-
paludal  blood disease,  caused  by  animal  poison, gene-
rally affecting depraved  habits, in  any clime or  season,
without material derangement  of the  skin  or  kidneys;
producing or accompanied  by  disease of  the intestinal
glands, and causing gradual impairment of  the blood; it
is reproductive,  possibly, by  a species  of  ferment, and
communicable;  the poison which  gives rise  to, or  is gen-
erated by it, seems  to cling to  and affect the  nervous
centres, and  is  only capable  of being  eliminated  slowly
from the system.   Hence, though  depuratorj- treatment is
required,  stimulants, with  nourishment, must be  used to
supply  and  keep  up  nervous  energy.   The disease  is
essentially adynamic, and the  poison renders  the blood
aplastic, with secondary inflammations  or congestions  of
various organs.    A knowledge  of  these  characteristics
will enable us to appreciate and compare the tout  ensemble
in   each disease, in a  more enlarged and comprehensive
way.   Thus,  too, many apparently isolated facts concern-
ing each, will be found subsequently, upon bringing them
together,  to  result  naturally from  well-known conditions;
 and these  facts, instead of  remaining  unattached, will
.soon  come  to  be  classified  and  to rank   as  unvarying
 features in their histories—as  well known  to every  one
 as   those  more  obvious ones  that had been long since

  *From  the researches of Prof. Joseph Jones, of Ga., in Trans, of Am.  Med.
'Association, Vol. XII, on malarial fever, I ascertain, what is quite in  accordance
 with my belief: that the "colored corpuscles of the blood, together with its albu-
 men, is diminished, whilst  the extractive matters of the serum are  increased."
 " The destruction of the colored corpuscles being more uniformly observed and
 more rapidly accomplished in malarial fever  than in any other acute affection.
 The  destruction is affected mainly in the  liver  and spleen. * * * * The alteration
 and  destruction of the colored blood corpuscles are invariably attended," Dr. Jones
 affirms, "by  abberated muscular and nervous actions." He also says that animal
 starch accumulates in the liver, whilst there is at the same  time an absence of
 grape sugar.  See Rev. Am. Jour. Med. Sciences, April, 1860. 
52
ILLUSTRATIONS OF DISEASE
recognized  and  described.  We shall then, likewise,  be
better able  to anticipate the occurrence  of  certain  mor-
bid  phenomena,  to  prevent the  tendency  to  them,  to
ward them off, or to put  in .practice  remedial  measures
-for their  relief should they be fully declared.   The illus-
trations employed above might be  indefinitely multiplied,
and  infinite comparisons established—each attended  with
real  benefit  to practical  medicine.   The  truth is,  very
much such  a process is that pursued by those who have
made solid  contribution to our stock of knowledge; and
•even he  that establishes  only a  single  fact,  assists  in
enabling  those coming after  to make large inductions,
and  draw general conclusions.   Many facts, as they are
successively ascertained, will be found to aid, suggest  or
explain  others previously acquired, and  conspire  with
them to build up a  regular system of medical  doctrine;
and  this slow process but confirms  the  words of the great
poet, in "Tocksley Hall:"

     " Science moves, but slowly, slowly creeping on from point to point."

  I will now, merely for the purpose of illustration, give
an outline of  the process that may  be adopted, by select-
ing from  my  own reading, and  bringing into one  view
several isolated statements  from  different  authors, which
require  the addition  of others  still ?to enable us  to  de-
rive the fullest advantage from them.
  Thus,  the assertion  is  made by Thudichum,  that  urio
acid  is  generated by the acid  fermentation of mucus in
the urinary passages.   This, if correct, is certainly precise,
and limits the area of its production—hence, we have next
to inquire whether, in Scarlet Fever and Gout,  in which
its presence is marked,  there exists this particularly acid
mucus;  and  if so, why and how is it produced.  Again,
C. Robin  states that it is found in the liquids vomited after
retention  of urine; whilst iSysten says that, obtained only
through  decomposition  of the  urates,  it  does not exist
normally  as  uric  acid,  but presents  itself accidentally,
deposited in  very small quantity in the crystalline  form. 
                  WITH THE  MICROSCOPE.                53

If this be so, then its great amount in Scarlet Fever and
Gout will with more reason be regarded as morbid, and the
special  liability in the two diseases to  decomposition of
urates  must  be enquired into.
   \\re  remember that urea is  one of the most  important
constituents  of the  urine,  since  it  is  the " vehicle  by
which  the largest proportion of the nitrogen derived  from
the disintegration of the tissues is eliminated." (Ilassall.)
Funke corroborated the normal existence of urea in con-
siderable proportion in the healthy cutaneous transpiration,
also—a fact  Avhich had been denied by Schotting, who, it
will be remembered, found  it in so large quantity in the
skin of Cholera patients.  (See Med. Chirurg. Rev. Report
on Physiol., from Moleschott's  Berthage, 1858; also,  re-
ference  in  Braithwait's  Retrosp., XXYII.)  We reason,
then, with more show of plausibility still,  respecting the
influence of diseases, or agents, whose  principle force is
expended on the skin in modifying the urea, or causing
its injurious abundance in  other portions of  the  body,
than when  we thought  the kidneys only  were concern-
ed in  its excretion.   So,  also, if Frerichs is  correct, that
the  phenomena of urpemic intoxication,  as  in Ecclampsia,
for example, (or Yellow Fever, I would add,) is not pro-
duced  by  urea,  or  by  any,  or all,  of the  excreted
matters  of  the  kidney,  but  by  the   transformation of
urea accumulated in the blood into carbonate of ammo-
nia;  then  the citric  acid and the  diuretics formed of
vegetable  acids, which the  writer  has  found  useful  in
Yellow  Fever, and which are so  commonly employed in
many  other fevers, have  a  scientific  reason  for  their
exhibition—as they neutralize the- carbonate  of ammonia.
These considerations may be found closely  related with
the  coagulation  of the blood, with black  vomit,  hemor-
rhage, etc., where the blood is  in a too liquid  or aplastic
state.
   Sugar, Xysten  says, is not found associated with  the
phosphates.  * In diabetes we must, therefore, seek to trace
the  relationship  maintained between  these  substances. 
54
ILLUSTRATIONS OF DISEASE
We  know,  too,  that  it  has  been  recently  established
that the  chlorides are  absent from  the urine in certain
diseases,  as  in  pneumonia.  Xow, in  diabetes,  there  is
an excess of it—whilst an  additional observation is made
by Thudichum that ursematine (another factor still) is  in
inverse ratio  to  the  chlorides, and ursematine (purpu-
rine,  urrosacine  of  some  writers)  is  very  much con-
cerned  in diseased conditions of the  liver.   (See Bird,
and  B. and F. Med. Chirurg.  Rev., April, 1861.)  When
better  knowledge  is  obtained concerning the  seat  and
special  maimer of production  of  these  principles, it  will
reflect light upon  the diseases in which  they are  impli-
cated,  and  vice versa.   So,  also,  I might  multiply  exam-
ples of  the  action  of  certain  remedial  agents in the
elimination from  the  system  of  special  substances,  and
trace their  adaptability to  the cure or relief of special
diseases in which the  substances are  shown  to  be  in
injurious excess.   Whether  this  knowledge  has  been
acquired  empirically,  as  the mere result of  experience,
or experimental investigations are instituted to  ascertain
the  applicability  of  certain agents  to  the management
of special diseases, is indifferent  to the  argument.  In-
vestigations  as to the  precise  condition  of  the  blood,
and the  changes  which it undergoes in  disease, will  be
equally  fruitful in  their  bearings upon  practical  medi-
cine.  See results of  examination  of Magendie, Andral,
Becquerel,  Jones  and others.
  It may have been from an  instinctive  yearning, natu-
ral to  every  man — his intellectual nature forcing  him
to  seek after the  occult  reason  of things,  and  rejoicing
in  the effort, however unsatisfactory.   "Felix  qui potuit
rerum  cognoscere causas;"—but, for years  past, the  writer
has been occupying his thoughts in the endeavor to trace
out and ascertain  the cause, the history,  as w7ell as the  ra-
tionale of  the successful  treatment of  several diseases
which  offered favorable  opportunities  for  comparison—
whether occurring in hospital or private  practice. He has
endeavored  to possess and  to  retain  in  his  memory, 
WITH  THE MICROSCOPE.
00
for the purpose of comprehending them better, all  the
peculiar distinguishing characteristics of Cholera, Scarlet
Fever, Yellow,  Malarial and Typhoid Fevers,  Syphilis,
Inflammation,  Rheumatism,  Gout—the winter  diseases,
viz:   Pneumonia, Catarrh, Croup, etc.—wishing also to
ascertain  the reasons for their appearance and disappear-
ance  at special  seasons ; why some of them  attack  only
certain persons, and  under  special  conditions;  and  also
to compare the  effects of the  most approved management
generally  adopted.
   I  trust, as I said  before, that each  and  every  one
of these  diseases will be investigated  closely and philo-
sophically in every  point of  viewr, with  every  instru-
mental means.   I believe that the  study will be fruitful
in results, and  that it offers  the most  satisfactory method
yet presented for attaining great ends.   But even where
we cannot explain  every  step  in the causation, growth
and  results  of  each; nor  know with the  utmost  cer-
tainty why it is  that  one set  of agents have  gradually
come  to  be employed for  their  relief,  and  why these
are  found  to  be more successful in the management of
certain diseases than  other  agents selected  at random;
still,  there is  undoubtedly  a  material body of  knowl-
edge  formularized  and made  available for use, which
we have  already acquired concerning diseases and  rem-
edies.  This is  daily  increasing, and however  wanting
in breadth, accuracy  and completeness, yet  enables us
to manage  these  diseases  in most  cases  with pretty
general  success, where  anything  like a fair  chance  is
afforded.    This success is  only the reward vouchsafed
the  physician,  in  return  for  his  devotion  to medical
studies*conducted after  the  most approved methods.  It
constitutes the  best  plea  for  the  pursuit of  medicine,
as a  distinct  profession  by an  organized fraternity en-
dowed with  legal  rights.   In  truth,  it  is the only  pro-
fession,   the  practitioners and  teachers of  which,  even
in a  democratic republic,  should  be under the  control
of Government; so  as to have  enforced,  as among all 
56
ILLUSTRATIONS OF DISEASE
 other civilized nations, certain  provisions essential  to the
 proper protection  both of the  physician  and  the public.
   The maladies cited above, as  well as  others, have,  it
 must be acknowledged,  their  appropriate remedies; the
 treatment of them is in  a measure  already  formularized,
 and success  or satisfactory results at  least, in any fair case,
 is  often  only a  matter  of time.  In proportion, too, as
 we  attain to  a more precise knowledge of  the mode of
 action  of the substances  successfully used for  their cure
 or relief, the  more rational  seems the fact  that they do
 prove  efficient agents—which  is only an illustration of
 a-posteriori confirming a-priori reasoning.  Syphilis,  Rheu-
 matism,  Gout, etc., are  best relieved by  certain  special
 agents, which  seem, by  general  consent, most  applica-
 ble  to them,  viz :  local   applications,  mercury, iodide of
 potash, renal  depurants,  opium,  quinine,  etc.   I  speak
 generally when  1  say that  in  these, as  well  as  in the
 majority  of  cases  of fever, including eruptive diseases,
 Erysipelas,  etc., the physician  has, principally, to follow
 Chomel's golden rule and "do  his patient no  harm;" he
 must  avoid  mercurial, drastic  and  other  too active pur-
 gatives, save in some cases at their inception,  as in Yel-
 low and  other fevers, for example, which are  ushered in
 with constipation  and an arrest  of  glandular  and  secre-
 tory  action;  he must use  cold  applications to  restrain
 inordinate heat, and for its  tonic influence in  contract-
 ing  the distended  capillaries; employ, frequently, warm,
 stimulating  foot baths, revulsives, etc.; administer tonic
 and eliminatory agents,  including quinine,  diaphoretics,
 and renal and blood depurants.   James' powder, the oxy-
gen-bearing  bodies, the  chlorates, citrates,  acetates, car-
bonates and  nitrates of potash,  or the  carbonate of lithia,
a  substance  recommended by Garrod as particularly effi-
cient,  may be selected;  plain  dietetic rules are  also to
be  Observed—not  forgetting  stimulants where  the ner-
vous  centres are depressed, and agents capable of lower-
ing  the action of  the  heart where  there  is  too  much
vascular excitement.  Employ judiciously these and  other 
WITH  THE  MICROSCOPE.
57
means  obviously  demanded  by  the  exigencies  of  each
case, which  science, art  or  experience have  taught us to
be   useful;  give  the  patient  time,  and  he  will,  in  a great
majority  of  cases,  recover  when  seen   under  favorable
circumstances.   That   is   under  the  only   conditions  in
which  a logical  mind would  admit  a  deduction  to  be
drawn, as to the value or applicability of  treatment  in a
given  case, and as  a rule  for the  adoption  or rejection of
similar means under like circumstances.*
   These  apparently very  simple  means  often  secure  the
best results.   A  knowledge of them  has  been  obtained
partly  in an empirical  way  partly  by experiment; but in
meeting  and  antagonizing  those  morbid changes  consti-
tuting  disease,  which  are operating in the human body,
viz  : nervous disturbance, inflammations,  congestions,  con-
stipation, chemical combustion during the  metamorphosis
of tissues,  accumulations of effete material—all  which, un-
  * It has been the curse of the statistical tables and the numerical system, that the
results deduced  from them have been permitted to condemn this or that mode of
treatment when, confessedly, no distinction is made as to whether the plan of
treatment, or the special therapeutic agent tested, is used at an early or an  ad-
vanced stage of  a malady.  The medical man gives his best aid to the sick when-
ever he is invited, at any stage of a disease; but, acting en philosophe, he is most
intcre.-ted in knowing what can avail in those which he sees from their inception,
as this can be secured—knowing full well that in many diseases the benefits to be
derived from treatment decrease in a geometrical ratio as the disease advances;
and rice  versa.
  He would, therefore, be in error to condemn any particular method or any special
agent, as entirely inefficient, which  was capable, in the great majority of cases, of
warding off or destroying a disease  used at its inception, because it failed to have
like powers when such morbid  alterations had occurred to the organs as scarcely
to afford  any chances of recovery.  Thus is explained half the discussion and  dif-
ference of opinion concerning the results of the treatment of Pneumonia—which
is still sub lite.   Astringents, with opium, greatly relieve the usual  premonitory
stage of  Asiatic Cholera, known as Cholerine, and when used in time, mate-
rially increase  the chances of recovery.  It would be illogical to  say that all
astringents,  or all treatment, were  utterly useless in Asiatic  Cholera, because of
fifty cases entering a hospital at the tenth hour, and who had the benefit of these
agents, forty-nine died.  Yet this loose system of recording, with  its delusive air of
precision, which vitiates all logical deduction, we are repeatedly called upon to
bow down before as conclusive.  Mere figures  are thus dangerously deceptive.   It
shows how futile are bald statements, meant  to prove that such and such a per
cent, of a given disease died in a given hospital.   No practical  deduction can be
made from them. 
58
ILLUSTRATIONS OF DISEASE
checked, lead  on to  fatal results—the  means indicated
above will be found to be sustained, it  is highly  satisfac-
tory to  believe, by what  we know  of the  most profound
chemical and physiological laws  governing the reactions
going on in the human  frame.  This or other plans, so
elaborated  after so many years  of the world's  experience,
continue to  succeed  in  the great  majority  of cases, be-
cause  the partially hidden laws of the human economy,
even  in  disease, respond uniformly under  the action of
the same  or  similar  substances.   This cannot be fortui-
tous, but must be under the  dominion  of laws  which,
under like  conditions, uniformly maintains  the  relation
of cause and effect, occurring repeatedly without material
variation.
  The method described  is the very opposite of the "no
treatment," or the pure  and unmitigated  medicine  expec-
tante system.   Whilst  sufficiently effective, it  avoids being
too actively injurious; it abstains  from the  nimia cura
medici  so  properly  reprobated, but,  at the  same  time,
equally  shuns  the opposite error.   In studiously  refrain-
ing from an}'  course  that would weaken the powers of
the system, it yet gives  the organisms time to perform
their appropriate functions, or to  recover those that were
impaired  or lost;  by its several processes it arrests or
moderates  the  excessive heat of fever, which vitiates  and
consumes the vital fluids;  removes the morbid substances
in the  blood, generated  by depraved  functions  or  by
chemical changes; by stimulants  sustains  the  nervous
centres,  overwhelmed  by morbid  poisons, or by  them
arouses  the too languid circulation;  it relieves irritability;
diverts from the congested organs,  and  leads to a gradual
restoration of health as its natural result.  Such methods
are pursued because  they have  been  found  to  be  the
most  successful, and,  as I said  before, they are only sub-
sequently sustained by what we  can learn of the  estab-
lished laws of  chemistry,  physiology and pathology.  But,
at any rate:
         " Sufficit scire quid efficiat, etiamsi modus nos lateat." 
WITH  THE MICROSCOPE.
59
  I would gladly take  up each  agent,  however simple,
whether it  be ice,  water, alkalies, acids,  tonics,  nau-
seants,  neurotics,  blood-letting, eliminatory agents, and
endeavor to  explain its active influence by the most rigid
laws  of chemistry  and  physiology, where they  aid  us—
but space  and time  are wanting.   A few striking exam-
ples,  however, will be cited of the applicability  of  reme-
dies  to disease.  I  do this because there is a tendency,
even  by  those high in  authority  (whether  proceeding
from  indecision, or  from  the  consideration of the fact
that mild, remedial and hygeinic measures have been shown
to be the best in  many cases) to go  to vicious extremes
and  to decry all medical treatment.   It  is  an art,  we
admit, but the tendency of medicine is toward  its estab-
lishment  upon  a  scientific basis.  I dwell upon the sub-
ject more in detail, to  express  my  entire dissent from the
views of those who speak and act as if the profession
they  still continue  to teach or practice was all a matter
of the merest guess-work, without  the  faintest shadow
of rule, method or principle about it.
   To begin  with a strong example:  In  the belief and
 experience of the writer, even  Yellow Fever,  if it cannot
be aborted  at ita inception, or shorn of its terrors after
 it has  made progress, will recover under any fair condi-
 tion  when seen at the  commencement  of the  attack; this
 is accomplished by  a mild but efficient  mercurial  purga-
 tive  combined with quinine, cold applications, revulsives,
 blood  depurants, opiates  and  quinine pcrseveringly and
judiciously  employed.*   This  treatment  is not  mere
 routine, but an achievement of art, and a result  of  the
 progress  of human knowledge.  Its  apparent  simplicity
 is no argument against it—the main object kept ever in
 view in  its application, is to  remedy evils already  exist-
 ing with the least injury to the invaded  organism.  AVith
 time, greater improvements will  still be made; the treat-
 ment &of other diseases,  now  the  opprobria  oi"  medicine,
See the method in detail in the Charleston Medical Journal. 
60
ILLUSTRATIONS OF DISEASE
will be still more clearly  established, and  they will be
more rapidly, certainly  and easily  managed by  measures
put  into  practice  at  their  very inception—thus  accom-
plishing for them what,  esteemed  impossible, has  been
already done for  other  diseases.    His own  experience,
as well  as   that  obtained  from books, has  taught the
writer the  truism, not always acknowledged,  however,
that there is a good and a bad way of doing  everything,
with  intermediate grades also.  It is surely possible  that
one  may not be possessed of what his neighbor has, and
be  glad to  adopt what is  taught  him only  after  long
delay by the indisputable success  of others.  The  writer,
like  every man  of ordinary common  sense, is  compelled
at every  step to  be  appalled  at his own  feebleness and
ignorance, yet  he speaks without presumption  in ex-
pressing the belief that it  accords with  the  experience
of almost every  professional man,  to  be forced  to  admit
having  acquired  new and more successful  modes of man-
aging  diseases  which  at  one  time  proved  intractable.
This  will be acknowledged  by  all save  the hopelessly
indolent,  those  blind  to progress,  infatuated  in  holding
ou to beaten tracks, and realizing, in  their  own persons,
the  forcible and  truthful  expression: that  " there  is
nothing like the  respect  which  ignorance  has  for igno-
rance."   These  qualities  are  often  coupled with the  pos-
session  of  an   obstinacy  which  is not,  as boasted, the
result of  rational  incredulity,   but  that fancied pre-emi-
nence and superiority which the assumption of a general
air  of disbelief carries  with it, is often  sufficient  motive
with  them  for  its parade—whilst  the opinion  may be
ventured that such, having  no fixed  principles of belief
or of  action, flee for refuge  in every exigency  to the
"mild chloride of mercury."   This we call calomel! but
it  came from out the furnaces of our  masters, the  alche-
mists, in  contrast  to *the  more terrible energies  of the
corrosive  sublimate ("Draco ferox"),  personified  as the
"Mild Dragon," the "White^ Eagle."   In  the most scorn-
ful words  of the "Divine Poet:"
" Non ragioniam di lor, ma guarda e passa " 
WITH  THE MICROSCOPE.
61
  Scarlet Fever,  also,  is  far  less actively  and  far more
successfully treated than  formerly.   There was a,  time
when measles, under  active treatment, was a more  fatal
disease  than  now: when it   is  established  that,  with
care,  a  rigid  confinement to  mild demulcents, it  almost
certainly  terminates  favorably;  wdien  Intermittent,  Re-
mittent and Congestive Fevers, the multiplication of  their
paroxysms remaining  unarrested by  quinine,  destroyed
entire villages,  or, by their ravages,  left  rivers unnavi-
gated;  when  supportive  treatment was  not ascertained
to be  the  basis  of  the  management  of Typhus  and
Typoid  Fevers.   Notwithstanding  all  the  controversy,
Pneumonia makes fewer  victims,  both  among  whites
andncgros; and the  prevention of Small Pox,  the arrest
of secondary and tertiary  Syphilis,  and the rapid disap-
pearance  of  diseases  of the  skin,  under  appropriate
means,  furnish  such  striking  examples  of progress  as
to be most encouraging.  Per contra: Blood-letting  was,
in times past,  greatly abused,  and so  were  emetics;
salivation was once the rule.   I  hazard  little  in  saying
that thousands  of the survivors  of the  generation  now
passing  away, are suffering from the indiscriminate  and
wholesale  use of mercury,  which was  sapping literally
the life-blood of the nations; and  that those now coming
upon the stage,  are  happy  in  being  partially  delivered
from  it.  This proceeds  from  a more just conception of
its mode of action and its effects.
  Again.  There  is no doubt  that  the  zymotic disease,
Diptheria, which  has  extended  from  California  to the
Atlantic  coast,  is  curable, when seen  early, by  nitrate of
silver  applied locally, and by  muriated tincture of  iron,
brandy and  quinine,  with nourishment  given internally;
equally  certain  that delay,  or  an  opposite  course,  viz:
emetics,  nauseants, depletive  or  weakening  treatment,
will  prove rapidly fatal.   In the  hands  of one physician
nearly  every  case of Typhoid  Fever terminates fatally,
whilst another,  with no  better opportunities, but under
a radically  different  system,  manages the disease  judi- 
62              ILLUSTRATIONS OF DISEASE

ciously  and successfully.   It is susceptible of proof that
supeivtartrate  of  potash and iron  will  put an end  to
erysipelas,  dependent  upon  an  impaired condition  of
the blood  and  capillaries,  as well  as  to  those  eruptions
so closely  related to erysipelas, which  break  out  over
the face and  body,  and are  accompanied by large, albu-
minous exudations;  also, that  quinine, with  morphia, is
essential to the rapid  recovery  from Brow Ague  and
Neuralgia;  that muriated  tincture  of iron will rapidly
and  certainly, and without the assistance  of instruments,
relieve impervious urethra, caused by an abnormal con-
dition  of the mucus membrane, whether owing to morbid
sensibility,  to  relaxation,  or spasm  of  the  capillaries.
The strong compound  tincture of  iodine, or ointments
of this substance,  with mercury, applied  locally, at  the
inception of disease,  act powerfully  as discutients;  arrest
rapidly and certainly glandular diseases, carbuncles, whit-
lows,  boils, inflamed  glands,  etc., which,  unchecked,
would  be  followed  by suppuration,  by  wasting  dis-
charges, accompanied with the usual  constitutional dis-
turbance and prostration of the general health.
  Alkalies,  soda,  lime  water,  an   occasional mercurial,
revulsives, with  attention to diet,  must  precede the use
of quinine in the cure of Gastric  Remittent Fevers  in
children,  wdiich  they accomplish most satisfactorily.   So
mercury and opium  in  Iritis and Peritonitis, opium and
anti-spasmodics  in Hysteria, iron  in  Anaemia,  ergot in
Parturition, ether, chloroform and  cold water in surgical
maladies  and for the relief of  pain,  furnish examples.
The application of many of these, unattempted, undreamt
of twenty years  since, give triumphs over disease and suf-
fering which even the imagination  of man had rejected
as  impossible,  and which  are  the  fruit  of modern pro-
gress.   They repel, by the most conclusive proofs of util-
ity,  the  attempts of  those who  would speak slightingly
or  with disdain  of the  resources of the instructed physi-
cian.
   I am  not wanting in appreciation  of the  great minds 
WITH  THE MICROSCOPE.
63
of the past, or of what they  accomplished in their day
and  generation;  but I do not believe that Galen,  Boer-
haave, Sydenham or  Broussais  cured fevers  as rapidly,
safely, or  as  pleasantly  as  we  do.  Neither had  they
attained  to like  success in the  treatment of  many other
diseases  which  now  yield,  under  the  administration  of
the mildest agents, in  the  feeblest  hands   armed  with
knowledge which was denied to the most gifted  of our
predecessors.
   We may, it is true, with only  a moderate approxima-
tion to accuracy, explain why it  is  that laxatives,  mer-
cury, tonics, iron, quinine, opium, anesthetics, astringents,
stimulants, nourishment,  have a peculiar  action beneficial
in the several diseases before  mentioned, or in' others.
After  experiment,  and  furnished  with  the results  of
accumulating experience, we may only  speculate  upon
the  influence of  these agents (primarily,  perhaps,  or
after absorption), upon the nerves and  nervous  centres,
upon the  circulatory system  and  the  capillaries—giving
tone  and producing normal  contraction,  with depuratory
discharges, attended  with the promotion of  the  general
health and strength of the  whole  system.  But  the most
important point of all is most clear: that  they  do act
beneficially,  and it is far  better to use them  than  to
resort to no treatment at all.  This will  be granted with
respect  to their applicability  to  the cure  or  relief of
many diseases;  if  it  is not,  then the  physician,  so far
as they are concerned,  if  he  has no better substitutes
to offer,  is,  by a legitimate  conclusion functus  officio;
and  if  the  same  is  to  be  affirmed of  all   the remedial
measures so far at our disposal,  viz:  that they  are use-
less or  injurious, as  many  would seem  to  imply,  if we
judge by by their words, then   the  public teaching of
medicine as  an  art should be  abandoned.   But,  unfor-
tunately, those who  deny any rational or efficient system
of medicine,  in practice often use the most  powerful
medicines unscrupulously and  heroically.
   Dr. Billings'  work may  be consulted, with  Williams', 
64
ILLUSTRATIONS OF DISEASE
Headland's,  Todd's,  Bennett's,  Mialhe's and  those  of
others, on the several  points  which  they have specially
examined and discussed, and  which  have  been  referred
to above.
   Certain features of malarial fevers, as they prevail with
 us, require to be re-sketched more clearly, in  order that
 their  distinctive  peculiarities  may  be more  accurately
 defined  and kept in view.   I must, therefore, take occa-
 sion  here to make one or two practical remarks on  the
 subject  of  Gastric   (or   Gastro-enteric)  Remittent Fevers,
 whether  occurring in  children or  adults,  which are  sug-
 gested  by  my  own  observations,  made repeatedly both
 with  respect to their treatment and the  relation  they bear
 to fevers more strictly of malarious origin.   I do not know
 any writer who has urged either point  fully enough, and
 yet the  omission to keep them  clearly in view is easily
 attended with disastrous consequences.
   I must  first  admit  that, possibly, more  or less  marsh
 malaria, giving a periodical, or rather a remitting, char-
 acter to fevers occurring both during winter and summer,
 is found to impress those  met with  both  in Charleston
 and in the surrounding country; and that the  existence
 of a malarious element may  in part account for  the remit-
 tent  character  of  fevers  apparently  purely  of  gastric
 origin —certainly caused  by some derangement  of  the
 digestive and nutritive functions—existing  in cities  which
 are almost, if not entirely, exempt from  intermittent fevers.
  Now,  gastric remittent  fevers,  so  called,  are a  com-
 mon  form of disease, particularly  among children in the
 City of Charleston.  They are characterized by a slight ten-
 derness upon pressure over  the abdomen, and by  a tongue
pointed and red  at the margins—not furred, save a little  in
 the centre.  The tongue is never  white  and  flabby,  or
 what  is called foul, as in bilious, in  intermittent, or in worm
 fevers;  nor has it a yellow fur as in disorders where the 
WITH  THE MICROSCOPE.
Gi)
liver  is particularly  involved.  The  sub-acute  inflamma-
tion or  irritation existing in the gastro-intestinal tract, the
result of  the impaired or  over-tasked  digestive  organs,
is  a  main  diagnostic feature, I consider,  in  the disease;
whether the  remissions which  also characterize  the  fever
are, or are not,  dependent upon a coexisting malarious or
paludal influence—supposed never  to be absent from our
entire  seaboard as  well  as our river courses.   I only
refer  here to the possibility of  a malarial  complication,
giving rise to the  remissions in  Gastric Remittent Fever
met with  in  the city; but think it more important to  lay
stress on this point:  that when we find  a  pointed  tongue,
red   at the  margins, occurring  in any fever, whether
within  the  limits of the city or in the  rural, or what  are
more generally  considered  the  malarious districts, it must
be taken  into consideration as  indicating a material element
in the disease, viz:  a sub-acute irritation or inflammation,
to be removed by appropriate means.
   In  the  next  [dace, and  what follows naturally, is, that
these fevers  can be  certainly brought to a successful ter-
mination; never by quinine alone as  in  pure intermittents,
but by mild mercurial alteratives  occasionally  used, with
 Do vers' powder at  night;  soda  and nitre mixtures, lime
water or other similar agents given repeatedly;  also, by
 revulsives of  mustard applied to  the abdomen  and by
foot-baths assiduously used, so as to aid in removing  the
gastric derangement, with cold sponging to the arms and
 head freely  and  continuously employed  when the fever
 rises.  Then, and not before, quinine will be found service-
 able.   Such a course of treatment, it may be safely assert-
 ed,  never  fails.   Having thus  treated the  disease  very
 frequently in this city, I have never seen a case terminate
 fatally.
   The frequent and prolonged use of  calomel  and opium
 for  davs, which  are or were  supposed by some essential
 to the' relief of gastro-intestinal  inflammation, as well as
 in the  management  of  the so-called  Bilious  or  Country
 Fever, or an  exclusive  reliance  upon  quinine,  are  un-
        5 
6G
ILLUSTRATIONS OF DISEASE
 called for, if not decidedly injurious, in cases of Gastric
 Remittent Fever.
   Gastric remittent fevers, be it observed, are  not confined
 to cities; but they  may occur just as frequently, though
 probably under  a graver  type by reason  of the greater
 amount  of  malaria, in  the country, in  situations where
 fevers of paludal  origin  are rife, and where  malaria is
 generally,  but often erroneously, thought to  be the sole
 cause  of all the fevers wdiich manifest themselves—thus
 often  leading to  great  errors  or important omissions  in
 treatment.   When  this  element,  viz:  gastro-intestinal
 irritation, marked by a red, irritated, pointed tongue, gives
 rise to fever in  those  residing in  malarial regions remote
 from  the city, or when it  accompanies  attacks  of bilious
 remittent fevers  caused  by climate, the same  treatment
 indicated above must  be pursued.  For we  have  in  both
 cases  an irritated, inflamed or congested condition of the
 gastro-enteric mucus membranes plus the malarial poison.
 We  are  not, without  reason, to insist that here quinine,
 calomel  and opium must necessarily constitute the basis
 of all treatment.  We  must  in  both situations  equally
 have  recourse:  first,  to  preparatory treatment, including
 revulsives, etc., before  resorting  to  antiperiodies, if we
 desire not to prolong the  irritation which keeps up the
 fever, and which is often an essential cause of it.
  Agues, pure intermittents and fevers of verminous origin,
 are very different things.   In  these  a single  mercurial
 laxative,  a full dose of opium, quinine or an  appropriate
 vermifuge, are amply sufficient—because it is  of unmixed
 malarial  origin in the  one case, and  the existence  of a
 parasite  in the other—hence the specific or the vermifuge
 is omnipotent.   These distinctions should be kept  ever  in
 mind, in order to  avoid useless  or injurious  medication,
 or the omission of that which is essential.
  In  gastric  remittents  or in  bilious remittents, existing
in  town  or country, accompanied  with irritation of the
gastro-intestinal mucus membrane, there may  as [ admit
be a malarial element; but the latter is always superim- 
WITH  THE MICROSCOPE.
67
posed  upon a  dyspeptic,  irritative or  inflamed state  of
the mucus 'membranes  with  depraved  nutrition;  there
is also generally, if not always, acidity coexisting.   Hence
the alkaline  agents, soda  and lime water, wuth the renal
depurants and diaphoretics, nitre and  occasional mercurial
alteratives, as stated above, must be combined with revul-
sives, with ice  and  cold  applications, before quinine can
be supported or employed wTith advantage.
  In  bilious  intermittents or in remittent fevers of great
violence,  dependent  upon  great  intensity of malarial
poison, where  there  is  evident torpor or  congestion, or
chronic disease of the  liver, calomel  and quinine in full
doses, with other  appropriate  means,  may be used  be-
fore the paroxysm often with great advantage.  Mercury,
calomel  and opium, or  drastic cathartics, need  not  be
given  every  four or five  hours for  days—as  was  once,
may  be  is now, the practice with some—for their  sup-
posed curative  powers,  in  any fever, save those caused  by
inflammation of the fibrous tissues,  pleuritis,  peritonitis,
iritis, etc.  Thus given they  irritate and  keep up the gastro-
enteric inflammation or  irritation, and with it the fever
and general excitement of the system.
  The writer had  abundant opportunity, during  four years
service  as Physician and Surgeon  to  the  Marine Hospital
in this city, to  treat a large number of cases of remittent
and intermittent fevers, often  of  high grade of intensity.
These occurred  among persons wdio had been  exposed.
or who slept at night,  upon the  banks of  the Savannah,
the Pec Dee  or the Santee  river, or  they came from  the
coast of Africa or the Isthmus.   Mercury was used  not
ten times  in  over  a hundred  cases which  terminated
favorably.  It was avoided with a  special  view to test the
question whether  or  not  it was essential  in  the  man-
agement of bilious remittent fevers.  I  cann'ot give  the  ,
figures  accurately  now without recurring to my books;
but the  reader may consult the  article on "Sulphate of
Cinchonia," in  the Charleston Medical  Journal, where, of
a report  of  fifty  cases treated in  succession  with this 
68
ILLUSTRATIONS OF DISEASE
agent, not one died.   Mercury was often never used, save
an  occasional dose to aid in  stimulating the excretion of
bile,  or  where  the  tongue  was inclined to  assume  the
aspect it has in Typhoid Fever—indicating an  arrest of
glandular and secretory action.  I would not object to a
full dose of calomel, with soda and ipecacuanha, at  the
inception of these cases;  and where  there  is  dryness of
the tongue  and a tendency to coma and delirium, stimu-
lants and revulsives are specially  indicated.
  The most usual formula,  as stated  in the  article, was
the following, used at the inception of the treatment, and
continued for several  days:
  JJr Sulph. of Cinchonia, grs. x.
     Arom. Sulph. Acid, gtt. x.
     Sulph. of Morphia, grs.  |, given three times a day in
water.  Sometimes when  the patient  entered early,  the
treatment was begun  with the following combination:
  Jfc Calomel, grs. vi.
     Ippecac, grs. ^.
     Sup. Carb.  Soda, grs.  iii.
  Dovers' powder and sweet spirits of nitre  were given
occasionally  at  bedtime—sinapisms and foot-baths, with
cold applications to the head  were employed when  neces-
sary,  and a very large use of stimulants with revulsives
to  the neck  and spine,  with  an  occasional mercurial
whenever there was,  as stated, a tendency  to  dryness of
the tongue  or stupor, showing depression of the nervous
centres, as occurs in  remittent fevers assuming a typhoid
character.  Purgatives were not  employed.  This method
was abundantly successful.  There was  never any attempt
made to  deplete, to purge, to salivate,  or to do anything
more, with  the  exceptions mentioned above, than simply
to give quinine or cinchonia, to eliminate  the  materies
morbi through the various channels,  and to  sustain  the
patient.  Alcoholic stimulants, as I  said, were very wrell
borne  when  required in  those cases  where the  nervous
centres and the cerebral organs  seemed  overwhelmed by
the great intensity  of the  malarial  poison.   Diuretics, 
                   WITH  THE MICROSCOPE.                60

chlorate of  potash, etc., were also occasionally employed
at intervals  between the  administration of  the  quinine
or cinchonia  mixtures.  Here, too, when the redness of
the  tongue  indicated gastric  or  gastroenteric complica-
tions,  sinapism,  alkalies  and  an  occasional  alterative
were more  studiously employed, precisely upon  the prin-
ciple that they  would be  used  in the same  condition so
much  oftener met with among children.  But,  as  I said
before, very many cases, both of intermittents and remit-
tents,  got well without a single dose of mercury.*
   I  must be indulged whilst  inserting here the following,
extracted from  Stille's  Therapeutics,  Vol. II.  I endorse
in full the docrines it conveys, and believe  their adoption
in practice would be a  great boon conferred  by the prac-
titioners of medicine upon the  people.   It  was only con-
firmed by my own previously  acquired  experience in the
hospital:
   "The  cholagogue action of mercury  is invoked  in  this
affection to relieve the  overloaded liver, as it  is  in Yel-
low Fever  to stimulate the non-secreting  liver.   Leaving
unattempted  here the  task of reconciling  these  apparent
contradictions,  let  us endeavor  to learn whether  or not
experience  has  proved  mercurials to  be useful in  Bilious
 Remittent Fever.   In reference to  their  purgative action, it
 may be remarked that  this is  generally sought for  at the
beginning  of  an  attack,  by  the administration  of ten
grains  of calomel  at bedtime,  and some  saline  laxative,

   *I insert in a note  an abstract subsequently obtained from  my printed reports of
 ca.se, treated at the Marine Hospital, made during three years, to the City Counc.l
 and to the Faculty of the Medical College of South Carolina.  I give the totals-
 several cases of those terminating fatally entered the hospital in a moribund con-
 dition, and yet there  were but 8 fatal cases of 216, including 13 of break-bone; 91
 cases in succession were treated  without a single fatal one :
                                            Cases.      Deaths.
                                          ___1U       0
      Intermittents..............................
                                      ......... 79       5
      Remittents............................
      Typhoid and ivmittent assuming a typhoid form...... 10
      Break-bone ....................................
                                             216        S
• 
To
ILLUSTRATIOXS OF DISEASE
 or else  jalap, on the  following  morning.   But  even  at
 this stage such treatment is  unnecessary, unless the abdo-
 men is  full and hard,  the tongue  much coated,  and the
 alvine evacuations sensibly  disordered.   In  this  disease
 the  real remedy is quinia, and it is  much better to obtain
 its specific  operation as soon  as  possible, feeling assured
 that then the  associated local  derangements will be  all
 the more readily removed.
   "It may  be  presumed that the employment of calomel
 as  a constitutional  remedy  in this  disease, whether by
 the  daily repetition of slightly laxative doses, or the more
 frequent administration of still smaller quantities, is  still
 the  general  practice  in  some  portions of the United
 States.*   So far  as  those forms  of the  disease are con-
 cerned which originate  in the Middle States of the Union,
 we have never found it necessary to prescribe mercurials
 except as purgatives, relying, for  the cure of the  disease,
 upon quinia alone.  It  is  possible that the  more inflam-
 matory form of Remittent Fever met with in southern
 latitudes may call for a different management.  But the
 excellent reports  of  Dr. Boling, and  several other south-
 ern physicians, render this supposition improbable.  More-
 over, if we  turn  to  the East Indies, whence the  calomel
 treatment first emanated, we shall find that it  no longer
 holds  its original place  in  the  medical  creed  of  that
 country.  One of the most  eminent  of  the East Indian
practitioners, Dr. Charles  Morehead, says:f  'The  prac-
tice, at  one time  too common, of  exhibiting  calomel in
doses of four or  five grains three  or four times in  the
 course of the  day, without  any  very definite  object in
view, and continuing it for  a  succession  of days, cannot
be too strongly discouraged.   Xot only is it unnecessary,
but, for the  following reasons, often  positively  injurious.
In watching the progress  of cases thus treated, it is  not
difficult to detect a train of  symptoms much  more fairly

 "* Compare Boling, on Remittent Fever, Am. Jour, of Med. Sci., July, 1816, p.
29; and Dickson, Elements of Medicine,  p. 2C>."
 "-(-Clinical Researches on Disease in India, I 202,206."' 
WITH  THE MICROSCOPE.
71
attributable to the treatment than to the disease, because
it  is  in  cases thus  treated  that this  has  been  chiefly
observed.  The sj^mptoms  to which  I  allude  are uneasy
feeling, sometimes amounting to pain, with  a  sense of
oppression or sinking at the  epigastrium, and occasionally
griping of the abdomen, for  which leeches are not  unfre-
queutly applied, and purgatives unnecessarily given.   The
frequent  repetition of the calomel  keeps up  also a  foul
state  of the tongue, nausea and irritability of  stomach,
aggravates  the febrile excitement, and produces an  irri-
table  state  of the bowels,  marked  by  frequent watery
discharges.   The  convalescence of  cases thus treated  is
always tedious, and frequently complicated with  diarrluea
and clay-colored dejections.'  .   .   .   'I am of opinion
that an endeavor  to  induce mercurial influence in Remit-
tent Fever is erroneous in theory and of no  value in prac-
tice;'  not only  so,  but 'it  is  opposed to all  rational
theory, and very injurious  in practice.   If it be  true  that
prostration  of vital  actions and  a deteriorated  condition
of  the blood are  pathological states  to  be much dreaded
in Remittent Fever, and if mercury  deteriorates the blood
and favors prostration, on  what principle  of reasoning
can it be  supposed that induced mercurial  influence can
have  any other  than  an  injurious  effect   o.n Remittent
Fever?'   The author further attributes to  the  mercurial
treatment so  long prevalent in that country, the frequent
occurrence  of a cachexia marked by asthenia, dyspepsia,
injured  teeth, pains in  the sides and  loins, foul tongue,
constipation, pale fyeces, and depressed spirits."
   After much reflection upon the  causation  of  fevers, I
have  come to conclusions, as follows:   There  are several
exciting  causes, generally  atmospheric  in  their nature,
but differing in character—any  one or  several  of which
(as we do not know whether it is  a unit) are capable  of
o-iving  rise, respectively,  to the several forms  of fever,
recognized 'as  distinct.  The  intensity  of  the   resulting
fever  is  in  some  ratio  with  the intensity  of the cause,
though  modified  by the varying  condition, corporeal, con- 
ILLUSTRATIONS OF DISEASE
 stitutional, etc., of the  recipient.   The  duration  and  in-
 tractableness of the fever also depend upon  certain special
 conditions: the  intensity or concentration of the  external
 cause being one—the special state  of the individual sub-
 jected to it being  another.  The individual  Avho has  been
 exposed  to  the cause in its  most  concentrated  form, or
 whose system  has  been impaired by any previous  depress-
 ing influences or agencies, is most likely to  yield to these
 diseases.
   I will refer  here briefly to one or more forms of fever,
 not miasmatic;  but  am  only inclined now  to lay stress
 upon the latter, as a special  subdivision of this  FCssay is
 devoted to the  morbid appearances  observed in intermit-
 tent  and  remittent  fevers.  For the  first  illustration,  I
 will select one form  of  disease where the exciting cause
 is  anything but  atmospheric; but  where,  in the subse-
 quent history of the  results, fever  is  met  with  and  the
 tendency to  its assuming a virulent form is  much aggra-
 vated by the  condition of the surrounding  atmosphere—
 as in hospital  gangrene and traumatic fever occurring in
 ill-ventilated  hospitals.   A  wound   is received:  capillary
 stagnation, impeded   circulation, disturbed  nutrition,  in-
 creased  fibrin,  etc.,  occur,  and  inflammation  and fever
 follow    Thjs  is accompanied  by  accumulation  in  the
 system  of effete matters, sometimes purulent, increasing
 the  difficulty,  leading on to general  constitutional  dis-
 turbance, etc., and requiring to be  removed or  modified
 by special therapeutic  and hygeinic means.
  Again,  a person is  exposed to the morbid effluvia or
 bad  air existing in greater or less proportion in a single
 house, a city, or a section of country, and he  foils a victim
 to that peculiar resultant ever accompanying or following
 sufficient  exposure to  one form  of materies morbi, viz :
 Typhoid  Fever.   So, with  Typhus  Fever, the   cause!
 symptoms, course and general history of which are some-
 what different  from Typhoid.   Every  individual exposed
does not take these diseases, but only those whose systems
from the various accidences of life, are more prone to their 
                  WITH THE  MICROSCOPE.                i 3

reception,  or  who yield more readily  to the  influences
which produce them.   So with Yellow Fever;  a certain
condition of atmosphere is  generated in, or the materies
morbi is brought into a crowded, foul, or badly ventilated
city near the sea, during the  heats of summer, and certain
persons fall a  prey to it more readily than  others—from
previous conditions peculiar to them, which  render their
persons  more  liable  to  the  inception,  incubation  and
spread of the peculiar poison, causing Yellow Fever.   The
stranger or the  native  child, during the  hot seasons in
Charleston, yields to the poison  of Yellow Fever; in
Paris, one  is  more  likely  to be  affected  by that of
Typhoid;  in  Dublin, to  the  poison producing Typhus
Fever.
   So, also, malaria—paludal or marsh—exists  in particular
sections  of our country;  all breathing the  air, or  occa-
sionally exposed to its influence, do not take  the peculiar
fever  it is  capable of producing, but  only  a limited  num-
ber.   Some of these  may be previously  enjoying a high
degree  of health, but have inhaled or absorbed  a very
largo dose of  the  poison;  or, what is  more  probable,
they  have  been previously  subjected to one  of  the most
common exciting causes,  viz:  a great  amount of fatigue,
or to the chilling and sedative influence of cold or damp
night  air,  to  rain, to  the  effects   of  great   solar  heat.
Perhaps they have suffered  from gastric or gastroenteric
disease,  depraved  digestion  from  prolonged  excesses in
eating or drinking, all which, when repeated or long con-
tinued, tend  to depress  the  powers of life, to impair the
activity  of the  secretory  functions, and  to   render one
person more prone than another to  yield to  the noxious
influence  of  the surrounding malaria.   Others,  living in
the same  section, exposed under precisely similar external
conditions,  may inhale or  absorb  the  same  amount of
malaria, and have  it eliminated from their systems; they
do not yield to it, because their digestive organs  and their
entire glandular and  vital apparatus perform their  func-
tions  more perfectly, so  that  if the poison   is received 
74
ILLUSTRATIONS OF DISEASE
into their systems,  they are enabled  to eliminate or to
throw it out.
  I have  repeatedly followed up from their inception, or
have had  detailed to me by others, the history of attacks
of intermittent and of bilious remittent fevers occurring
among gentlemen living in the country where malaria, in
varying amount, is  probably always present.   It  was not
necessary  for these, usually residing  during  the  summer
months on  comparatively  dry,  pine-land  ridges,  wholly
or only partially exempt from malaria, to sleep on a plan-
tation  or  to be  drenched by a  hard rain, to suffer from
an attack of fever;  but the mere subjection  to  any  de-
pressing cause, any unusual exposure to the heat of the
sun, to  more  than  ordinary fatigue, changing the air  by
visiting the  city  or  neighboring  islands, and  whilst there
taking fatiguing walks, or, as in several cases  under my
own eye recently, a long drill, sufficed to develop a fever
characterized, by periodicity.  Generally  these  attacks were
of short duration and easily, if properly, managed—some-
times the}' prove  dangerous, from the supposed stimulating
influence  of sea air; but this is  more  apt to  occur, I am
rather  inclined to believe, when  those are seized who are
also  suffering  from  gastro-enteric  complications,  and  in
whom purgatives are too  freely  employed.   These cases
show conclusively that  the attacks were not always owing
exclusively to any greater prevalence at the time of malaria,
but that  the fever  was developed or  excited  by causes
inherent in,  or  dependent  upon  the  special  external  or
internal condition  of the individual—there  being always
enough malaria to  impart a paroxysmal character to the
fever, the malaria  alone being insufficient to give rise to
it.   There  has always, previously, been some  exposure
to malaria—-for  fatigue  alone, or exposure of any kind,
would  never give rise  to such fevers in any  region abso-
lutely exempt from paludal influences.  In special situa-
tions, and at  certain seasons also, malaria is more abun-
dant.    The  fever following  the  exposure  or fatigue, is
often a clearly marked  intermittent; and it should be added, 
WITH THE MICROSCOPE.
75
that those living  in  the city  who  suffer from  an attack
of Intermittent  Fever, have  almost  always, if not invaria-
bly,  been  residing in  or  visiting  the  country, though
well-marked intermittents have  seemingly been produced
within  the  limits  of the city.  I  have seen more  than
six cases of severe Bilious Remittent or malarial Fever in
one  house  in Charleston, which was in  close  proximity
with very marshy ground.
   These statements  are also  reconcilable  with  another
result  of my observations, accumulated  dining several
years acquaintance with  life  in city  and country, that:
malaria  may exist in some localities, as  for  example  on
our river swamps in the neighborhood of the  Savannah,
Pee Dee, and  Santee rivers  and elsewhere, in so concen-
trated  a form  that those exposed  often  succumb  with-
out the  additional aid of fatigue, but solely from the dose
of it breathed during the normal condition  of  existence.
The intensity  of  the  malarial  poison  fluctuates every-
where, and  this  will  have  a  great deal  to  do with  the
gravity  of  the  fever elicited by  any  cause.   Even  the
pine-land residences, also, resorted  to  for their  supposed
greater  immunity from  malaria,  vary  greatly  in  this
respect—dependent somewhat upon the character of the
season, but for the most part, I believe, upon their greater
or less protection by sufficient barriers, whether of wood
or by  their distance from the  cultivated lands and  the
swamps.  The former are more noxious  than the latter,
in my opinion,  because  more  exposed  to the influence of
the sun.
   Let  us now  consider  another distinct  form  of  fever,
already referred to :
   A child living  in  the City  of Charleston, if breathing
marsh  malaria  tit  all, very rarely receives  it in so concen-
trated a state as  to  suffer by this cause alone from Intermit-
tent or from Congestive Fever, or even what may be styled
an attack of Bilious Remittent Fever. But should the same
child be  subjected to  a repeated and long-continued course
of improper  nourishment,  including cakes,  candies, etc., 
76
ILLUSTRATIONS OF DISEASE
to which they are so often injuriously treated, after a time
nutrition  becomes  impaired or  arrested;  the necessary
chyle being imperfectly elaborated  from the irritated and
depraved condition of the mucus and  glandular structures,
effete matters accumulate in  the system each day more and
more; the wheels of life are finally  clogged, the play of
affinities between the organs are disturbed or arrested—
and  fever is  declared.   Everything has  been slowly con-
spiring  to this end, but  it requires sometimes the addition
of a cold,  perhaps,  or other disturbing cause, to  develop
the fever, which is  not  an  intermittent, but  a gastric  (or
gastro-enteric) remittent.   It is always a remittent, generally
lessening  during the day to be increased at  night,  until
it slowly  disappears after one  or more weeks duration.
Sometimes the fever is very high, but it varies in intensity
in proportion to the sum of the causes which produced it
and  the strength of the constitution;  by which term I
mean :  the general  endowment which  the  organs of the
individual  possess  for  performing  their  normal  healthy
functions—and  consequently for regaining those functions
when impaired  by excesses.   Even  when  a  cold, or other
accidental  additional cause,  does not hasten the develop-
ment of the  fever,  it  is produced,  as the French  call it,
d'emblee, seemingly  by  an effort of nature  to rectify the
abnormal  condition, gradually  induced  by the depraved
state of the  nutritive organs,  which  has  reached, as it
were, its climax.  But this fever  is seemingly much more
than a  mere  temporary cmbaras  gastriquc, if it is not  a
direct result of gastro-enteric irritation  or  inflammation.
At any rate, the fever  indicates the general  disturbance,
the commotion  of nature,  as it were, accompanying the
efforts  of the system  to throw out the  morbid  products
generated—the effort to  rectify, in other words, the abnor-
mal  condition induced by the depraved state of the diges-
tive  organs.  The remedial measures before indicated, viz :
revulsives, cold  applications, mercury and chalk, alkalies,
nitre, eliminatory agents, followed by quinine, all tend, logi-
cally, I  may say, to aid  in restoring  the imprudent—often-
times innocent—sufferer to his or her pristine condition. 
WITH  THE MICROSCOPE.
77
  Sometimes, as  I said before, when  one,  whether  child
or adult, with these gastro-enteric complications,  removes
to,  or lives  in a more malarial  region,  he there suffers
from  the usual  result  of pure  malaria,  which,  when  it
affects any system with healthy organs, produces intermit-
tent fever or chill and fever;  but the attack must, necessa-
rily, under the conditions just specified, be super-imposed
upon  the gastro-enteric derangement.   The resulting fever,
when this complication exists, in my opinion, will invaria-
bly be a remitting fever; and the treatment, to be safe and
quick, must  be directed to both  conditions or elements  in
the disease which results.  I say that a fever with  a gastric
or a gastro-enteric complication  is a  remittent, because I
believe that the constatd presence of the  gastro-intestinal irri-
tation or inflammation  maintains and keeps up the continued
circulatory excitement—the malaria being responsible only
for the periodicity.  Often, were  it not for the gastric irri-
tation, or the weak  organ, or the fatigue, the individual
would  escape, even  though  exposed  to the malaria—and
thus  many do escape;  any or each of  these health-impair-
ing agencies is like the additional feather upon the camel's
back, which suffices to bring it down.
   I have spoken of Bilious Remittent Fever—using it as a
distinct term—because I believe  that remittent fevers oc-
curring in malarial regions are often accompanied by spe-
cial disturbance of the biliary organs—much oftener than
either  intermittents,  or the gastric   remittents,  of  cities.
We never hear of a bilious intermittent.'  But intermittents,
agues, chill  and fever, lead  to chronic enlargement of the
liver, spleen and mesenteric glands,  followed by anoemia,
leucocythcemia and other blood  degenerations which are
natural  results of the congestions occurring in these blood-
making organs  during the  cold stage.
   Congestive fevers, bilious or other, are gastric remittents
complicated by  the effects of malaria in virulent amount,
occurring in persons whose  nervous  functions  are greatly
disordered,  and  whose  systems,  from various depressing-
causes peculiar to them, cannot react  during the  apyrexia. 
 78             ILLUSTRATIONS OF DISEASE

   it is  highly probable, indeed, that the  peculiar phenom-
 ena, of  the fever (intermittent or agues) caused solely by so
 subtle an agent as malaria are produced  entirely by its in-
 fluence  upon the nervous system, and that the chill more
 especially is a nervous  phenomenon.  My reasons for this
 opinion are strengthened  by several  considerations :  1.
 The chill and fever may occur in one exposed to malaria
 without being accompanied by the slightest particle of in-
 flammation—he being perfectly well both before the attack
 and during intervals  after  the earlier  chills.   2.  Par
 vole d exclusion: the congestions produced during the cold
 stage or chill can only  be  accounted for through  nervous
 agency, reflex or other—as all  acknowledge to be the case
 in the equally sudden and remarkable phenomena of hys-
 teria, an  eminently nervous  disease, in  which there are
 cold sensations experienced, often with arrest of secretory
 action and violent  congestions.  Asthma, perhaps, might
 also be  cited, as sudden spasmodic attacks  appear to de-
 pend upon nervous  stimulation or irritation  set in motion
 by the  influence of cold, etc.   3.  The most  efficient rem-
 edies—opium,  quinine,  arsenic—all  producing  a special
 effect upon the nerves, put an end to, or prevent the chill.
 Quinine acts almost certainly  as a prophylactic also, by its
 continued influence,  I  think, upon  the  nervous media, as
 before described. That it does act on the nerves is obvious.
 The ringing in  the ear, the relief afforded  by its  use in
neuralgia, etc., may be  mentioned.   4.  An  approaching
 attack of ague may be  prevented  or deferred by deceiv-
ing the  mind, or by acting in some way upon  the emotions.
 A powerful  shock of any kind certainly arrests the chain
of morbid phenomena, seemingly by its influence upon the
mind through the nerves—substituting some sympathy or
mental state stronger and more potent tf an that caused by
the malaria—the dominion which it exercised over the sys-
tem being, for the  time, overcome.   It is highly probable
that this is an antagonism between nervous agencies.  It will
be  remembered that  every organ of the body, including
the whole glandular  system,  is controlled by the  nerves. 
WITH  THE MICROSCOPE.
79
  Lastly, a sensitive, delicate child, with fine nervous or-
ganization, has no digestive  derangement whatever, is not
exposed to marsh miasmata, and, therefore, does not suffer
from  Gastric Remittent or Intermittent Fever; but, after
latigue, coupled with exposure to the sun, it is seized with
a hot, burning fever of a single  day or a few hours dura-
tion,  and  known  as Ephemeral  Fever.  Here, calomel or
quinine are not required, but if anything  at all,  a mild
laxative, a diaphoretic and rest.
  Scarlet fever,  measles, small pox, are each sui generis, are
disseminated by exposure to special morbid poisons, work-
ing in the blood after  the nature of a ferment, and which
are peculiar in their nature.  But this is not  a treatise on
fevers, and I only desired to  refer to some special distinc-
tions  which I regard as of practical importance.
  I will now state some of the results of my own  Exam-
inations, so far as  special details are  concerned,  with a
few general conclusions arrived at from  a review of the
whole  paper.   I have had to  suggest a  portion  of the
nomenclature  used—so  that  of the thirty-six  substances.
elements,  etc., designated as having been sought for in
the excreta, in  fluids, tumors,  concretions, etc., whether
successfully or  unsuccessfully,  I am  responsible for the
isolation of a few, to which  my attention  was  attracted
either  by  their  frequency or  peculiar appearance.  These
were  so characteristic as  to warrant my  arranging them
together in the tables presented, and, without yet  assign-
ing them  names, to  content myself  simply  with an exact
description.   To  demonstrate the advantage of thus  noting
everything remarkable,  I have since,  by consulting the
drawings,  etc.,  of  others, been able to  recognize  sub-
stances not at first known to have been before described.
Thus, the bodies observed by Beale in Rheumatism, "cells
of iieute Rheumatism," I have  since  recognized; I had 
80
ILLUSTRATIONS OF DISEASE
segregated them for future  attention  long since.   The
same is true, also, of corpora aniylacia,  of nitrate of cys-
tine  (which I have reason to believe are quite  abundant),
circular bodies formed  of concentric layers  or  rings, etc.
  I  think  that I have  found  cystine  in  original eystals
three times.   (See  cases  described and  references to  it,
under that head, in the  Statistical Table, No. 1.)
  It  should be remembered that the appellation "organic
globule,"  sometimes "inflammation  granule,"  (but the
terms are not synonymous, in my opinion,) refers to the
bodies described by G.  Bird, and by Beale and  others;
but  that  they were not,  in every  case  where  I  mention
their presence, subjected to the action of  acetic acid.  In
appearance, however, they corresponded  alone  with the
description  given  of  these bodies  by  Bird,  and  with
nothing  else—neither  with blood,  pus,  mucus  or  oil
globules.   The "organic  globule" of Bird differs, I think,
from the  "inflammation  granule"  represented by J. II.
Bennett.  The precise  phenomena, resulting  from  the
repeated examination for  sugar  by the cupro potassic test,
are  always faithfully  stated ;  but  I have often  been
doubtful respecting the  interpretation  of the action  of
these reagents which depend upon  mere shades of color,
and  hence lay no stress  upon this item.  It will be seen
that  the record may prove  serviceable, however, for I have
since  met  with the  following, which I translate  from Sys-
tems "Dictionnaire," as it calls attention to certain  diag-
nostic  marks  derived from the behavior  of albuminous
urine under the  influence  of sugar and  potassa.   I had
noted the  varying coloration when testing for  sugar, and
as I  preserved the  record in every case, it serves at the
same time to  illustrate the practical truth contained  in
the  quaint  axiom  gathered  from  Sir  Thomas Browne
adopted as a motto and acted upon in the preparation  of
this  paper:
  "The results of researches made  by leery on the subject
of albumen of the  urine  in different morbid  conditions:
1. That this  substance has not  a composition  entirely 
WITH THE .MICROSCOPE.
81
similar  to  that  of albumen of the  blood;  2. That it is
not found  in every ease with  the  same  chemical charac-
teristics;  3. That albumen, voided  under  the  influence
of Bright's Disease  accompanied  with  anasarca,  differs
essentially  from  that which is  contained  in  the  renal
excretion  of females  cncientes,  or which is secreted in an
accidental  and  ephemeral  manner;  4. That it  is always
possible, by inspection alone of the urine and by the aid
of a  special reagent, to distinguish  these two species  of
albumen.
  "The oxyde of copper held in solution by caustic potash,
gives rise  in contact with  albumen  to  a beautiful violet
red color, and produces  a black precipitate, floculent and
more or less abundant.   These two  effects  are  not mani-
fested simultaneously.  The violet color  appears wThen it
is cold, as soon  as  the  oxyde of copper finds  itself  iu
presence of the  albumen.   The precipitate, on the  con-
trary, does not show itself in a fluid  of which the temper-
ature is above 40° to 50°  centigrade;  but at the end of
several hours, and even then, it is not completely formed—
but it suffices to determine its apparition, to heat  the liquor
in the flame of a spirit-lamp for one or two minutes.  This
precipitate, formed  of the  sulphuret  aud phosphuret of
copper,  is  the product of the action of the oxyde  of copper
upon the  sulphur and the  phosphorus abandoned by  the
albumen, which, under the influence of the potash hydrate,
is transformed and passes to a  state of proteine.   In  order
that this double reaction should be  produced, it is indis-
pensable  to  avail ourselves of an excess of the alkaline
cupric liquid.  AVhen the copper is not employed in suffi-
cient proportion, the liquor, at first of a violet tint, is dis-
colored  little by little by the heat, and soon resumes its
primitive   transparence  in  abandoning the saline  com-
pounds  formed;  it suffices, then, to  add anew Mi quantity
of the reagent to restore the color which  it  had  presented
before being submitted to  ebulition, and  to complete  the
precipitation of  the whole of the sulphur and all the phos-
phorus  of  the  albumen.   By the  aid  of this reagent,
      6 
ILLUSTRATIONS OF  DISEASE
the employment  of which  is very  simple, we  can  recog-
nize in a  liquid traces of albuminous matter which  would
have  escaped the action of heat and of nitric acid.   It is
prepared  by adding drop  by drop  in  liquid and concen-
trated potash a solution of the copper salt, until we  obtain
a  liquid  of a  beautiful  dark  blue shade.  In order to
secure  the  exact admixture of  these two substances, and
to  avoid  the  precipitation of  the oxyde of copper, we
should, at each  new drop that  is  allowed to fall, rapidly
agitate the vessel which holds  the  potash solution.  The
white of  egg,  the serum  of the blood, and  all the pro-
ducts  of  secretion  containing albumen, furnish with the
alkaline cupric  liquor the  characters indicated above.  But
the albuminous urine of pregnant  women does not give
rise to any reaction in presence  of the alkaline cupric mix-
ture;  on the contrary, that of  Bright's Disease, compli-
cated with  anasarca, assumes a  violet color, precipitates ;i
black substance,  comports itself, in  a  word, just as does
the white of egg and the serum  of the blood."
   Let  us now  examine the "Statistical Table" No. 1, to
discover  if it exhibits any  characteristic features as peculiar
to  any disease.  I  think  it will show plainly a striking
numerical preponderance  of certain  principles in  one
disease, or in classes of allied  diseases—which are again
quite absent, or exist to a much  smaller extent, in another
disease or class of diseases far removed from the first.
   This table I have divided into  thirteen subdivisions, each
representing a single disease, or  one or two diseases closely
related to each other;  and  by glancing the eye down the
column  of figures  appropriated to each, we can  readily
note  the  frequency with which  any of the thirty-six prin-
ciples or  elements occur—the presence or absence of which
was  recorded.  I  am  not  aware that a work similar to
this has  ever  been  undertaken.  As incomplete as it is,
I  think some  of the results  furnished by it  will repay
observation.                                   .  .
   The resemblances between the two first subdivisions tuai
we observe  arranged side  by side,  which include Yellow, 
                                                STATISTICAL  TABLE.-NO.  i.

Prepared  to show the  relative Prevalence of  Cert vin Principles,  etc, in  somk  op the Cu«sfs nv ^,
                                                                                                                      ---M OF DlsKASE HEREIN  IN VKSTU'.ATKP.
No. 1.
Xo. 2.
	s^			hi \
				
				
>	S = _.	undice.	^	•5^-1
>t	"		w	H 1
32 Cases.   : 19 Cases
 (i Ob'ns. in I
  1S5S.
14 Spec'ens.|37 Spec. ex.
 7 of Epide-i
  m i c  o f i
  1858.
Albumen. .
Blood.....
Haematin .
Bile ......
Purpurine.
Pus......
Mucus
Casts (Tub.  Urinif.)........
Oil Globules (Fat)..........
Organ. Globules, (Bird).....
Phosphates—Am.  Mag......
Urate of Sodaf.............
Urate of Ammonia.........
Granular Matter...........
Amorphous Matter, granular.
Oxalate of Lime............
Carb. of Lime.............
Circular bodies—concentric  (o))

Yellow bodies—cellular........
Uric Acid.....................
Rough bodies, like sand.........
Round black  masses...........
Nitrate of Un-a...............
Crvst.  after X. Acid (not plates)
"Staghorn" and dendritic eryst..
Cystine......................
Absence of crystals............
Sugar....._...................
Cryptogamia..................
Epithelial Scales (cells)........
Vibriones....................
Brunonian bodies..............
Acidity......................
Alkalinity....................
Neutral......................
Undescribed forms.............
18	2
G	1
1	
20	8
16	20
0	0
1	1
1	5
2	1
24	14
18	12
1	4
11	5
5	
1	1
laft.N.A
l(3in'5 3	8)	18 5
4(lin'o	8)	5 1
6		1
2		1
8		1
7		4
6		4
<		11
5		1
1 3		1 1
  *A peculiar crystaline form
rather characterized by prevale
reality -nitrate of crystine" of KoDin s, riate a.v.vi >.  id™ «""« ~»...--~ -...........,■,.,.... ■ «»• " v. ■■->.,                                             ., ri,aracteri
  t Urate of ammonia and urate of soda would not be separated by some authorities.  Ox of lime amorphous matter (granular?) and dendritic crystals after nitric
  ** Hard bodies like uric acid not dissolved l.v nitric acid.  Observe absence ot oil and fat-globules in Yelloiv Fever.
  ?White chalky deposits characteristic of Divisions 10 and 11; albumen in only two cases.  Beale considers the white deposits to be pli
Clinical Med.." and Todd's "Encyc. Anat. and Physiology.")
and visible after nitric acid, many of them characteristic feature of Conorrheal Rheumatism, as well as of Vesical iwdF'^l'/'Xve i' am „„«■ iiiclin"d to'^eganl "^ in
nee of nitrate of urea urates and phosphates and by the absence of pus and mucus corpuscles  ■•Sta"lii)in" and Dendritic uw." ■•
Robin's, Plate XXXIV.  (Sec  also OhvmieAnatmnviu^.Vol. II p. 527.) ^                                   ^ ^ ^ characterist;c of Division 11.

                                                                                         of lime-Walshe refers to it in  osteomalacia.
" Microscope Id 
 
WITH THE MICROSCOPE.
SM
Reniittent and Intermittent Fevers, have often attracted the
attention of the physician and pathologist.  Of forty-four
specimens oi' Yellow Fever examined, albumen was present
eighteen times; whilst in thirty-seven  specimens of the
renal excretion of periodical fever, it was found hut twice.
  Bile  occurred twenty times in Yellow Fever, and but
eight  times in  Intermittent and Remittent Fevers; whilst
in both there was so slight a tendency to a condition like
desquamative nephritis, that tubular casts existed  but once
in each, although  the kidneys were excreting albumen.
as we  have just stated, eighteen times in Yellow Fever.
On the other hand it will be observed, in inspecting sub-
diyision five, containing  "Bright's Disease," that "casts''
are recorded eight  times out of ten specimens examined
with the microscope—albumen making its appearance seven
times there also.
   Epithelial  scales (cells) were  met  with  seven  times  in
 Yellow Fever, and  four  times  in periodical fevers; their
predominance  being strangely  marked  in  section eleven
(Dyspepsia  and nervous  attacks,  non-epileptiform), where.
in five cases and fifteen specimens, their number reaches-
as high as six.   The presence of cryptogamia  was partic-
ularly  frequent in Yellow Fever, relatively to other dis-
 eases.
   Blood, again, was seen  six times in Yellow, and  but
once in periodical fever; all of which  are  natural results
and, in my own opinion,  correspond with the  most ap-
proved views  respecting the difference in the pathology
and terminations of the two sets of disease.
   The amnion,  magnes.  phosphates  and urate of soda are met
 with—the one twenty-four, and  the other  eighteen times-
in  Yellow  Fever—fourteen and twelve  being the num-
bers affixed for these in periodical fevers;  and the preva-
lence  of these also as products  of renal depuration, seem
natural  to  the  two forms of  disease.  These  two sub-
stances are rarely found associated with tubular casts (see
section ;">),  or  with -'bloody and purulent urine" (section
7); whilst the first exists frequently with "chylous urine' 
84
ILLUSTRATIONS OF DISEASE
 (section  6),  and  in Rheumatism (section  0. where the
 proportions are given).
   Oxalate of lime, ascertained to  be present only once each
 in  Yellow and periodica]  fevers, out of  forty-four and
 thirty-seven  specimens, respectively, is met with six times
 out of the  five cases  of Xervous Dyspepsia (section 11,
 where fifteen specimens  were examined), and in  three  of
 the four specimens examined of "diseases  of the  osseous
 system" (section 8).  Oxalate of lime is not found to be
 associated with "tubular casts," nor with the substances
 met with  in the  examination  of  "nervous  epileptiform
 attacks."   The  section last named is rather characterized,
 as I said before, by the phosphates, by amorphous granular
 matters, and by vibriones.  I found carb. of lime in both
 oases of "diseases of spine and osseous system."
   Oil globules,  rarely present (once in  forty-four  speci-
 mens) in Yellow Fever, are met  with five times in  period-
 ical;  and so little  am I  inclined to consider the  uniform
 globules constituting chylous urine  as identical with fat
 globules that I  record the presence of the latter but twice
 out of the nine specimens of "chylous urine" (section 6).
  Purpurinc  (urrosacine of some authorities),  which Bird
 in his paper on "The Depuration  of the Blood," calls "a
 slightly metamorphic form of an element of the bile, and
 which contains  no  less than sixty-three  per cent,  of car-
 bon," was, as might naturally be suspected,  very promi-
 nent in the renal excretion of both Yellow and  periodical
 fevers.  I think the appearance and disappearance of these
 and the phosphates, also  of  albumen, is of critical  import
 in these diseases.   In two out of three cases  of Jaundice
 (section 3), it was almost  black from excess of purpurine.
  Bile was present twenty  times in Yellow, and eight
 times in periodical  fevers.  It was,  of course,  found in
 the three cases  of  Jaundice,  and its  absence was striking-
 ly manifest in  nearly all  the remaining diseases—eleven
 in number.
   Uric acid.  As I stated before,  in a previous publication
in the Charleston  Medical Journal,  its  raritv in  Yellow
Fever is  extraordinary.    It  is  seen but once  in  forty- 
WITH  THE MICROSCOPE.
80
four specimens, and then  only after nitric acid had been
added, so that the assertion was strictly correct.   Future
researches  may readily account for this non-secretion, or
arrest of escape of uric acid crystalized.   It is met wTith
nine times in periodical fever,  also in Scarlet Fever; but
most marked in frequency in  "Dyspepsia  and  nervous
attacks  non-epileptiform;" not so in "nervous  epilepti-
form attacks."
  With  reference  to  the  bearing of these observations*
upon the absence of uric acid and the apparent defect in
normal  amount of nitrate  of urea also, in Yellow Fever.
and  their  presence in periodical fevers, I  have  spoken
more fully in the several  papers in  the Charleston Medi-
cal  Journal, upon the pathology and treatment  of the
two  diseases.  The rarity  of the appearance  of  crystals
of nitrate of urea, upon  adding nitric acid  upon  a glass
plate or in a watch glass,  is also very striking; but, as it
will  be seen, I succeeded  in obtaining them  much  oftener
in the epidemic of 1858.   I cannot account for this differ-
ence, if it  is not a  true one, save through the fact  that my
examinations during the prevalence of the  last were made
more promptly.   I was  certainly warranted in marking
the  absence  of this substance  in  Yellow Fever after the
epidemic of  1850;  for in casually looking over my draw-
ings at  its conclusion, I found that  in thirty-seven speci-
mens of the renal  excretion, examined after the addition
of nitric acid, nitrate of  urea  plates  were  observed but
once.  Whilst, at the conclusion  of  my  researches upon
periodical  fevers,  out of  nineteen cases (of  which thirty-
seven specimens were examined) I found plates of nitrate
of urea eighteen times.   This  difference between Yellow
and periodical fevers can hardly be fortuitous.
  Nitrate of cystine.'  It will be remembered that  I found
cystine spontaneously crystalized in its striking form three
times in several diseases.   Observing during my repeated
search for nitrate of urea that, sometimes alone or together
with plates of nitrate of urea, there were other crystals dif-
ferently  shaped, in the  original drawings I took special
pains to represent them.  These generally  assumed two 
ILLUSTRATIONS OF DISEASE
torms (not plates); the one, consisting of projections from
a central nucleus, thus:
The  other, made up  of dendritic, plumose,  or, as I have
styled them,  "Staghorn" crystals, are seen  in the accom-
panying cut:
>~^i&I§>

It will be observed that both or" these are distinct from 
WITH THE MICROSCOPE.
87
the diamond-form lozenges, made by the crossing of lines
of crystalization, which, it seemed  to  me from repeated
examinations  under  the  microscope,  was  the  mode  of
growth of nitrate  of  urea  plates. • The upper part of the
accompanying  figure gives an imperfect  view  of nitrate
of urea:
  I have not now the opportunity of subjecting the crys-
tals thus obtained and depicted  above, to the appropriate
reagents; but I  have every  reason  to believe that they
are for  the  most part nitrate  of  cystine.   They  correspond
very closely with M.  M. Robin and Ycrdeil's plates  of
this substance.  M.  Robin, Vol. II, " Chimic Anatomigtte,"
suggests  that nitrate  of cystine will probably  be found
much more frequently than  is usually  supposed; and  he
gives  an  interesting history of this substance, together
with that of cystine  itself.  I hope that future  and more
careful  examinations  will  show its  pathological  impor-
tance.   These bodies  were obtained  most abundantly  in
"Gonorrheal, Syphilitic and  Ordinary Rheumatism" (sec-
tion !>), and  in  tlDyspepsia and nervous attacks, 11011-
epileptiform" (section 11).
  As  will be seen, by consulting the essays referred to  in
the Charleston  Journal, the  excretion  or nonexcretion,
or the absence of escape of  uric acid and urea (together
with the other phenomena of a disease like Yellow Fever),
are points intimately connected with its pathology and
treatment, and have, therefore,  a most practical bearing.
The inflammation  of  the  capillaries; the  complemontal
action   of the skin  and  kidneys; the congestion  of the 
88              ILLUSTRATIONS OF DISEASE

latter;  the  coma consecutive upon  this; the  escape of
albumen, blood,  bile, purpurine—all these arc  neglected
in the  consideration of its  pathology,  obviously  only to
the discredit of the observer.
  My own  opinion  is that their  consideration,  the  estab-
lishment of their absence, presence, frequency or amount,
is fruitful  in utility.  In  comparing two allied diseases,
like Yellow and periodical  fevers, the  establishment  and
consideration of similar data must evidently be important.
We  are not called upon  to  assert that any of these sub-
stances  are  absolutely present or  absent;  their  relative
increase or  decrease may be equally significant and in-
structive in  a pathological  point  of view—just as  the
relative amount of tubular casts,  blood, pus, bile, etc., are
important, though some  of them  may be  said never to be
entirely and  absolutely absent.  The  question  of plus  and
minus,  of amount  in  other words, though roughly  calcu-
lated, is often enough to  confirm  a diagnosis, or give
assurance to  what would  otherwise  only be a mere  suspi-
cion of certain  pathological  changes.  A single  tubular
cast, for example, seen under the microscope, would  not
prove a case to be one of Bright's Disease, whereas fifty
would be conclusive. 
                         TA1U.1-:  NO.  ^.-PIUXCIPEES,  SUBSTANCES,  l'X;  1 .,
Observed  in  Black Vomit of Yellow Fecer, Bilious Fever, Cancer of  Stomach, Gastritis and Ordinary Vomit, relatice frequency.
                                          etc., to aid in disiinyuishiny the first-named.
Mack matter dissolved by nitric acid..............
Black matter not dissolved by nitric acid...........
Not coagulated by heat or nitric acid..............
Coagulated by heat and nitric acid (albumen)......
Degenerated blood corpuscles absent...............
Degenerated blood corpuscles present..............
Blood corpuscles not degenerated.................
Round masses  not blood corpuscles, cellular.........
Irregular crystalline masses (sandy?)............%,
Bound black masses (hard, uric acid V)...........".'.
Circular bodies, concentric.  (See Diseases)........
Large crystalline  masses not dissolved by nitric acid.
Fluid glairy-adhesive............................
Bilr......*.....................................
Sugar.........................................
Oil  globules....................................
Epitliel. scales, columnar and pavement............
Cryptogamia...................................
Hii'inatin crystals...............................
Cryst. after nitric acid (not plates of nit. of urea). . .
Wedge-shaped bodies, characteristic...............
Bodies—starch granules or resembling them........
Acidity........................................
Liver cell!.................................
Corpora amylacia  several times present............
No. 3.
Black Vomit of Yellow Black Vomit of Heniit-j Black Vomit of Cancer
       Fever.           tent (Bilious).       nf Stomach. Gastritis
                                       and Ordinary Vomit.
        (1
        1
3 and 1 doubtful.
3 and 1 doubtful.
      « 0
2 cases examined.
5 cases examined.
not C
not e
xamined.
xamined.
absent both  ease:-
2 ?  abs. 4 times.
1 and 1 ?

    4
    1
    1 
90
ILLUSTRATIONS OF DISEASE
  Examination of Statistical Table  No. 2.   For purposes  of
comparison, it embraces the  three following subdivisions:
1.  Substances found in  the  black vomit  of Yellow Fever,
specimens from eight  cases  examined; 2. Black vomit  of
Bilious  (periodical) Fever, two cases; 3.  Black vomit ob-
tained in Cancer of  Stomach, Gastritis, Dyspepsia—one
case of ordinary vomit is also included  in the  last subdi-
vision, which I regret.
  It is only in this way that we shall ever come to ai in-
definite conclusion respecting the true  distinctive nature
of black vomit of  Yellow Fever, i. e., by comparing it side
by side with black matters vomited  in other affections not
Yellow Fever.
  This  table, for want of a  larger number of cases exam-
ined  of diseases  other  than Yellow  Fever,  must be  re-
garded as only the beginning of a work  of this kind, and,
indeed, of  any attempt  to  ascertain, by a microscopical
and chemical examination  of the matters vomited, such
a  difference between  Yellow Fever and other  diseases
apt to be confounded with it, as shall be  practically useful.
So far  as the  present paper teaches anything (indepen-
dently of  any merit  in  the drawings themselves),  I can
only say that the  most repeatedly characteristic substances
in  black vomit  of Yellow  Fever, are "black  matters not
dissolved by nitric acid,"   though this was found once
also  in  subdivision 3, which embraces "black  vomit of
 Cancer of the Stomach," etc.
   A "glairy" fluid is  very common in the black vomit of
Yellow Fever—it was only  once found  in the other sub-
divisions, 2 and 3.  "Epithelial scales" in two varieties, are
 often met with in the  black, or  coffee grounds, matters
vomited in Yellow Fever.   Other  substances almost char-
 acteristic,  so  far  as these data  teach, are " crystals after
 nitric acid," not assuming the  form of plates of nitrate of
 urea.
   It appears also, from my examinations, that  "degene-
 rated blood  corpuscles" were  three times  absent in  the
 eight specimens  of black  vomit of Yellow Fever  exam- 
WITH  THE MICROSCOPE.                01
ined.   It is often difficult  to state positively that the black,
or brownish  granular masses,  so  often seen  with  the
microscope  in  the  matters vomited in Yellow Fever,  are,
or are not,  disintegrated  blood  corpuscles.   This is  the
more  so as they do  not  often assume a circular or  im-
perfectly circular outline.
  The  "circular bodies  with concentric  rings" I have
called attention to in Table  No. 1, are also  seen in  the
vomit of Yellow Fever.   "Corpora amylacia" are several
rimes noted in each of the subdivisions in the table  (2)
under consideration.   The  reader, however, can  very well
himself note the special phenomena  in each subdivision.
I have never yet examined wdiat  is called the "white vomit"
of Yellow Fever; this should not be omitted,  as it may
represent a transition stage interesting  both  in a purely
microscopical,  as  well as  a  purely  pathological point of
view.

  Table No.  3.—Surgical  Diseases, Tumors,  Concretions, etc.
I  need  not  call  special  attention   to the  peculiarities
observable from a comparative examination of this Table,
but will refer the reader to it. 
STATISTICAL TABLE  No. 3.-SURGIOAL  CASES,  FLUIDS, ETC., AND  SOLIDS.
Fluid from Ventri-
  cles of Brain.*
3 Cases.
3 Specimens.
Dropsical  Fluids
  obtained by Tap-
  ping, etc.

5 Cases.
5 Specimens.
Fluids from Testi-
  cle,  Hydrocele.
  etc.

3 Cases.
3 Specimens.
Blood from Uterus,
  Arm and Heart.

1 Case each.
Gall Stones "Cho-
     leliths."
 Granular masses....................................
 Blood disks..........................................,
 Organic globules...................................,
 Albumen.............................................,
 l'urpurine..............,.............................
 No purpurine........................................
 Bile present........................................,
 Bile absent...........................................
 Iodine absent.......................................
 Cryptogamia..../...................................
 Vibriones............................................,

 fCrystals after nitric acid   -&^_........
 Crystals after nitric acid absent..............
 Fat globules.........................................
 Chulesterine.........................................
 Neutral.................................................
 Sugar..................................................
 Round bodies like urate soda..................
 Large irregular crystaline bodies.............
 Crystals after nitric acid, diamond form...
 Crystals before nitric acid, diamond form.
 Fibrous structure...................................
Cancer cells..........................................
Osseous structure..................................
        1
        1

        4
        i
        4

        2
        4
        0
        0
O(lirreg.form pl'sj

        0

        2
        2
        2
2 (irregular forms)

        2
        1
2—some irr'r, pale
Irregular, pale
  *Some of this fluid was mixed with a little blood in one case.
  t These are precisely like the nitrate of cystine, which I have reason to think are so much oftener found in the renal excretion than is  generally supposed  though M
Iiobinhintsatsuchapossibilityiyol.il). 
F  E  V  E R S.
  Before commencing the first of the six subdivisions  of
Diseases into which this  Essay  is divided, viz:  Yellow
Fever, I desire to make  one  or two explanatory remarks:
I speak frequently and present specimens of "albuminous-
looking'' bodies—referring to fine, delicate, light  masses,
sometimes  granular, often  amorphous, and often assuming
a regular shape, which I suspected to be always albuminous
in character.   This is not strictly true, I find, upon more
extended observation, for albumen is  often  invisible in a
fluid, even  by the microscope, before heat or acid is added.
The reader will see many specimens scattered through the
following  figures.   At  first,  I drew many  of  them sup-
posing that they might.be tubular casts.  The definite shape
and well-defined outline of these lead me still to presume
that they have assumed a form  given them during their
sojourn in  the kidney, and their number is almost charac-
teristic of Yellow Fever.  I append the three figures which
follow,  in  order that they may be compared with  an ex-
cellent  specimen of the desquamative casts which I ob-
tained from a case of liright's Disease, or true Albuminous
Nephritis—see the third figure.   The first two figures are
from cases of Yellow  Fever; in using the third  here, I
anticipate another subdivision of this Essay (Fart II). where
diseases of the kidneys, etc.,  are illustrated.
%  ?-$
 
94
illustrations of disease
ft
W\z4     <,   m
              No. 1.—YELLOW FEVER.
  RENAL  EXCRETION EXAMINED WITH THE  MICROvSCOPE and
                  BY CHEMICAL  REAGENTS.

  Case 1st.—August 22.  Ilensler: "With bloody urine, and
recovery.   Yellow Fever, sick  seven days ;  specimen  of
renal discharge obtained 20th, patient very ill.
                        Upper surface  under microscope.
         O < / ' /r\   see -^i&- 1> presenting large quanti-
         ✓ "/?' OC  \ **es °^ regu^ar ^at globules ; no nu-
        r /'0  ^/o^ / i c^euBi even with the glass of highest
     P q   c aOq    i power.  One  or two of them occa-
  ^    O 'i®'^$A  °J sionally broken, irregular  and yel-
   \   ; c ns    /    lowish—generally regular; vibriones
      V____Z^^     present.
         Fig. l.                           ^-------^
  Lower strata, Fig. 2, red, with blood ;  /s£t£ O  q  q\
under  microscope, blood  corpuscles    x   © ^
abundant.   Xo   crystals ;  occasional \         ;:.•;■'
masses of granular matter.           \       %~>
Pig. 2. 
WITH  THE MICROSCOPE.
95
  Another specimen examined 2o7/*.
Patient is recovering as it were
by a miracle.  Urine now free of
blood, clear amber color, yet some
shrunk-up blood corpuscles under
microscope, see Fig. 3.   Yo crys-
tals ;  epithel. scales; not much
albuminous granular matter.
Disks at rigbt of figure small, -white and clear.
  In same specimen, examined at end of third day, I found
dumb bell crystals, urate of soda  and phosphates.  Figs.
4 and 5.
             Fig. 4.

  Case 2d.—August, lSoO.  Mathews:  Specimen  sent from
                    Roper  Hospital ;  sick  three weeks.
                    First case—resembling, if not clearly
                    Yellow Fever.  Patient taking infus.
                    serpentaria,  chlorate  of potash,  and
                    quinine.
                      Urate of soda and amnion., magnes.
                    Phosphates under microscope.

       Fig. 6.

  (;,,,,, &/—August 20th.  Cunningham:  sick since 2^1;
Yellow Fever ; ^Roper Hospital ;  specimen obtained this
inornino-; light  colored, not much  sediment.  Under  mi-
croscope, epithel. scales  very large; round  white bodies;
 
96
ILLUSTRATIONS OF DISEASE
blood corpuscles, small, wrinkled, crenulated ;  large granu-
lar masses, no crystals, non-crystalline black masses.

G

tp
0  r
Fig. 7.
  Action of reagents: Urine rendered turbid by heat ; more
evident by nitric acid ;  no  purpurine ;  no crystals when
the specimen was examined the day after.
  Another specimen, sent from the Hospital August 30th,
examined 1st  Sept.  Dark greenish  hue; large amount of
sediment.
    Microscopic examination of up-
  per surface : whole deeply stained
  as it were with bile; confervoid
\ growths — minute little whitish
  dots, with prominences, not per-
I fectly round (see  centre of Fig.)
  Also, vibriones ; no blood corpus-
  cles or crystals.
  Lower strata: very thick sediment;
large amount of fine, granular, yellow
substance, apparently stained with bile
— homogenous;  also,  some  whitish
bodies as  described  in upper  strata
(Fig. 8), probably vegetable growths.
Fig. 9. 
WITH  THE MICROSCOPE.
  Action of (hcmical Reagents: Heat rendered it very turbid
and thick, nitric acid  giving it a greener color—more de-
cided  than I had ever observed in any specimen of urine
(bile).   Acetic acid produced no change.   Fermented with
carh. of soda, with the effect of clearing it considerably.
With  hydrochloric acid fermented, but leaving no deposit
or thickening :  hence  no  albumen,  and the fine,  granular
matter, so often seen  under the microscope, not  always
albuminous.
                   Same  examined Sept. 2d. Yellow  crys-
                 tals,  resembling in shape haBmatine; not
                 unlike  uric  acid plates;  specimen still
                 having  color  of  bile ;  no blood corpus-
                 cles ; same white particles as above no-
                 ticed.
       Fig. 10.
  Action of Chemical Reagents: With heat, cleared up com-
pletely ; very much less  sediment;  with nitric acid very
dark,foamed,showing purpurine and bile; no great amount
of sediment, as in the other examination ; no albumen; hom-
ogeneous; turning blacker than I have ever seen with nitric
acid (purpurine).
  Keamined on 3d.   Still  entire absence  of crystals, unless
the ha?matin depicted  above.

  Another Specimen exam-
ined on  6th Sejit.   Odor
peculiar; yellow globules,
with prismatic rings—very
yellow color ; also, yellow
masses and globules,  like
yellow oil  (stained with
excess of bile); yellow oil globules could be seen floating
on surface.
  Heat had no  marked  influence ;  nitric acid discolored
and blackened  it (purpurine and bile); foamed with soda.
Fig. n. 
98
ILLUSTRATIONS OF DISEASE
  Case 4th.—Lawson : Recovery.  Specimen examined 17th,
collected 16th,[185G; sick five  days with Yellow Fever;
aet. 21.
               Upper surface : Vibriones small, active.
Fig. 12.
  Small black' bodies, always with centre
white — some double;  characteristic —
resembling dumb bells ; urate of soda.
Fig. is.
  Lower strata: (Fig. 14,)
abundant precipitate, al-
most entirely of urate of
soda; also, large crystals
of amnion, magnes. phos-
phates—both kinds abun-
dant.  Patient convales-
cent ;  taking  whiskey,
milk and  lime  water  ;
the urine  in this entire-
ly different from  that of
Lockerly's.
Fig. 14.
  Examined by Reagents:  neither  nitric  acid  or heat give
evidence of  presence of  albumen ; purpurine abundant;
ferments much when nitric acid is added.

  Case  5th.—Mrs. Watts :  Recovery,  after Black Vomit.
Specimen collected  Sept. 5th, examined
7th, 1856 ;  Roper Hospital; Yellow Fe-
ver ; very little sediment; colored.

  Upper surface presented nothing char-
acteristic under microscope;  roundish,  \
clear  bodies, with nuclei; hardly to be
considered disintegrated blood corpuscles.      Fie-15-
 
WITH  THE MICROSCOPE.
99
  Case 6th.—Mrs. Iliekcy: Sick with Yellow Fever eight
or ten days.  Specimen  procured yesterday,  10th ; color
red, resembling blood.
                         Upper surface under the micros-
                      cope : Blood corpuscles abundant;
                      small, round,  white—not  iritic—in
                      size slightly variable ;  no  nucleus,
                      but occasionally a little dot in cen-
                      tre of each, perfectly circular, though
                      artist has  not  copied  accurately.
                      Compare this with Fig. 1.  One light
                      colored crystal present—not charac-
        Fig. 16.         teristic.
  Lower  strata: Same in
appearance, — only  with
flakes  of mucus ;  blood
corpuscles perfectly circu-
lar ; triple phosphates and
dark colored urate of soda.

  Examined by  Reagents :
Not  coagulable  by heat
but by nitric acid, which
only separates large sedi-
ment upon cooling; boiled up excessively,  as usual when
urates and phosphates are  exposed to acids; does not fer-
ment with soda.
^<^
Fig. 17.
  Specimen from same, collected
to-day, 11th Sept.:  Much lighter
colored than first, as if containing
less blood or none ; crystals much
smaller;  none of the white bodies
(blood disks);  urate of soda and
amorphous matter.
Fig. 18. 
100
ILLUSTRATIONS OF DISEASE
  Action of Reagents:  Cleared up by heat;  reddened almost
like blood with nitric acid (purpurine); ferments and  boils
up; no separation upon cooling; does not ferment with soda.
  Specimen from same
examined 12th :  Very
light, white sediment;
strong  ammoniacal
odor; urates and phos-
phates abundant, with
extraneous substances,
hairs, fibres, etc.
             Fig. 19.
  Examined by Reagents:  Heat does  not coagulate it, nor
nitric acid,  only effervescing very  much—no  discoloration
following; sediment and crystals dissolved, and fluid made
clear by the addition of the acid ; no albumen.
  Note.—Patient entered with Rheumatism ; had had black
vomit; convalescent the 13th.
  Case 6th.—Specimen examined 16th, obtained 17th, 1856.
Lockerly: With Yellow Fever, from  Marine Hospital (sick
eight days); no black vomit.
   Upper surface of urine examined with  microscope, pre-
senting nothing characteristic.
  Lower strata (Fig. 20): Light, granu-
lar,  floating masses—apparently  albu-
men ;  also, hard, thick  crystals,  not
veiy regular,  but solid.   The  light,
granular masses abundant;  also, abun-
dance of the small, yellowish, circular
bodies (degenerated blood corpuscles ?)
variable  in appearance, scarcely  pos-        Fig. 20.
sessing a nucleus—only dotted—clear and increasing as the
fluid dries on the glass.
 
WITH THE MICROSCOPE.
101
  Many hard, rough, yellow
bodies, resembling uric acid;
one immense—darker in the
centre than at circumference.
These  characteristic, [artist
has not  copied  my figure
closely,] see  Fig. 21.  Much
granular matter.
           Fig. 21.
  Examined by Reagents:  With  application of heat, albu-
men abundant; coagulated and separated  by addition of
nitric acid ; some fermentation ;  no purpurine;  slight fer-
mentation when soda is added.

  Case  7th.—Specimen sent on 15th, examined  same day.
Peterson:  Roper Hospital;  Yellow Fever.   It is possible
that this specimen was retained at Hospital  before being
sent to  me.  Thick ;  strong ammoniacal smell.
                            Upper surf ace showing: Con-
   ©                      fervoid growth ; urate of soda ;
                          triple phosphates.

o
<&>
   -*>*
•V**"

^
£>
Fig. 22.
  Lower strata:  Presented
accompanying microscopical
appearances—objects in Figs.
23 and  24 unusually large,
visible to  naked eye : Fig.
23,  triple  phosphates  and
urate of soda.
23. 
102
ILLUSTRATIONS OF DISEASE
Fig. 24.
   Fig. 25 :  Light-col-
ored ;  not  stained; ap-
pearing  upon evapora-
tion.
Fig. 25.
   Chemical examination:  Heat  cleared  it up; with  nitric
acid neither thickening or changing in color.
   The following  examination  proves that  the above was
alkaline, urate of soda, etc. :
   1. Nitric acid  destroyed  the crystals completely, all ex-
cept the tubular extraneous bodies, with effervescence.
   2. Hydrochloric acid had  a similar action — not  influ-
encing the vegetable growths, but almost destroy-
ing the tubular forms ; a black  mass,  as repre-
sented Fig. 26, was left; nor  could nitric  acid
complete the destruction of this.                   Fis- 26- 
WITH  THE MICROSCOPE.
103
  Another specimen, collected 17th, examined 18th:  Very
large amount of yellow, chalky deposit.
J^L    Upper surf ace: Crystals dark brown.
       Fig. 27.
  Lower strata:  (Fig. 28.)  The crystals of urate of soda,
etc., of  course  all  destroyed by  nitric  acid, under the
microscope, with effervescence.   Blood corpuscles present.
The tube-like bodies were rendered paler by nitric  acid;
these are  nearly  always  foreign  substances, particles  of
wool or cotton from bed, etc.   The yellow bodies were not
destroyed,  nor their color lost;  hard, ciystalline bodies
also not destroyed.
                          Fig. 28.
  Action of Reagents:  But slightly  affected by  heat; by
nitric acid, darkened more than that obtained on 17th, rela-
tive Iv (purpurine);  no  particular increase of sediment.
 
104
ILLUSTRATIONS OF DISEASE
  Bile scarcely appreciable by test ;  alkaline.
  Vegetable growths  even more distinct after ammonia
was added—or it possessed a very slow effect upon them.

  From a portion set aside after nitric acid was added in a
test tube, and examined on the 17th :


                         The upper surface presented, un-
                       der microscope,  the   appearances
                       depicted in Fig. 29:  Light yellow,
                       somewhat  granular  matter,  with
                       dark,  round  bodies ;  blood  red—
                       thicker; confervoid growths.

      Fig. 29.

   Lower  strata, represented by Fig. 30 :  Dark crystals,
round, like urate  of soda ?  It is difficult to understand
how such bodies, which are plainly urate of soda,  should
have remained un destroyed b}T nitric acid. There must be
some  mistake.  The tube or hair-like body remained  after
all acids  had acted.   The dark, fibrous  masses to right of
figure, stained yellow ;  confervoid growths.
                         Fig. 30.

  Specimen from same, collected 17th, examined 17th :  Clear
amber color; mucus-looking particles floating in it.
  Action of Reagents: Not thickened or turbid by heat, but
 
WITH THE MICROSCOPE.
105
very much darkened by  nitric  acid, showing purpurine,
with effervescence.

   Case 8th. — Specimen  obtained  10th,  examined 12th.
 Wray: Roper Hospital; very ill on the 10th ;  light colored.

   Upper surface:  One crystal  of triple phos-     px*
phate ; urate of soda present.                    *^
             Fig. 32.


   These (Fig. 33)  proba-
 bly  foreign  substances :
 hairs, bits of bed clothing,
 etc.;  some  have strange-
 ly the appearance of ani-
 mals :  Polonius  would
 have  said,  "very  like a
fish."
                   Fig. 31.

  Lower strata: Pale, chalky
and  flaky  sediment;  ani-
moniacal  odor; against the
light,  urine  in vial  has  a
greenish  yellow  color, like
bile.   Some of  the scales
represented are stained with
yellow  bile—some  much
more yellow  than  others;
one  in lower  part of cut
light, and of a  chalky color.
33.
  Action of Reagents: Heat did not coagulate it, or make it
more turbid ;  with nitric acid, effervesced  so actively that 
106
ILLUSTRATIONS OF DISEASE
nearly all in the test tube escaped:  did not coagulate ;  it
became  slightly darker, then  cleared up.  There was seen
afterward some  separated matter floating in it (trace of
albumen ?)

  Case 9th.—Brady: Yellow Fever, from Roper Hospital.
Patient  was discharged Sept. 12th.
     Specimen  light colored,
 \  dark,  rough  bodies ;  vege-
 1 table growths ; the streaked
 I granular matter  in  lower
 /  part  of cut  light  colored
/  (yellowish.)
             Fig. 34.
  Action of Reagents: Does not coagulate  by heat,  rather
clears up ;  nitric acid only darkens it (purpurine); does not
even cloud ; very little effervescence.

  Case 10th.—Specimen obtained 22d Sept., 1856, examined
24th.   Armstrong: Third day with Yellow Fever ;  resident
of Elizabeth  street; had  taken calomel, quinine  and cit.
potash.
  Action of Reagents: Spe-
cimen  pale ;  mucus  pres-
ent; acid  reaction; clear-
ed  with heat ;  purpurine
slight; no albumen; nitric
acid clears it; no fermen-
tation : no sugar; no bile.
Confervoid growths abun-
dant and characteristic.
a;
Fig. 35. 
WITH THE MICROSCOPE.
107
  Case 11th.—Specimen obtained 17th, examined 17th Sept.,
1856.  Kelligan: Roper Hospital ;  Yellow Fever—not dis-
tinctly marked.   Specimen exhibited  dark froth,  as  if
tinged by bile.
  Action of Reagents: With heat, thickening; very albumi-
nous ;  nitric acid separated the albumen;  color darker,
showing  bile and purpurine ;  darkening very much ;  no
effervescence.
part of figure were clear and pel-           "0 %
lucid, resembling organic glob-
ules.
                                        Fig. 37.
  Action of Reagents:  Examined with heat; did not thicken,
but became a little clearer, though leaving shreds ;  frothed
a great deal ; hue greenish ; when nitric  acid was added,
nearly all boiled over; did not turn near so dark as on the
day before.  A great deal of sedimentary matter separated,
showing that albumen  is exhibited  on the second day.
Iritic  hue, showing bile, on white plate ; alkaline reaction.
  Note  (made  subsequently).—kV In another specimen of
Kelligan's ?  urine found in a test tube (to which nitric
acid was added several  days since)  with much sediment in
it, I noticed the  same  albuminous appearance—identically
similar to same phenomena as observed in examination of 
108
ILLUSTRATIONS OF DISEASE
Fig. 38.
Shempfel's case, further on, with
the addition  of crystals of dark,
red hue floating in the tube, many
of them regular;  nitric acid dis-
solves  them,  with  evolution of
bubbles."  The crystals, Fig. 38,
are undoubtedly those of uric acid.
  Case 12th.-
19th.   Luna
thick.
-Specimen  obtained  18th, evening, examined
 Roper Hospital;  Yellow Fever?  Pale color,
  Action of Reagents: Not altered by heat;  slightly red-
dened by nitric acid (purpurine); not cleared.
^5g>
  Re-examined  20th, with reagents and
by microscope;  slight trace of bile; al-
kaline reaction.

  Surface: Triple phosphates, and granu-
lar matter with usual elongated form.
Fig. 39.
  Lower stratum :  Urate of
soda, phosphatic   deposits;
corpuscles resembling mucus,
and  very minute, crystalline
plates.
                                      Fig. 40.
  Case 13th.—Specimen obtained Sept.  18th, evening, ex-
amined 19th.   Shempfel: Roper  Hospital. 
                 WITH THE MICROSCOPE.              109

  Appearance of specimen: Reddish colored, dark froth
on surface, stained with bile; red flakes at bottom of vial.
  Action of Reagents: Heat very much thickened  the entire
mass ;  not so dark; nitric acid did not increase this ; im-
mense deposit;  (behaved in the same way when  examined
the 20th, with hydrochloric acid and heat; no  purple  or
lilac color;) (no purpurine?)

    ^     Surface: Examined 19th, granular matter.


  Fig. 41.
^?~~1 •
                         Fig. 42.
  Red, albuminous-looking  granular matter; the flakes in-
vesting  the tube, which is  of vermilion color, look under
naked eye  like clotted blood,  as in Fig.  44, also.   No
crystals or blood corpuscles.
  Action of Reagents.—Examined on  20th for bile; no col-
oration  on white porcelain;  acid reaction; same examined
20th, with microscope:



       Wtffl  c>   o^        Surface: Vegetable growths,
    &uu$     o£ -o    Vj   white, transparent, round disks
                           and epithel. scales.
v
Fig. 43. 
110
ILLUSTRATIONS OF DISEASE
  Lower strata (Fig. 44):
Dark red, granular sed-
iment, and strings appa-
rently formed of disor-
ganized blood or colored
mucus, both visible to
the naked- eye and un-
der microscope, or  like
brownish colored stains
(albumen?) ;  confervoid
growths.
  Action of Reagents.—Boiled with  liquor potassae,  etc.;
sugar decidedly indicated.
               Note.—The specimen  collected the  18th,
             and then mixed with nitric acid in test  tube.
             Examined 21st, the albuminous-looking resi-
             due I find  now to be  fine,  brownish and
             granular; no crystals  or other  substance.
             See Fig. 45.
    Fig. 45.
  Same specimen obtained 18th, examined on 21st.
  Upper surface  had  on it a white pel-
licle, like cheese,  made up of a vegeta-     rj 0^  oo<j
ble growth, composed for the most part
of single buds.  Fig. 46.  Nitric  acid
dissolved the irregular crystals—did not
affect the confervoid growth ;  it impart-
ed to them a red dot like a nucleus.
oP6
50


Fig. 47.
Fig. 46.
  The same appearance was noticed
the same day in examining the speci-
men of urine obtained from Farley,
only the confervoid growths were
longer;  not destroyed by aqua am-
nion.; crystals forming'in both cases
(viz: Farley's and Shempfel's?) rep-
resented in Fig. 47. 
WITH  THE MICROSCOPE.
Ill
   Another specimen  of renal excretion  obtained from
Shempfel's ; sent to me 22d, examined 23d : 'Acid reaction;
dark, yellowish  red, apparently tinged by  bile; sediment
red.
  Lower stratum:  Generally                    >'n>
stained of a yellow color, as      \y ®        ^
if by bile; tubes,  or fibres,    <§'       '%^   Q^
abundant; granular (albumi-      iisr   ...  fc  /-v
nous-looking)  matter, some    "s:^s   NU>     l^
resembling tubular casts.
  Examined for  nitrate of
urea with a negative result.
                                        Fig. 48.
  Reagents: Very  albuminous by heat; not much efferves-
cence;  with nitric acid no increase, only a  separation of
the albumen ;  no change in color; no bile, tested by nitric
acid on  white  plate;  sugar hardly present by the cupro-
potassic test.
   Case  14th.—Jodnth:  Marine  Hospital; Yellow Fever;
specimen sent of reddish color.
  ---^  ffl  ®^ '3m     Urate of soda and rectangular crvs-
  H * *  D     tals

     D  □

       Fig. 49.
  Action of Reagents:  Ilcat does not coagulate it;  with
nitric acid, clears up ; it dissolves and lessens the red color,
with great effervescence.
  Case  15^/i.—Specimen  obtained  12th, examined 12th ;
Roper Hospital.   Ruddy:  Yellow Fever?  Disease  not
stated  on label  sent;  specimen light colored ;  cloudy in
middle strata ; entered Hospital the night before, having
been sick two days. 
112
ILLUSTRATIONS OF DISEASE
  Epithel. scales, beautifully tessel-
lated, very  large;  no crystals  on
upper  surface;  urate of soda  in
lower strata.
50.
  Action of Reagents: Heat rendered it  slightly cloudy;
with nitric acid it scarcely effervesced, but reddened (pur-
purine), and  separated;  some  sedimentary matter floating
through it.
  Same specimen examined 12th: it has changed  color;
whitish, large amount of sediment.
  Urate  of  soda  and  triple
phosphates, with minute gran-
ular matter,  and fine, circular
bodies, larger  than " organic
globules,"  but smaller  than
blood disks.   [The artist has
not copied my drawing accu-
rately.]

+*%.
 9    1 »fc
<& <tf $   ••'/•*
    *  «ssr-
Fig. 51.
  Action of Reagents : To-day heat clears it up—nitric acid
also clearing it—with no sediment or separated matter.
  Some 'twelve or thirteen specimens
of uric  acid crystals were found, sub-
sequently,  in  a test  tube  laid  aside,
containing  some  of  Ruddy's  urine
with nitric acid.  Fi«\ 52
Fig. 52. 
WITH  THE MICROSCOPE.
113
  Same specimen which  had been  examined 12th,  re-ex-
amined on 15th.
                     Upper Surface.
*- . »• •v,'    -%. - -.,


a
                          Fig. 53.
  Lower strata white, chalky, and filled with urate of soda
and  triple phosphates; wedge-shaped bodies, films of hair,
cloth, etc., with large epithel.  scale.   [Artist has not done
justice to my drawing.]
Fig. 54.
s 
114
ILLUSTRATIONS OF DISEASE
  In a note appended to this ease, 1  find written:  " among
specimens of urine  on  my table, collected during the past
eight days ; none have confervoid growths."

  Case 16th.—Specimen obtained 22<1, examined 24th Sept.,
1856.  Sent from Roper Hospital.  Furlong:  Renal excre-
tion pale, thick, yellow.

  Action, of Reagents: By heat, no sediment;  foamed with
nitric acid, with separation and deposit of sediment;  bile
present,  by test, of pink hue, on white  plate with acid;
very slight trace, if any, of sugar by cupro-potassique test.

  Lower stratum (very much as in  case of Tobin): Fine,
granular dots ;  also, yellow, granular bodies,  of the regu-
lar,  roundish, elongated form, so common in Yellow Fever;
with crystals of amnion, magnes. phosphates.
  Same specimen examined 25th.  Action of Reagents: Strong
alkaline reaction;  thick, lightish-yellow color; foamed over
and thickened by heat; with nitric acid, nearly all wasted;
thickened, but with no sediment like albumen ;  no sugar.

  Specimen of 26th ? examined 27th.  Lower stratum,  see
Fig. 56 :  "Albuminous " matter, resembling tubular casts;
epithelial  scales stained  yellow; minute, rectangular crys-
tals and extraneous  bodies. 
WITH  THE MICROSCOPE.
115
                          Fig. 56.
  Specimen of renal  discharge in  Furlong's case—though
kept for two  months,  still contained  vibriones in  active
motion.
                                              i v,,
  Examined Feb. 19th:  Not increased m   A* I Vv/
size—quite as small;  very active,  bee big-   \\fJ\>i<]\
57.                                               J't)
                                               Fig. 57.
  Case 17th.—Specimen  sent  Sept.  18th, examined  isth.
1856.  Farley:  Roper Hospital; Yellow Fever; pale, amber
color;  clear.
  Action  of Reagan's:  Neither heat  nor  nitric acid produced
the slightest effect ; latter only reddened it a little (purpur-
ine) ; neither deposit nor thickening.
  He-examined 19th.    Still  amber colored, pale, white-
cloudy at bottom. 
116
ILLUSTRATIONS OF DISEASE
Fig. 58.
   Upper  surface:  Small,  rounded  bodies —
white and clear;  hard, crystalline masses.

  Light, purple, crys-
talline  bodies,  centre
prismatic,  Fig. 59.— <^ /^
These appeared when
the preparation dried
on the glass—forms which I had never met before.
  Nitric acid converted the above, Fig. 59, into  these den-
dritic crystals ("stag-horn"), dissolving the unusual forms
represented in Fig. 59, and leaving these, Fig. 60.
Fig. 60. 
WITH  THE MICROSCOPE.
117
  Lower stratum tender microscope: Unusual number of epi-
thel. scales, of large size, with nuclei, mucus or pus corpus-
cles; light, crenulated disks; granular matter;  light yellow


0

Q  ®    -,.J
Fig;. 61.
color predominates; also, films and foreign bodies, bits of
hair, wool ? etc.;  few confervoid growths; no crystals.  Figs.
61,  62.
  These preparations  (Figs. 61,
62), when allowed  to  evaporate  #^
on the glass, did not present the
same appearance as did the first
(Fig.  58), treated in  the  same   £g)
way;  they  furnished  nothing
similar to what is depicted, Fig.          Fi;r 62
59 ;  but  when the preparation
of the lower strata was allowed to evaporate,  and exam-
ined on the 20th, I obtained this result.   See Fig. 63.
 
118
ILLUSTRATIONS OF DISEASE
  Transparent, pale,  parallelograms, broken off at  ends;
fractured ;  crystalline ;  white, pale  disks, some delicately
fine—nature unknown; pale dots, with slight nucleus.   «
  Specimen  of 18th,  examined  20th.—
Tested  for  bile, none present;  acid
reaction;  under  microscope, epithel.
scales present still; no crystals.

  On 22d.—Vegetable growths of un-
usual length, not destroyed by  aqua
ammon.  See Fig. 64.

Fig. 64.
   Case  18th.—Specimen  sent  Sept.  22d, examined 25th.
Daly: Roper  Hospital.  Labelled renal discharge  "of the
night;"  very  much of white sediment, pale, thick, yellow
colored.

  Action of Reagents: Cleared, then thickened by  heat;
albuminous;  with  nitric  acid, darkened (purpurine) ; no
effervescence;  albumen coagulated by acid; sugar,  I think, 
WITH  THE MICROSCOPE.
119
present, by cupro-potassique test (more sediment when this
test was employed than usual); acid reaction.
  The original  specimen  was and  is whitish, resembling
chalk and water, with abundant chalky sediment, an  inch
high in the vial.   Examined w7ith microscope 27th ; strange
that there are no crystals.
                              Near lower stratum: Rounded
       ">r ■„  Ai. "'**\      " albuminous-looking" masses,
                           finely  granular  (Fig.  66) oil
                           globules.
Cb
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'.-,».' *■
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\
X
o
fe-,-
to
Fig. 65.

\

^
Light, pale,  white,  confer-
void growths.
See Fig. 6~>.
X
Fig. 66.
^'2
  Case  18th,—30th  Sept.,  1856.  Patient  of  Dr.  O.  A.
White's.  Boy Morgan: Tradd street; sick seven days; im-
proving : little fever, no black vomit or bleeding.



N'.\



Fig. 67
   Action of  Reagents:  With
heat,  no deposit;  with nitric
acid, distinct greenish hue: no
sediment (had been taking gal-
lic acid.)

  Light  yellow  (albuminous)
granular masses, with tube or
hair-like bodies. 
120
ILLUSTRATIONS OF DISEASE
  Case  19th.—3d  Oct.,  1856.   Specimen from  patient of
Dr. O.  A.  White.  Murphy:  Sick two days ;  fever  had
been  violent;  "white  vomit;"  case  well  marked; renal
excretion scanty since first clay.
  Action of Reagents:  No  albumen; purpu-
rine ;  no  sediment  after nitric  acid  added;
delicate scum of upper surface under micros-
cope presented vegetable growth ? of this form,
Fig. 68.
\h
$#).;£?;»*■


                           Fig. 68.

  Lower stratum: Yellow "albuminous
masses," granular, well defined—and
I note, as unusually frequent in Yel-
lowr Fever; shape received in kidney,
I think.
^>:
FiR.
  With  nitric acid  set  aside  to
evaporate,  saw beautiful,  " stag-
horn"  crystals—visible  to  naked
eye—and fine, delicate frost work,
thinner than plates of nit. of urea,
Fig. 70.
Fig. 70.


  Case 20th.—Specimen sent Oct, 7th,
1856, examined 9th.  Daren: Roper
Hospital.

  Specimen  reddish,  as  if stained
with bile; clear, white, variable, pale
disks in upper part of figure, probably
oil ;  yellow, fibrous masses, orange
color;  large cells, not unlike epithel.
scales;  no crystals.
Fig. 71. 
WITH  THE MICROSCOPE.
121
  Action (f  Reagents: Heat made it so thick as not to allow
light  to pass, turning  it more yellow;  separation  taking
place  without nitric acid;  nitric acid colored it red from a
brick-dust color;  purpurine present;  no frothing; on  a
slip of glass, the cloudiness was plainly seen ;  bile evident;
purplish discoloration  by  usual test ;  no sugar (perfectly
clear  when boiled with liquor potassse),  or possibly only a
trace.

   ('use 21 .sV.—Obtained 22d Sept., 185(5, examined 24th.
Conner or Conn el': Roper Hospital.   Renal excretion }Tellow,
colored by bile ; froth also tinged yellow.
  Action of Reagents:  The  chalky deposit, when heated,
almost wasted by frothing away; no deposit with heat.  A
sediment in test tube after nitric acid  was  added, has a
thick, glutinous look;  no sugar;  bile present  by  usual test.
  Loirer stratum : Urates and phosphatic deposits, many of
the crystals crenulated  and irregular.   Fig. 72.
Fig. 72. 
122              ILLUSTRATIONS OF DISEASE

  Specimen of 26th.   Paler, reddish yellow.
  Treated by Reagents:  Albuminous by heat; the albumen
separated by nitric  acid, without any  froth  from  either
agent; some discoloration (like purpurine);  the color turns
to a very rich, dark yellow; no greenish collection ;  pretty
thick with albumen ; acid reaction.  When  nitric acid was
added to test for urea, hardly any  crystals ; evaporation by
heat precisely similar to 0' Conners, presenting very delicate
markings, with "stag-horn" and dendritic  crystals, "nitrate
of cystine."   See Fig.  73.
Fig. 73. 
WITH  THE MICROSCOPE
123
Specimen of 26th examined  microscopically 27th.
                              Lotvcr strait/ :  Presented
                           thick  (albuminous) looking
                           bodies, compacted in appear-
                           ance ;  brownish  yellow,  re-
                           sembling tubular casts, and
                           perhaps characteristic of Yel-
                           low Fever;  I have  noticed
                           them very frequently ; also,
                           granules, with yellowish nu-
cleus.
Fig. 74.
Fig. 74.
  (1ase 22d.—Specimen sent the 23d, examined 23d Sept.,
1856.  0'Chanel:  Roper Hospital.  No crystals, only yel-
lowish stained masses, closely resembling those depicted in
Fig. 74.
  Action of Reagents: Reaction
acid; heat showed much albu-
men, separating it; nitric acid
turned  the  albumen to a blue
color!! the lower portion of test
tube darker, the blue rising to
the surface with the froth.
Fig. 75.
  Tested for bile:  Purplish, blue color  (nearly green), on
porcelain plate ; no prismatic colors.
  For sugar: Very slight traces, with cupro-potassique test
(no thickening).
 \   In testing for nitrate of urea, discovered by
^1 microscope thin plates of crystals—not char-
    acteristic—with dark bodies.   Fig. 7<J.
Fig. 76. 
124
ILLUSTRATIONS OF DISEASE
  Upon adding nitric acid on 24th, to test for  urea, found
the accompanying by using the microscope.   See Fig. 77.
   These  forms  also
often accompany plates
of nitrate of urea, and
I find them to predomi-
nate in certain  diseases
illustrated in other sec-
tions of this Essay.
.ft-:* :•■'.
                                      Fig. 77.

  Specimen sent 22d, examined 24th.  Action of Reagents: Same
dark, biliary color;  heat gave same indications — if any-
                                thing, there was more de-
                                posit ;   with  nitric  acid,
                                abundant  green sediment,
                                more than  at the examin-
                                ation of the previous spe-
                                cimen ; bile present, de-
                                cided ;  sugar  none;  acid
                                reaction.
                                   Lower  stratum:  Dark,
                                yellow-stained, fibrous and
                                granular matter ; no crys-
                                tals ; also, stained epithel.
               ,p.  *Q            scales.
               Fig. 78.

   Specimen obtained from OConncl:  Collected 26th, examined
 27th: Yellow, biliary color.
   Lower  stratum: Urate of  soda  abundant,  all  jagged;
 also, large  striated and crenulated crystals, as  represented
 Fig. 79.
 
WITH  THE MICROSCOPE.
12.
fo*"6

                          Fig. 79.

  Action  of Reagents: Tested for nitrate of urea and exam-
ined with microscope, I  obtained the same dendritic plu-
mose crystals visible to unassisted eye, which I denominate
" stag-horn," and suppose to be nitrate of cystine, Fig. 80.
Compare Figs. 73 and 81.
Fig. so.
  Upon  beating  this (the preparation just used),  I did
obtain the accompanying arborescent  and laminated crys- 
126
ILLUSTRATIONS OF DISEASE
tals upon evaporation, very delicate; these resemble closely
nit. of urea, but I have it stated in a note that "the por-
tion  set by with nitric acid presented no crystals of any
kind, save a  few round,  apparently crystalline bodies,"
which  I  had  drawn, but  which the  artist omitted in  the
accompanying wood-cut, Fig. 81.
                         Fig. 81.

  Specimen obtained 26th, examined same day.
  Action, of Reagents:  Frothed up with  heat, and boiled
over with nitric acid; hardly thickened; scarcely, if any
albumen; specimen still yellow and  sedimentary,  but cer-
tainly  very  great  improvement, judging from  the renal
excretion ; reaction neutral; sugar none;  no sediment with
liquor potassse.
  Case 2od.—Specimen obtained 22d,  examined 24th Sept.,
1856.   Tobiu: Roper Hospital.  Pale  colored, abundant,
white, chalky sediment. 
WITH  THE MICROSCOPE.
127
  Action  of Reagents:  Alkaline reaction; cleared by heat
and by  nitric acid without sediment—frothed by  latter;
sugar none; no purpurine; bile very slight; pinkish  dis-
coloration by usual test.

%
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■s^o^V
 Lower stratum: White, chalky
deposit,  composed of  urates
and phosphates, Fig.  82.
          Fig. 82.

  Case 24th.—Examined 11th, collected  10th  Sept., 1856.
Fitzgerald: Roper  Hospital.   Dark  colored, slightly crys-
talline masses  present,  some epithelial scales ;   circular
bodies larger than white blood disks, with granular nuclei;
chloro-hydrate of amnion, represented on left of figure.

Fig. 83. 
128
ILLUSTRATIONS OF DISEASE
  Action of Reagents: Heat docs not coagulate it; nor nitric
acid—only makes it  darker (purpurine)  than in Brady's
case ;  effervesces a great deal.
  Another specimen obtained 12th, examined 13th.   Light
amber color, not much sediment.
Upper surface under microscope. Fig. 84.
  Ijoirer strata: White, chalky,
composed  of  urate of  soda
and amnion.  m,agues.  phos-
phates ;  vibriones exceedingly
minute; confervoid growths
present.
Fig. 85.
   Case  2oth.—July ISth, 1858.  From  Dr. O. A.  White-
Patient resided Tradd street, near King; first person seized
with  Yellow  Fever  this season,  and  recognized  by  Dr.
White ; taken  sick  four days since; renal excretion  col-
lected this morning, light color.
  Action of Reagents: With heat and nitric acid, albumen
abundant; acid reaction; no  purpurine, yet dark, muddy
color; bile abundant  (the black vomit was also examined,
see under that section); examined with  microscope 14th.
                      Vibriones abundant, almost the first
                    that I  have  observed since last  epi-
                    demic  of Yellow  Fever;  these  not
                    represented in Fig. 86.  Fragments of
           %  /,'.:.    casts stainecl yellow; albumen,  often
            g  :g    round,  resembling  tubular casts,  and
               ':--:    highly  tinged with bile (compare Fig.
                    74); no crystals (examined  14th); no
       Fig. S6.        sugar.
iftS


 4).
*&• 
WITH  THE MICROSCOPE.
129
  Examined 15th.—Found triple phosphates;  also, urate  of
soda, all crenulated in form.
  Note,—Weather has  been  very-
rainy for a week past,  heavy falls
of rain;  patient a policeman, who
had  been sent to the Lazaretto in
1854 for Yellow  Vovvv !  !  All then
concurred that  it was  a genuine
case; this attack, from which he
died with  black vomit,  not less
genuine ; no  nitrate of urea at any
examination,  though   they  were
Fig. 87
repeated,  this substance being specially sought for.

   Case 26th.—Sept. 16th, 1858.   Marine Hospital:  Thomp-
son: Has taken—R.  Calomel, grs.  xx; quinine, grs.  xx.
                           Third  day  of sickness,  renal
                           excretion pale:   triple  phos-
                           phates of  great size.

                             Action  of Reagents: No albu-
                           men ; slight purpurine  ; nitrate
                           of urea plates abundant, not rep-
                           resented.

          Fig. 88.

   Case 27th.—Specimen obtained Sept. 11th, 1858, exam-
ined 13th.  Jleathei's:  Marine Hospital.  Third day sick,
maniacal delirium; renal discharge red-
dish ;  no albumen bv usual tests.
Under microscope:  Fig.  89, triple   A
osphate  large, abundant; nitrate  of  ^-
Pi
urea plates abundant.
Fig. mi. 
130             ILLUSTRATIONS OF DISEASE

  Case  27th.—Specimen sent Sept. 10th.  Smith:  Marine
Hospital.   Kxamined two days before  death.

  miction of Reagents: Albumen present;  nitrate of urea, or
rather "stag-horn" crystals in watch glass visible, with albu-
men ; no plates like nitrate of urea of  (i.  Bird; not like ni-
trate of urea under microscope; what was laid aside on glass
slide with nitric acid only, presented  acicular crystals ;  no
cystine.   (A specimen from  Dr. De Saussure, jr., of a pa-
tient with  Yellow Fever, presented  albumen  and  "stag-
horn" crystals ; nothing spontaneously crystallized.)

  Case 28th.—Sept. 16th, 1858, morning; examined in four
hours.  Eilers: Marine Hospital; sick  eight days ; bleeding
largely  from gums; has  not taken calomel  for six days;
taking  quinine and alkalies (sec "Hospital  Book").  Pa-
tient very ill—died subsequently.  Renal discharge of yel-
low color.

               Action of Reagents: Slightly acid ; albumen
             abundant;  no purpurine;  bile  evident by
             test.   Triple phosphates abundant  the day
             previous to that on which he died.
    Fig. yo.

  Set aside  on  glass slide, with nitric acid, obtained :
        Fig. 91.

  Case 29th.—Specimen sent October 17th, 1858.   Hunter:
Marine  Hospital.   Collected eighth  day  of the  disease.
Albumen,  together  with bile,  present.   Examined  with
microscope three days after: contained triple phosphates.
 Star crystals of un-
usual  form.    See
Fig. 91,

  Also, these forms;
no plates.  Fig. 92.
U^
Fig. 92. 
WITH  THE MICROSCOPE.
131
  Another specimen, 0*7. 20///.  Action of Reagents : Does not
coagulate so readily with  heat, although albumen is great
in amount: appearance turbid; looks  exceedingly yellow.
as if it contained much bile ;  turned pink, irridescent hue ;
with nitric acid, showing bile.


                      Specimen  of Oct.  20th,  examined
                   with microscope : triple phosphates and
                   oil globules in yellow fluid (bile); also,
                   minute, rectangular plates  numerous ;
                   urate of amnion,

        Fig. 93.

   Patient  had great pain and weakness in the back.  Spe-
 cimen of  three days  ago  (1st examination)  contained no
 nitrate of  urea.  In specimen of the 20th, oil globules evi-
 dent, but not in the specimen obtained 17th.  No nitrate
 of urea.  Patient died.
0
 
132
ILLUSTRATIONS OF DISEASE
   No. 2.—BLACK  VOMIT OF  YFLLOW FEVER.

COMPARED WITH  BLACK VOMIT  OF BILIOUS  FEVER,  OF CANCER
   OF THE STOMACH, OF GASTRITIS, AND  ORDINARY VOMIT.

  I insert these figures without the text, which  is not at
hand.  The first seven, I believe, are illustrations of Black
Vomit of Yellow  Fever.   For  explanation, the  Statistical
Table No. 2. may be consulted.
Fix. 9L
Fig. 95.
Fig. 96.
Fig. 97. 
WITH THE MICROSCOPE.
133
mem:- ®
0
^
*
Fig. 99.
Fig. 98.
Ps*v.,
f* ■'" I.-
9
%a* -
«»
.*>* <5:-.?'....-'^o;5,-
0° O
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      CLINICAL  INVESTIGATIONS,

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              C1IAR1.KSTON, S. 0.. ISA.

   1CBIIMIK1) BY THE M.l'TIl  CAROLINA MKDR'AL As>U( 1ATION.

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