n-'-; 'wV^lur; r;!'SWv;>r-!?a',:,;i-:'.''-:-;'T:.T. ■ :.,,;V..iru. r.;.....•<,..•,.;;..:i:Ti,; ,;^.-;/; :.::i.^^- rA *'«.' ....V:,-"JU.1.,:UTJ'.:rvn,- «: :'..;. . •.. u' ■./•ua'.iwc.';.',',.', ;., ..,- •. , y.wm. UNITED STATES OF AMERICA WASHINGTON, D. C. 6PO 16—67244-1 MANUAL PATHOLOGY PRACTICE OF lEDICIIE B Y 1 SAMUEL HENRY DICKSON, M. D., PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF NEW YORK. ,on NE'W- YORK JENNINGS & HARRISON, PRINTERS, 122 NASSAU ST 1850. , 1850 Entered according to act of Congress, in the year 1850, By SAMUEL HENRY DICKSON, In the Clerk's office of the United States District Conrt for the sonthem district of New York. « GENERAL PATHOLOGY. The science of Pathology of necessity presupposes, and is founded upon an acquaintance with the doctrines of Physiology. Physiology is built upon a knowledge of Anatomy and organic Chem- istry. As Physiology is the history of the natural and healthy condition and functions of the body, its tissues, parts, and organs, so Pathology consists in a knowledge of the morbid condition of the parts, tissues and organs of the body, and the derangement of its functions. Disease has been variously but inexactly denned; it may be described briefly as consisting in some change of structure or composition of the body or its parts, or some impairment of function—causing suffering or danger. It always implies irregularity or aberration in the perform- ance of one or more of the functions of the body. This irregularity of action may be owing to obvious alteration in the structure of some part of the body, or it may occur without our being able to detect any change in the structure of any part. Hence the distinction of diseases into Functional and Organic—and hence the im- portance of a close inspection of the condition of parts of bodies dead from disease—a description of which constitutes the useful and interest- ing department of morbid anatomy. Disease may be local or general. It is local when the cause pro- ducing it acts with special force upon some single part or organ, while yet no participation in the morbid consequences is extended to other parts. It is general when the primary local affection has been commu- nicated or extended throughout the system. Each of these may pro- duce the other. It is plausibly argued that all diseases are primarily local, and afterwards radiated or rendered universal by nervous sym- pathies, and by vitiation of the fluids of the body. General disease may also in turn produce local affections, as in hepatic and splenic inflam- mation from the concussions of fever, and in gout and scrofula. Disease, the perversion of some vital action, is never spontaneous, but always results from the agency of a disturbing cause or causes. The Causes of Disease are almost as varied and numerous as the agents which impress the several organs and tissues. They are naturally separable into two classes, according to their in- trinsic character, 1. The Specific, 2. The Incidental. Th6 first act by 4 and through their peculiar properties, which exert an influence essen- tially injurious to the organism. The second produce a morbid effect, not by any hurtful quality belonging to them, but by excess or una- daptedness; both which terms ultimately refer to the condition of the recipient. The first may be spoken of in a general way as the Poisons. The second include all contingencies incident to animal life. Causes of disease are divided in the books into Remote and Prox- imate. I prefer the terms Efficient and Constituent. The Proximate cause has been absurdly enough regarded as the dis- ease itself. I would denote it as being the first essential link in the chain of morbid actions, whose results become obvious in the symptoms of disease. This is the Constituent condition upon which depend all the circumstances which give diseases their characteristic and peculiar form. The discussion of proximate causes—a very complicated and obscure subject—is better deferred, therefore, until we enter upon the consideration of maladies separately. It is in fact an inquiry into the Nature of Diseases. Remote causes—the agents efficient in the production of disease— are distinguished into the Predisposing and Exciting—terms happily chosen as suggesting clearly enough their own meaning. As to the specific energy of these modes of causation, I infer that disease in the abstract may be attributed to the disturbing influence of exciting causes, while the mode and seat of the disease generated, will be determined by the existing predisposition upon which the former has acted. Yet we cannot always draw a line clearly between them. Predisposition may be so strong as to develope disease without the need of application of any transient excitement—as in gout, scrofula, &c.—and on the other hand, an exciting or occasional cause shall have power to produce immediate predisposition, or rather perhaps of itself to determine the nature of subsequent and consequent disease, as in small pox and other contagions. Brown, Broussais, Parry, and other pathologists have taught that the effect of all such causes is only an increase or enhancement of the natu- ral actions—in other words, that morbid differs from healthy action mere- ly in intensity or degree. This is an important and mischievous error. That morbid causes occasion difference in nature or kind of action, as well as in degree, is proved by the changes which take place in the secretions of disordered surfaces, which are altered in properties, ob- vious and chemical; and by the new peculiarities of diseased structures which are built up, as in fungus hematodes, cancer, &c. Predisposition, though spoken of as a cause, is properly a passive state. 5 It is sometimes obvious and definite—as when exhibited in form and physiognomy. Sex, color, and temperaments belong to this class. It is evident that such predisposition is not incompatible with health. The intense or exquisite development of any Temperament, however, is a condition, if not absolutely morbid, yet full of danger. It is perhaps properly a Pathological state. An obscure and indefinite predisposition belongs to the intercurrent period of paroxysmal diseases, and to the latent period or incubation of an invading malady. Predispositions are Original and Acquired. The first may be sub- divided into, 1. The Idiosyncratic or personal, 2. The Hereditary or parental, 3. The Tribal or national or generic. The Acquired may be, 1. Normal, arising from habit, mode of life, &c, and 2. Abnormal, induced upon previous or existing disease. These latter are often of irresistible force; sometimes becoming matters of habit, "a second nature;" at others, probably engrafted on minute changes of structure in the parts affected, as in rheumatism, gout, scrofula. All the individual predispositions may be transmitted hereditarily. Of this the examples are indefinitely numerous. Idiosyncracies are either the result of internal peculiarity of con- formation, or of sympathetic association; and thus present instances of both original and accidental predispositions. Among external sources of predisposition, we enumerate climate, topographical peculiarities of surface, of country and soil, &c.; hence national temperaments: state of society—many diseases are the pro- duct of civilization and refinement, and so absolutely artificial: condi- tions of life and occupations, quantity and quality of food. Predispositions may be either permanent or transient. Among the latter we comprise those which belong to age, infancy, puberty, &c, to the conditions of fatigue, debility, excess; and to the state of sleep, which is apt to offer easy access to asthma, epilepsy, cholera, &c. Exciting causes may be classed under several heads. 1. The Atmospheric, including known and unknown qualities of air, thermo- metric, hygrometric, electrical and barometrical conditions. All ex- tremes seem to be compatible with health, but there is a tribal difference as to the liability to be affected by them; abrupt alternations are con- sidered unsafe. Change of climate is a very familiar cause of disease in the present day of emigration. Vegetables and the lower animals are affected by, it as well as man. The evils thus occasioned may be lessened by cer- tain precautions, but all emigrants to distant or contrasted climates must 6 expect to suffer more or less before they can attain a complete assimi- lation or adaptation to their new circumstances. Heat produces apoplexy, phrenitis, inflammatory fever, hemorrhage. It affects the internal viscera by increasing the force and frequency of the circulation, and by their sympathy with the skin, whose exhalation it increases largely; thus it gives rise to hepatic, gastric, and intestinal derangements. Cold causes pernio and other external inflammations; and by con- stricting the surface, and interfering thus with the functions of the skin, gives rise to a host of diseases of undue determination—pleurisy, ente- ritis, catarrh, &c. Alternations of temperature are proverbially injurious. Heat ap- plied after cold is perhaps the most dangerous of the two changes. 2. The Dietetic, comprising all food and drinks. Man is omnivorous and may subsist and enjoy health on an infinite variety of diet. Yet we can trace many diseases to food of improper quality, or in improper quan- tity. Scurvy arises from salted meats, probably from all restricted and exclusive diet long persevered in, under circumstances of physical and moral depression; dyspepsia from undue use of acids and condiments; colics, &c, from meals too large for the stomach. Cookery is a truly important science, and it is an absurd affectation to disparage it. The preparation of food requires talent, judgment, skill and care. The chemical rules are not well decided, and the best practice is yet em- pirical. Much of the ill health of our country is ascribable to ill cooked, hastily eaten, half-masticated victuals. Water with which food is diluted and thirst quenched, is never pure. The various substances which it contains in mixture and solution, earths, alkalies and gases, differ according to the soil through which it percolates. They may all become injurious to health. Intemperance in drinking fermented and alcoholic fluids is dange- rous in proportion to their intoxicating power. Their immediate im- pression is made upon the stomach and brain; but acting upon predis- position, they may occasion an infinite variety of maladies. 3. The Personal, referring to the special habits and mode of life of the individual. Dress, Amusements, &c, if not properly regulated, all become in their turn exciting causes of disease. The female stay or corset has been animadverted on much more than it deserves. Properly ar- ranged, it gives support as well as adds neatness and beauty to the form. It may be so tightly drawn as to interfere with locomotion and respiration, and to oppress the abdominal viscera: the steel piece may also be too broad, and thus injure the breasts. 7 Occupations are among exciting causes. Millers, stone-cuttefa, needle-grinders, cotton-ginners, are subject to bronchial and pulmonary inflammation from the mechanical irritation of particles inspired. Paint- ers, gilders, &c, are injured by the fumes of the metals they employ. Manufacturers in general suffer from confinement and monotony of life, with utter hopelessness of change or improvement of condition. The passions must be enumerated here. I regard them as all stimulating in their immediate influence, which is directed primarily upon the sensorial organs. Anger, grief, and joy, produce apoplexy, hemorrhage, phrenitis, hysteria, &c. Love is a dangerous passion even if successful; when otherwise, frequently gives rise to insanity. Fear increases the velocity of the circulation, and often adds greatly to the force of muscular action; it has been known in a few hours to give the hair a silvery whiteness, and the whole frame the aspect of sudden and premature old age. 4. The Social, comprehending all the details of public and muni- cipal Hygiene; density of population, &c.; manners and customs of civilized life, savagism, &c, &c. 5. The Poisons, divided into the vegetable, animal, and mineral; to which I would add a fourth, the gaseous or aerial, as the sources of some of them are not well known, while their form is obvious. The Vegetable poisons;—some of these act by inhalation, as the upas and mancinella; others by contact with the skin, the cerbera ahovai, mannarilla, cashew nut, rhus radicans and rhus vernix, mustard, &c—these irritate and inflame; others still upon the stomach and intestinal tube—these are our emetics and cathartics; and others on the nervous system—these are the narcotics, which relax, intoxicate, and produce stupor, coma and convulsions; lastly, others require to be introduced into the circulation, as the woorara and ticunas. The mineral poisons are multiplied in number by chemical pro- cesses. The metals are in their proper state harmless, but the salts of many of them are deleterious, as of mercury, lead, arsenic in a high degree of intensity, copper, antimony. The pure alkalies and the acids are irritating and corrosive. The Aerial poisons .—Some of these are of known chemical origin and qualities, as the several irrespirable gases; others are in both these respects obscure and undetected, as epidemic contaminations and ma- laria. Of the first class, the most common is the carbonic acid gas, and the other combinations of carbon and oxygen so often met with in mines, wells, vaults, &c—these produce asphyxia. The pre- 8 caution should be taken of sending into suspected places a lighted candle; if this cease to burn, quicklime should be thrown in, in suffi- cient quantity to absorb while slacking, the superabundant carbonic acid gas. Charcoal burned in ill-ventilated apartments consumes the oxygen, and combines with it so rapidly as frequently to have thus occasioned loss of lives. Air which has been breathed becomes soon unfit for respiration. A terrible instance of the effects of confinement in a close apartment is recorded in history as having occurred in Cal- cutta upon its surrender to the Suba of Bengal in 1756. One hundred and forty-six of the English garrison were confined in a narrow dun- geon during a hot, airless, and miserable night—one hundred and twenty-three perished before morning. The want of ventilation of which the above is an extreme case, is in intermediate degrees productive of varied morbid influences, as implying the presence of numerous and diversified aerial poisons. To this we attribute the fact that general mortality everywhere, is in proportion to the density of population, when it transcends a certain rate. The notorious insalubrity of cel- lars as domicils is owing also to it. It increases the proportional fre- quency of phthisis. Typhus is generated surely by it. Bandelocque ascribes scrofula to it. Toynbee attributes deafness and frequent ear- ache to the same cause. Malaria.—This term is preferred in compliance with modern usage to the word miasm, which has both etymologically and in the wri- tings of many physicians, an extension so wide as to include all aerial contamination, whether chemical, contagious or epidemic. It is best defined as a peculiar distemperature of the air of certain regions, derived from sources to be considered in order, traceable only by its effects, and as yet undetected by any chemical or mechanical investi- gations. Its nature is unknown : its very existence has been made matter of dispute: all the influences ascribed to it have been attributed to the mere agency of moisture, or of moisture associated with heat; an error evidently owing to the concomitance of these exciting causes and their tendency to promote its efficiency. The principal source of malaria is believed to be the decomposition of vegetable matter. Vegetable putrefaction developes animalcular life and fungous vegetation. It gives out often unpleasant odors and gases unfit for respiration. It is always unfriendly to human life and health, and even in the most local and limited way—as in the foul hold of a ship, or a potato cellar, is capable of originating serious evil. The growth and production of vegetables, as well as their subsequent decay, are fostered by the presence of moisture and the action of high temperatures. Certain effluvia thus disengaged produce forms of fever 9 and other diseases, whose occurrence is regarded as proving the pre- sence of malaria ; an agent capable of being everywhere identified by these its effects. Hence malarious fevers appear in summer and au- tumn, and are intense in proportion to the temperature of the region affected. In hot countries the plague, yellow fever, bilious remittent, &c.—in colder regions intermittents of chronic character, hepatitis, jaundice, &c, have been ascribed to this cause. Cold, when sufficient- ly intense, puts a check to the influences of malaria. Heat promotes the action of malaria, by generating a predisposition in the system favorable to it, and hy stimulating and afterwards relaxing the vessels of the skin and liver. Moisture is not only necessary to its produc- tion, but likewise becomes the medium in combination with which this poison acts upon the body—a combination, it would seem, of essential necessity to give it effect. Hence the known insalubrity of fogs and dews in malarious districts, and hence the advantage of elevation from the exhaling soil. A certain degree of concentration and a certain amount of dose, are necessary also to the efficiency of malaria. It is in this property chiefly that a virus, technically so called, differs from a poison; the former being independent of both these circumstances; thus the small- est particle of variolous or vaccine matter can infect the whole body. It may indeed be diluted to inefficiency, but if it infect at all, the degree or force of its action has no reference to the amount or concentration. The action of a poison however is always modified by the dose. This constitutes the principal objection against the doctrine of the organic nature of malaria—as consisting of animalcular life of ultra micro- scopic minuteness, or of cryptogamic vegetation, equally beneath the reach of our vision, however powerfully aided. The sources must be large and extensive to produce malarious disease. A contagious virus adhering to any fomites in smallest amount is often efficient; but it is impossible to convey enough malarious atmosphere from the place which it renders deadly, or any of its constituents, animalcular or fun- gous, to produce disease at a distance. Calms are favorable to the concentration of malaria; winds and storms waft it away, disperse and dilute it. Malaria probably acts upon the skin primarily. Thus we account for the insusceptibility of the negro race, who perhaps differ from the white as much in this point as in any other. It also acts more readily during sleep, when the functions of the skin go on with energy. Anything which depresses the vital power may be said to assist its invasion—fatigue, want of food, of rest, of clothing, &c. Habit diminishes in the white man rather the violence of its effects 2 10 than the susceptibility to its action. Many residents in low countries have regularly annual attacks—these are of no great severity, but in- fallibly undermine the constitution. A stranger is assailed more vio- lently. The latent period is of doubtful length, and differs probably in proportion to the intensity of cause applied, which may at once excite, or may only generate predisposition. Trees are found to oppose an efficacious barrier to the invasion of malaria. It is somewhat uncertain whether this is owing to the me- chanical impediment which they offer to its passage, or whether it is better accounted for by the supposition of the existence of some at- tractive force, which causes the miasma ;to adhere to their foliage, or by the suggested evolution of some efficient counter-agent. This last conjecture may assist us to explain the healthfulness of pine barrens; among the favorable circumstances in whose position, I would enume- rate the terebinthinate exhalations from the trees, as probably balmy, tonic and salutiferous. The Jussieuia grandifiora of our southwestern bayous is maintained by Dr. Cartwright to be a corrective or antidote to malaria. Among the sources of malaria the decomposition of decaying volca- nic matter has been mentioned, and applies well to the phenomena familiar in Italy. The country about Rome is not marshy but volcanic; so of Civita Castellana, Fondi, &c. Ferguson declares the only neces- sary condition to be " paucity of water succeeding its abundance." Some medical philosophers would substitute the agency of specific ani- malculi for all miasmatic and epidemic influences; and Dwight has proposed animalcular putrefaction as a source of malaria. The most plausible and rational theory of malaria is that taught by Prof. J. K. Mitchell, of Philadelphia. He ascribes the poisonous influ- ence to the presence of the minute sporules of certain fungi diffused in the atmosphere; and supports this view by a large accumulation of facts and much ingenious reasoning. It is not inconsistent with the great mass of observed phenomena. Fungi are abundant wherever vegeta- ble decomposition goes on rapidly; their production is favored by ani- mal putrefaction ; volcanic tufa is fruitful of them. There are how- ever difficulties in the way of this hypothesis not yet surmounted ; ob- jections not yet removed. Ozone is an atmospheric poison discovered recently by Schoenbein and supposed to give rise to catarrh and influenza. It is the oxygen of common air rendered active by electricity. It is known to be present by the increased promptness of reaction between iodine and starch Cholera has been ascribed to it, but without reason. The Animal poisons are divisible into three classes: 1st. Those 11 which result from natural and healthy but peculiar actions. These are secretions intended for attack or defence, as the sting of the bee, wasp, &c, and the venom of the snake. 2d. Such as are produced by diseased processes—the milk and butter of a milk-sick cow, the saliva of a rabid animal of the feline and canine tribes, vaccine and variolous matter, &c. The saliva may become poisonous by rage, or other con- ditions of the mind and body of the subject. Instances of this sort are given by Wright; and some curious facts to the same purport are re- corded by Dunn in his account of the Oregon Indians. The processes which immediately precede, and those which accom- pany or follow death, tend to generate a poisonous quality in animal matter. The flesh of diseased animals is unfit to be used as food and becomes injurious when so used—in one instance a specific disease is thus communicated, " milk-sick," a gastritis. Among anatomists a very severe and not unfrequently fatal affection is produced by punc- ture and inoculation, with the scalpels, &c, imbued with the fluids of a subject. The absorbents inflame, and the glands; a cutaneous eruption comes on, attended with violent irritative fever and great prostration of strength. History, both ancient and modern, offers us frequent instances of pes- tilence produced by animal putrefaction. The burial grounds of Paris, London and New York proved to be injurious to the health of the vicinity. Catholic churches on the continent of Europe require to be disinfected occasionally. Putrescent animal matters used as food are often highly poisonous, as in the instance of the German and Bologna sausages. Contagion is defined to consist in a peculiar matter given out by a diseased surface, which possesses the power or quality of generating in a healthy body a diseased condition similar to that whence it derived its origin. It must possess the power of reproduction or self-multipli- cation ; it is therefore probably organic in its nature, whether animal- cular or vegetable, a fungus as some suppose, is not easy to decide. Contagions perhaps vary among themselves in this particular, some being animalcular and some of vegetable character. To prevent confusion in the use of language, I would follow the dis- tinction proposed by W. Philips, in which contagion is pointed out as the morbid poison, and infection as the act of communicating disease. The matter of contagion may be either palpable or impalpable. Vac- cine, chancre, gonorrhoea, psora, offer examples of purely palpable contagions. These are transmissible only by actual contact of the morbid secretions with some portion of absorbing surface. Scarlatina, rubeola, parotitis, pertussis, give out an imperceptible 12 emanation which affects the healthy subject, we know not exactly how, coming in contact with some surface which admits its entrance or impression. Variola, plague, varicella, produce a virus of palpable form, which is capable of acting either when directly applied, or after having be- come impalpable by solution or diffusion in air. Of the physical and chemical qualities of the matter of contagion but little is definitely known, except in a few instances. It is not only thrown out in a distinct form, but seems to be diffusible in the blood, unless we suppose the whole mass of blood to become contagious mat- ter. Transfusion of blood has communicated glanders and farcy in the horse and ass ; and Home, Speranza, and others, have communi- cated measles and scarlatina by sanguineous inoculation in the human subject. There are but two agents in nature which have been plausibly regarded as specific disinfectors—lime and heat. Chlorine and some of its combinations have been ranked here, but I think without sufficient proof. Vinegar and sulphurous acid are also employed. Contagious matter is considered a virus rather than a mere poison, because quantity does not modify its effects. Hence also it has been supposed to act by contaminating the fluids of the infected body, and impressing on them a progressive change or assimilation, as it has been termed. This change is spoken of as analogous to fermentation. The matter of contagion varies in reference to its modes of efficient application. It infects by 1st. Inoculation—insertion in a wound or abrasion, either of a palpa- ble matter or of diseased blood—as in vaccine, small pox, herpes, tinea capitis, hydrophobia. Under this head we place, of course, sanguineous inoculation, and transfusion of blood, as in measles and scarlatina. 2d. Contact—favored of course by friction or protracted application, as in ophthalmia, psora, gonorrhoea, syphilis. 3d. Confinement in vitiated air, as in hospital gangrene, erysipelas, perhaps phthisis. 4th. Near approach, as in typhus, scarlatina, measles, hooping cough, parotitis. 5th. Fomites. Various articles which absorb contagious matter are so called ; woolen and cotton cloths, furs, feathers, &c. These retain it long and tenaciously, and preserve its virulence little impaired. The clothes of a physician, it should be always remembered, may, by thus entangling contagious particles, convey them and communicate disease. 13 6th. Atmospheric diffusion, as in plague, small pox, dengue, cholera, and numerous others. Contagion has no other source than the morbid actions in diseased bodies; but it is an error to infer that contagious diseases arise exclu- sively from the influence of contagion. They differ widely in their origin. Some are easily traceable, as psora, lues venerea, typhus, ophthalmia; of others the history is obscure, as of measles, pertussis, &c.; but indeed it is obvious that all must have had a spontaneous beginning, apart from contagious transmission. Contagions differ in regard to their latent periods after infection; some of them follow a known rule, liable to exceptions. Thus, after vaccination and variolous inoculation, about three days pass away before any obvious results occur. For the most part they are indefi- nite. Typhus has been known to assail immediately after exposure ; the latent period of measles often extends to a fortnight or three weeks, and hydrophobia has been postponed for six months or even a longer time. Contagions differ also in comparative force or efficiency; from small pox, which extends itself either by inoculation, contact, mere approach or aerial diffusion, to phthisis, which requires close and protracted confinement within a vitiated atmosphere of narrow limit. Scarlatina, typhus, pertussis, and cholera, will occupy a middle place in this comparative catalogue. It is probable that no disease is contagious throughout the whole of its duration, and it would be interesting to know the contagious stage of each individual malady communicable in this way. Small pox has perhaps two such periods ; the first being the eruptive stage, when an impalpable matter is given out from the whole surface ; the second is ascribed to the maturation of the palpable virus, which is assumed to be diffusible in the air. The contagious periods of febrile diseases seem to me to be much more limited than is generally supposed. It is not easy to decide the question of the contagiousness of any given form of disease ; the following would appear to be the best and most reasonable tests that can be offered : If, in repeated instances, under the notice and by the report of com- petent observers, a single case be the forerunner of others in the immediate neighborhood, provided the circumstances of season and locality are sufficiently varied to remove it from the list of endemic affections. If it exhibit an evident preference for a dense population, or confine itself within the limits of towns, cities and villages. If a household or community, previously healthy, be attacked sue- 14 cessively after known intercourse with a sick hody, or contact with fomites. If those escape uniformly or very generally, who take care to avoid such cases and fomites, and infected neighborhoods. The questions concerning contagious disease are of very great importance, as they bear upon the commercial and ordinary intercourse of nations. Superfluous regulations of a restrictive nature have often been stig- matized as cruel; the imputation will lie more properly against such as are inadequate. Every community has a right, and is indeed bound in duty, to establish its own quarantine regulations. Some of the contagions are endowed with the property of destroying in a system once affected by them, the tendency or disposition to a recurrence or second attack—as variola, rubeola, pertussis, parotitis. From the singular fact that vaccine exhibits a protective influence in this manner, to shield from, and at any rate to modify small pox, some have inferred their identity; explaining the obvious differences upon the conjecture, that the former, in a course of successive transmissions through the systems of the lower order of animals, as the horse and the cow, has undergone these alterations in external character and symptoms. This view is not satisfactory. That there is a specific distinction between them seems proved by the fact that while vaccine protects against or notably modifies variola, it does not so modify or protect against itself, but may be repeated many times in the same subject. The majority of contagions, and especially the non-febrile, give no protection against second attacks, but may recur with indefinite fre- quency. Diseases are spoken of as endemic and epidemic ; the latter being divided into local and general epidemics. Endemics are of permanent prevalence in special localities, governed perhaps by known conditions of season and temperature. Intermittent fever, and bilious remittent, are endemic in all malarious regions; yellow fever in Havana and Vera Cruz ; cretinism and goitre in the Valais; pellagra in Lombardy; milk-sickness in several portions of our southwestern country; tumid leg in Barbadoes; plica in Poland. Local Epidemics, often confounded with the above, are occasionally prevalent, in certain localities. The causes of this prevalence are both transient and obscure, their influence bearing no obvious relation to seasons, as distinguishable from each other. Yellow fever sometimes prevails as a local epidemic in situations where it is not endemic • so also dysentery, typhus, &c. Both contagious and endemic diseases 15 may, from unknown circumstances, become local epidemics, as bilious fever, hepatic affections, scarlatina, plague and pertussis. General Epidemics.—Under this head we comprehend all those forms of pestilence which have at various periods spread themselves over the world, unconfined by the limits of geographical position above referred to, and in many instances uncontrolled by whatever conditions of sea- son, climate, and national peculiarities. Such was the " black death" of the fifteenth century; such are influenza and cholera. Of the several causes of endemics it will be best to treat in detail, under the several heads to which they belong. Concerning the origin of epidemics, a few observations may be made in this place: 1. Local epidemics have a definite reference, which although it may not be well understood is uniformly observed, to the locality and other circumstances of the position where they occur. 2. General epidemics admit of no such circumscribing conditions. 3. Endemic diseases, if of febrile character, often become local epi- demics ; the non-febrile show no such power, with perhaps some rare exceptions. 4. The febrile contagions, however generated, also become fre- quently, local epidemics. 5. Endemics are incapable of becoming general epidemics, because limited, as by the description of their sources. 6. Febrile contagions on the other hand may and often do become general epidemics, spreading on all sides, regardless of locality, cli- mate or season. The epidemic prevalence of disease depends simply on the multipli- cation and diffusion of the cause of the disease, whatever that may be—the materies morbi. The materies morbi of the general epidemics must be specifically different; no two being similar, we can lay down no laws of epidemics. The cause of influenza may be ozone ; but in- fluenza, apparently a mere catarrhal fever, is producible as many be- lieve by a contagious influence, animalcular perhaps; a sporadic attack may be brought on by exposure to cold and moisture or at- mospheric changes ; in some persons by exhalations and odors. It is probable that most of the materies morbi, the causes of general epide- mics, are organic, because they are self-multiplying. It is probable that some are of vegetable nature—fungous ; they abound under cir- cumstances favorable to growth of fungi. It is probable that others are animalcular ; their zigzag mode of progression and capricious limi- tation are thus best accounted for. In order that it may produce a general epidemic as contra-distin- guished from a local epidemic, the materies morbi must be capable not 16 only of indefinite reproduction, but of retaining its characteristic causa- tive influence throughout every variety of season, climate, local position, temperature, habits and modes of life, whether individual or national. "A single word," observes Farr, the registrar-general of Great Britain, " is required to replace the long periphrasis, epidemic, endemic and contagious diseases." This word he has supplied—" zymotic," from the Greek verb signifying to ferment, implying, in accordance with Liebig's notion, the presence of a small portion of poison multi- plying itself. The capacity for propagation or self-extension is most notably differ- ent in the different forms of epidemic disease. Suppose a ship to arrive in any given seaport town, having her hold filled with infected atmo- sphere from a rice-field ; or from a city where typhus is prevailing ; or from Vera Cruz or New Orleans when suffering from yellow fever; or from some seat of epidemic cholera. 1. The rice-field air, however impregnated with poisonous malaria, would be harmless to all around. If any one entered he would bring away with him no efficient poison adhering to his clothes or person, though he might fall sick (especially if he slept in it) of remittent or intermittent fever. * 2. The typhus atmosphere may perhaps diffuse itself, though this is doubtful. To become efficient as a cause of disease it requires that a subject remain in it some time, or labor under some predisposition from fatigue, debility, or the like. 3. The yellow fever atmosphere would probably spread itself, the season being favorable, and attack subjects in the neighborhood. 4. The cholera atmosphere would scarcely fail to diffuse itself on all sides ; and in each of the last three cases, every patient would become a generating centre, adding to the quantity of virus in the air of the region into which such a ship is introduced. Parasitic animals are classed among exciting causes of disease. I do not doubt their evil influence, but regard it as questionable whether they are causative in a primary or specific sense. Psora is supposed to arise from the presence of the acarus, or " itch insect." Of many of the entozoa, the trichuris, strohgylus, &c.,the relations are unknown. The most familiar of them are the intestinal worms. Of these the lumbricus is met with most frequently, and seems capable of exciting in an infested child almost any form of disease, according to its predis- position. Ascarides and the taenia give rise to peculiar symptoms, but neither depend upon nor bring on any specific malady or derangement of the system. A great many varieties of disease have been ascribed to animalcular 17 or microscopic parasites—dysentery, cholera, yellow fever, &c. Even schirrhus, fungus hoematodes, encephaloid and tubercle are classed by Prof. Lanza as filozoid or parasitic. The parasitic vegetations shown by the microscope in aphtha, porri- go, &c. have been regarded as causes of these morbid affections. I think it at least doubtful whether they are not results rather, or effects of the conditions with which they are coincident. The fluids of the body preponderate very considerably, being in a ratio of 9 to 1 to the solids, as some physiologists calculate. This es- timate I regard however as somewhat exaggerated. The primary seats of the vitality of the different portions of the animal structure, are the sensorial and circulatory systems. Every part of every tissue depends immediately upon its nerve and the blood sent to it for its life, and these, the nerves and blood, are dependent upon each other. Each atom which is gifted with life receives it from nerve and blood. These then must be the primary seats of disease. Diseases purely functional may be said in the first instance to affect exclusively the sensorial system. Structural diseases, on the other hand, affect the vascular system primarily. Sensorial and vascular derangement intermingle together and produce each other. Nervous and functional affections may run into or produce vascular and structural derangements. Too intense light will occasion ophthal- mia. Functional affections of the vascular system, by continuance, can scarcely fail to produce structural disorder, as in fevers, inflam- mation, &c. It has been much disputed whether the fluids can ever be the pri- mary seat of disease—no one can doubt that they undergo certain obvious changes in its progress. Whether any such changes are to be estimated as among the primary and essential circumstances, is the true question, and I am disposed to answer in the affirmative. The ancient advocates of the humoral pathology carried their views on this subject quite too-far, attributing all diseases to alterations in the quail, ties of the fluids, some of which cannot be proved to occur at all, whether as cause or effect. But exclusive solidism went equally far into the opposite extreme. Truth lies as usual in the medium. Chyle varies in quality according to the food whence it is obtained. Blood must vary also, as derived from chyle. Scurvy and some cutaneous affections, are the direct result of confinement to improper diet. Blood is also liable to many and important changes of condition, referable 3 18 to the more or less perfect performance of the function of respiration. That important diseases may thus arise which shall depend directly on the state of the blood, cannot be rationally doubted. Typhus may take its origin in confined habitations, as well as in impure, insufficient diet. The humoral pathology of the present day seems to me to be pressed too far, however, by its advocates. I cannot accept the chemical theories of living change as explanatory of all nervous disease—of all sensorial action indeed—however ingeniously maintained by Harrison and others. Nay, even as to the secretions and excretions, they are somewhat less satisfactory than plausible. Diagnosis consists of such knowledge of the seat, nature and history of any given disease, as shall enable us to distinguish it from every other. Pain will often point out the locality of disease. The imperfect performance of known physiological function is, however, still more important as a diagnostic symptom. Sympathies of noted and recorded occurrence, whether understood or not, often serve as valuable guides. But we are liable to be misled by each of these. Some im- portant and dangerous diseases occasion little or no pain. Some painful affections imply little or no danger. And the morbid sympathies which connect the organs are in numerous instances highly irregular and obscure. Scientific diagnosis has recently advanced greatly, and deserves to be closely studied and carefully applied. By physical examination, auscultation, percussion, the speculum, the microscope and chemical analysis, we may learn much more of the seat and nature of certain cases than was formerly possible. Yet with all these means, we must not neglect the empirical signs, which betoken to the experienced ob- server certain coincident conditions. The usefulness of pathological anatomy—the examination of bodies dead of disease, deserves to be carefully considered in this relation. It cannot, except in a very few, and properly accidental cases, teach us anything of the causes of disease. Among the effects of disease which it detects and developes, it can- not help us to distinguish between incidental and essential lesions of structure. As to impairment of function merely, it gives no infor- mation. Nor can it ever aid us in tracing the primary locality or origin of disease ; nor in following up its effects in successive series of consequences. The true value of morbid anatomy lies in connection with observations carefully made, and exactly noted, during the pro. gress of any given case, collated with reference to the cause of the at- tack, its mode of commencement, and its entire and minute history. By 19 an observation of frequent or constant coincidences, we are taught to direct our attention to organs liable to become implicated in future cases of similar character. The physician, therefore, should not neg- lect to unite these offices; he should take careful and precise notes at the bedside of the sick, nor consider himself to have performed all his duty, until he has instituted a minute examination of the dead body. The tendency of all disease is, to death or disorganization. The old dogma of a restorative power in the constitution, a vis medicatrix naturce, should be abandoned as without foundation. The cessation of disease (unless when brought about by remedial treatment) is owing merely to the removal of the causes which produce it. Sometimes the exciting cause is taken away; at others, the predisposition upon which it acted disappears—is, as we say, exhausted or worn out. The well constructed, admirably ordered mechanism of the animal body, resumes its natural action, when the impeding or disturbing agent ceases to exert an influence upon it. This however does not result from the action of any special power of resistance or remedial energy ; but it is the merely passive effect of the removal of the cause of the disorder, while yet the powers of life are unexhausted, and the organism not fatally impaired in structure. It is absurd to suppose disease to be in any case a natural or spon- taneous action of the living body, or to imagine any principle pre- pared or provided to procure its removal: doubly absurd to suppose that such principle should act, such effort be exerted through and by means of the very processes in which disease consists, and through which it developes itself. Disease, as Brown, and after him Rush, affirmed of life, " is a forced state." Morbid causes produce death in two ways. Disorganization to a certain extent, is evidently incompatible with a subsequent resumption of the functions of any given system of parts. But, besides this, the mere interruption of an important function for a time is often fatal, without any lesion of any part or organ, as in suffocation from drowning, and in some cases of syncope, &c. Death from disease must vary in its attendant circumstances, with direct reference to the modes in which it is brought about. Euthanasia or death from old age, is owing to defect of action in the organs of supply, and the consequent failure of all the functions from the waste and wear of the tissues. Death is best defined to consist in a cessation of excitability, the loss of the capacity of being impressed by, and of reacting upon stimuli applied. The phenomena of death do not constitute that state; they may all be present when animation is only suspended, and the subject capable of 20 resuscitation. Interment in cities or populous towns, should be strictly prohibited; the ancient practice of burning dead bodies, ought on many accounts to be preferred, wherever practicable. The Phenomena of Disease demand the most assiduous attention as forming the basis of Diagnosis and Prognosis in every case. They divide themselves naturally into two groups, the objective and the subjective. Those are objective which the physician may himself observe and estimate: those subjective, the existence and degree of which he can know only from the patient. It should be our constant effort to enlarge the extent of the first series, and to render the inferences from them more clear and precise. In many cases we must depend on them exclusively, as in the diseases of infants, idiots and suspected malingerers. In some maladies we are thrown upon the second series almost entirely, as in neuralgia and other affections of which pain is the chief element. Considered practically, diseases are mere collections of symptoms, the proximate or common cause of which is exceedingly obscure and difficult to be traced. These phenomena may, in this place, be con- sidered in the order of the physiological systems and functions which they disturb or affect, and their rationale attempted to be given. I. Of the Digestive System.—Its disorders are shown by 1st. Alterations in the appearance and conditions of those portions of the system which it is in our power to examine. The tongue is furred, or covered with a morbid mucous coating, when the stomach and bowels are deranged and their secretions vitiated. It is red, and sore, and ulcerated, when they are inflamed. In fevers it is swollen, and sodden, and variously discolored on the sides and surface, if the stomach is irritated and the hepatic actions disturbed. In typhoid affec- tions it is dry and of a dark hue; covered with a tenacious sordes or chapped. It is cold in cholera and pale. In purpura and the hemor- rhagic state of fever, it is livid and smooth, and exudes blood. Its papillae protrude, of a bright crimson tinge, in scarlatina. The gums are spongy, swollen, and disposed to bleed in scurvy, purpura, and in the hemorrhagic forms of fever. The lips, cheeks, and the whole lining membrane of the mouth are apt to ulcerate—especially in chil- dren—when the mucous tissue of the stomach and intestines is ir- ritated. The teeth and gums as well as the tongue are blackened by sordes in typhus. The abdomen should be explored. Meteorism is shewn by tension or intumescence, light and resonant upon percussion; by fluctuation 21 we know the presence of fluid effusions; aneurism by pulsatory tumor; and physconia by position, hardness, and weight. 2d. By functional disturbance manifested in any obvious way, as anorexia, gastric oppression, nausea. Vomiting comes on not only to rid the stomach of some load, but is produced by any mode of irritation of the alimentary tube and its inflammations ; it may arise also from gastric sympathy with other organs, as the uterus in pregnancy, the brain in apoplexy, in sea-sickness, and after blows on the head. In fevers, it supervenes upon both gastric and cerebral derangements. 3d. By uneasiness or pain seated in any of the organs. Some ab- dominal pains are unaccounted for, such as those comprised under the terms gastralgia and gastrodynia; others arise from inflammation; some from flatulent distension, and some from mechanical pressure. Some probably depend upon mere hyperaemia, or vascular engorge- ment. It is usual to lay great stress on intolerance of pressure as diagnostic of inflammation, but this may be too much trusted to: parts forcibly distended are painful on pressure. 4th. By changes in the result of organic action, morbid secretions. The matters ejected in disease are exceedingly various; acid, oily, alkaline, bitter, white, brown, green, blue, black as in yellow fever, albu- menous as in cholera, &c. These qualities are not always to be ac- counted for; of some the explanation is obvious, and so are the inferences to be drawn from their occurrence. II. Of the Circulatory System.—Syncope, the cessation of action of the heart—palpitation, its convulsive action. The pulse, defined as the tactual impression made by the impetus of the current of blood through an artery of notable calibre, is constituted and modified by the fol- lowing elements. 1. The composition of the circulating fluid. 2. The condition of the great central organ, the heart. 3. The con- dition of the circumferential organs of circulation—the capillary systems, general and pulmonic. 4. The condition of the sensorial centre. 5. The condition of the arterial tubes, as to tonicity, contractility. Diseased actions in other systems, affect more or less the circulatory. The pulse of an infant newly born, beats about one hundred and forty strokes in a minute ; declining from that time, the average adult pulse is about seventy to seventy-five. In health the pulse is modified by a great variety of circumstances. Idiosyncracy.—In some persons it beats more than one hundred, in others not more than forty. Sex.—The female pulse is somewhat more frequent than that of the male. Stature.—In tall men it is less frequent, in dwarfs more so. \ 22 Muscular exertion makes it beat with greater rapidity. In sleep it is slower. The passions and emotions add to its frequency, and perhaps its force. Temperature.—Heat augments, cold (continued) diminishes its fre- quency. Diurnal changes.—The pulse is usually somewhat more frequent in the evening. These agents affect chiefly the frequency of the pulse in health. The healthy pulse is regular—that is, the intervals between the strokes are precisely equal; it is vigorous—that is, it resists with de- termined opposition, the influence of force applied to compress it; it is full—that is, the artery is completely, but not unduly distended by its blood. The systole of the heart occupies a given portion of time, contracting steadily without harshness or hurry. A morbid pulse may readily be distinguished then by comparison. It is more or less frequent than in health. " " hard or resisting. " " quick, (abrupt or jerking.) " " full. Irregular in interval. " force. Intermittent, regularly or irregularly. These comparative phrases address themselves to the judgment, convey a definite meaning, and are easily remembered and referred to. These several morbid qualities of the pulse may be variously com- bined, so as to offer a great variety ; the attempt to give fanciful names to which has introduced some disorder and confusion. Plethora, in strict propriety, is always a relative term, implying a want of proportion between the quantity or the stimulating quality of the blood, and the tone of the heart and vessels. Hence it may be met with in weak and debilitated constitutions. I doubt the possibility of an absolute or general hyperemia or undue abundance of blood. Local hyperemia, on the other hand, is one of the most common conditions of disease, being implied in all inflamma- tions and congestions. Anosmia—the deficiency of sound or nutritious blood, often results from hemorrhages, natural or artificial, and from disease. The fibrine and red globules would seem to be slowly supplied. The blood undergoes many changes in disease. It becomes buffy or sizy. This has been explained on the supposition that its coagulation 23 being slow, the red globules fall to the bottom, leaving the yellow lymph on the surface ; this explanation is easily shown to be unsatis- factory. Gulliver and Jones ascribe it to an increased aggregation of. red particles. Hewson and Davis to attenuation of liquor sanguinis. Zimmerman to defect of globuline and undue amount of albumen and fibrine ; and Simon to increase of hsematine. It may indeed be affirmed that the blood is always altered in disease. The change is often traceable in the proportion of its constituents. The fibrine, increased in the phlegmasise, is lessened in quantity in fevers and in purpura. The proportion of globules varies, being much lessened in chlorosis, protracted diarrhoea, intermittent fever, &c. In renal affections and some other diseases urea is found in it. In jaundice it contains the coloring matter of the bile. It becomes incoagulable from great fatigue ; in death also from lightning, and from a blow on the pit of the stomach. It is black in typhus ; attenuated and dissolved, as the phrase is, in scurvy; loses its salts and serum in cholera. Hemorrhage—a symptom more alarming than dangerous in itself, occurs in opposite states of the system; when active is less serious than if passive—in the former case may have some good effect as a mode of local depletion. III. Of the Respiratory System.—In affections of this system auscul- tation, mediate and immediate, should never be neglected. The stetho- scope should be familiar to every practitioner. Percussion also should be carefully made over the chest, and undue resonance or the want of it, noted. By collating the results of these modes of inquiry, the con- dition of the lung in every part may be ascertained with great preci- sion. Dyspnoea, mere difficulty of breathing, belongs to many varied disorders. Orthopncea, its intense degree, enforces the erect posture, and denotes the presence of fluid in the thoracic cavity or in the lung. Cough, the most common symptom of pulmonary inflammation, is yet not always present as a token of that condition. Expectoration of mucus, or of thin, bloody, offensive, ichorous serum, may take place in various states and stages of bronchial and pulmonic disease, giving occasion for very definite inferences ; purulent matter may either come from an abscess, from the circumference of a tuber- cle, or from the unbroken mucous surface. IV. Of the Sensorial System.—Pain is the most general symptom of disease, the expressions indeed being almost synonymous. It usually but not uniformly denotes the principal locality of disorder. The de- gree of pain depends upon the general sensibility of the patient, and * 24 upon the local sensibility of the part affected ; it is also modified both in kind and degree by the nature of the case, so that it bears no regu- lar proportion to the danger of the attack. The loss of sensibility, whether local or general, must augur unfavorably. Permanent dilatation of the pupil of the eye is untoward, as being probably occasioned by compression of the brain ; permanent contrac- tion by meningeal inflammation. Insensibility to light, as evinced by a fixed state of the pupil, is also unfavorable. Hallucinations of va- rious kinds, amounting to delirium and insanity, are more to be dread- ed when low and gloomy than if cheerful or violent. V. Of the Motory System.—Great muscular prostration is always to be dreaded. Relaxation of the various sphincters indicates a high de- gree of danger. Paralysis is still more unfortunate, whether of one half the body, transversely divided, paraplegia, usually affecting the lower limbs, or hemiplegia, which is confined to the right or left side, and both extremities. Trembling of the head, a common circumstance in the debility of old age ; of the hands and tongue, often from intemperance. Cramps or tonic contractions of particular mus- cles, result from many various irritations—are often connected with digestive disorder and uterine irritation. Convulsions and spasms, more common in childhood, derived from numerous causes ; in gene- ral more alarming than imminently dangerous. Convulsion is an affection of the true spinal or excito-motory sys- tem of nerves. It is centric or eccentric, the former most dangerous generally. A striking exception is found in tetanus, which may be excited either centrically or eccentrically ; the former not very dan- gerous, the latter or traumatic tetanus is fatal in large proportion. VI. Of the Excretory System.—It is very difficult to assign any ra- tionale of the coldness and corrugation of the skin in ague, or the gen- eration of so much cutaneous heat in certain fevers—most observable in scarlatina and yellow fever. Rush makes the remark, which is confirmed by my own experience, that a cool moist state of the skin in the disease last mentioned is indicative of great danger. Inordinate sweating was the principal circumstance noted in the ancient fatal epi- demic called sudor Anglicanus, as supposed to affect almost exclusive- ly the people of England. The perspiration undergoes changes of quality as well as of quantity, assuming a yellow or brownish hue becoming acid and offensive in smell. The skin itself suffers changes of color, being yellow as in jaundice ; pale, white, and semi-transpa- rent, as in dropsy; orange, in yellow and bilious fevers, and hepatic disorders, and from intemperance; and livid, mottled and spotted in petechial fevers. 25 The urine was of old regarded with special attention, and the most precise indications of the state of the patient supposed to be drawn from the appearances presented by it. It becomes abundant and lim- pid in nervous diseases, as in hysteria and some headaches ; scanty and high colored in fevers; loses its urea in diabetes, in one form of which it contains much sugar ; deposits sediments of varying color, under circumstances more exactly defined now than formerly. Its amount is much diminished in dropsies—containing varying proportions of al- bumen, and becoming readily coagulable in many cases. The knowledge of the condition of the urine has been much im- proved of late and rendered highly available in one diagnosis, progno- sis and therapeutic, by the nice chemical analysis instituted. The mi- croscope is used successfully to detect oxalate of lime when all ordi- nary tests fail to show it; we thus also discover the presence of blood corpuscles, and epithelial scales, &c. No scientific practitioner should neglect the close examination of the urine in both modes. Strangury—unfavorable in the commencement of fevers, is favora- ble in their advanced stages, as some writers affirm. Total suppression is declared by most to be a fatal symptom. I have however seen recoveries from it. The alvine excretions offer important observations, in warm climates especially. They are much influenced by the state of the liver, as well as of the intestinal canal. Long continued impediment to the process of fecification, or the remarkable stercoraceous change under- gone by the ingesta, always denotes danger. Clay colored stools show torpor of the liver—vitiated secretions of bile tinge them dark green and make them offensive and acrimonious. They are black under some particular states of enteric disease, as in yellow fever, containing flocculi or granulae of black color. In dysenteric irritation they are mucous, and bloody and sanious. A peculiar pink colored, highly offensive ichor shows instant danger, being occasioned usually by actual gangrene of some portion of the mucous membrane. This tissue may come away also in small flakes in the stools, or portions of fibrine or coagulable lymph are sometimes mistaken for it. In dysentery we meet also with scybala—these are sometimes described as lumps of hardened feces, at others as consisting of caseous or of fatty matter. The discharges in cholera are thin and flaky, resembling gruel or rice water. They have been called serous and albumenous, and af- firmed to consist of the serum of the blood little changed. This is however denied. In children the stools are often acid and green ; at times watery and 4 26 colorless. Purulent matter may come away from the intestines, either when ulcerated or highly inflamed. The countenance of the patient should be remarked, as expressive of his condition. Any obvious change is unfavorable. The countenance of malignant fever is always notable. Trousseau observes the absence of tears in children to be a bad symptom. In physiognomical diagnosis the rugse of the visage are much dwelt on. "Risus sardonicus" is described as a grim sarcastic smile, produced by involuntary contraction of the muscles of the lips and cheeks. The " Hippocratic countenance" consists in hollow sunken eye, pinched up nose, fallen temples, tense pale forehead, lividness of face ; universally, as far as I have observed, the forerunner of death. The decubitus, or posture in bed.—Inability to lie down is unfavora- ble—so is confinement on either side—lying on the back with the knees drawn up, and sliding to the most depending part of the bed, show great debility. Restlessness and jactitation are bad symptoms; it is worst of all when the patient expresses an anxious desire to move from bed to bed, and from one room to another. Periodicity.—The tendency to periodical revolution is one of the most remarkable phenomena of disease. It is of three kinds; the first refers to the influence of obvious agen- cies, as the return of day and night, the seasons with their coincident impressions, thermometric, barometric, hygrometric, which all observe regular intervals; the second is dependent on habit, which is partly voluntary and moral rather than physical; the third is an obscure characteristic quality of disease itself or of the cause of certain dis- eases. No form of disease perhaps can be found absolutely free from the influence of periodical movement. Diurnal revolutions are observable both in health and disease, as may be noted in the pulse, and in general in all our habits and cus- toms. They are likewise obvious in all fevers—continued, remittent, and intermittent. Continued fevers show some abatement in the morn- ing and augmentation in the evening. Remittents refer to the types of intermittent, with which they are most closely connected. Intermit tents have their special hours of access ; the quotidian in the morning, the tertian a little before noon, the quartan in the afternoon. Septenary revolutions are not less clearly distinguishable. The menstruation of the human female occurs regularly on the twenty- eighth day—its anticipations and postponements are usually of seven 27 or fourteen days. The relapses of fever occur at the same periods very generally. The first are attributed to insolation, the influence of the sun; the second in like manner to lunation, the influence of the moon. The combined influence of the two, liable perhaps to other compli- cations more obscure in their nature, will account for all the types of fever, as well as of crisis, or the agency of critical days. Certain diseases seem to possess an inherent or independent periodi- city, arising from some characteristic peculiarity in their own nature. These are called self-limiting ; they can neither be arrested in their course nor prolonged by any means known in our art. The exanthe- mata present the best examples of this order. Small pox, vaccine and scarlatina run through a definite course and terminate after a certain duration. The consequences or sequelae of these diseases, however, depending on lesions of the organs affected in their progress, may be indefinitely protracted. The true test of a self-limiting disease is its spontaneous subsidence at a determinate and calculable period. Some have confounded illimit- able or uncontrollable maladies with the self-limiting. The distinction is easy. We may protract an attack of typhus or of pertussis by mismanagement; we cannot add an hour to the duration of measles or small pox, though we may render them more violent and even fatal. The condition of convalescence may be briefly described as one of extreme mobility and susceptibility, modified by the contingencies of the preceding disease in a great diversity of modes, and requiring the special notice and attention of the practitioner. Modus Operandi of Medicines.—It is truly curious to observe that as all the means of life may become incidentally causes of disease, so most poisons may be employed as medicines or remedies for disease. All known drugs are revolting and injurious; they all disorder the sound or healthy system ; how then do they effect in the sick the resto- ration of health ? Our best medicines are drawn from the class of vegetable and mineral poisons, as opium and mercury, antimony, digi- talis, &c. There is no such power existing in any known agent as shall be dis- played in the mere production or increase of vitality or healthy action in an animal body; nor is there anything in nature properly deserving the title of antidote, except in reference to its chemical affinities. Medicaments must therefore be useful by an indirect agency, their effect being always modified by and dependent upon the condition of the recipient. 28 Therapeutical agents may be arranged under several heads in rela- tion to the mode in which they affect or impress the subject, as fol- lows: 1. Abstraction.—Darkness, silence, fasting, recumbent posture, cold, the lancet, leeches and cups, cathartics, diuretics, &c. 2. Stimulation.—Wine, alcohol, bark, opium, electricity, heat, &a 3. Revulsion.—The most important perhaps of therapeutical princi- ples. The use of cathartics in fever, of these and emetics in inflam- mation ; of the lancet, leeches and cups, (as properly under this head as the first) of sinapisms, blisters, acupuncture, &c. 4. The homceopathic action, as exemplified in the application of bel- ladonna in scarlatina; of vaccine, to prevent or modify small pox ; of emetics to prevent nausea, and of cathartics to cure diarrhoea. Yet homoeopathists reject altogether and protest against the doses ordinarily employed by the other schools, and exult in the alleged discovery that the most beneficent effects can be procured from atoms, or indefinitely minute portions of medicine ; exhibiting the thousandth part of a grain, or of a drop of our common drugs. 5. The contra-stimulant influence—exhibited best perhaps in the use of chloroform and of very large dosesof opium in tetanus, and of antimonials in intestinal spasm. The Italians of the contra-stimulant school, are found in the opposite extreme to the German practice of Hahnemann. They administer boldly the most enormous quantities of the remedies indicated, with the purpose of combating directly the force of morbid impressions made upon, or morbid action going on in the system. This is allopathy carried to ultraism. Nothing however can be more rational than the principle of counteracting by direct influences the specific effect of disease or its cause upon the organism, and of duly adapting the force to be exerted by the counter-agent to that of the morbid poison, either by amount of dose or concentration of specific power. Allopathists generally prefer to this heroic practice a system of more cautious and moderate medication, in which the same results are aimed at by repetition and accumulation of contrasted impressions ■—non vi sed sozpe cadendo. The true eclectic avails himself of each of these modes with discrimination. It is an interesting inquiry whether in our administration of medi- cines we essay to act on the cause of disease antidotally, or on the effects of that cause, arresting, removing, remedying them, and re- storing organs and parts to their normal condition. Perhaps in both modes, but I think chiefly in the latter. Thus carbonate of lead excites rachialgia, which we attempt to put an end to by the exhibition of sulphuric acid. This acts antidotally 29 by forming the insoluble sulphate of lead. When lithio acid abounds in the urine, we administer alkalies. So malaria, a fungus hypothetically, is conjectured to be destroyed by antifungous agents ; quinine, bebeerine, &c. On the other hand, alcohol used in excess creates a morbid irritability, which is subdued by opium and digitalis ; and strychnine hyper- polarizes the spinal cord, exciting spasm—which belladonna and ether relieve by depolarizing the same organ. Hence we are led to employ strychnine in paralysis, and ether and chloroform in cramps. 6. The alterative influence, such as we attribute to mercury, and the metallic preparations generally, to the mineral acids also, and indeed such as may be obtained from a great number of medicines, as guaiac, iodine, camphor, cathartics. By the word alterative, I would mean the substitution of the effect of the medicine for the effect of the originally acting cause. To be regarded as an alterative, a medi- cine must be capable of producing then a forcible impression, which may be kept up at will by its continued exhibition, and which shall readily subside on withholding it. By the combination of these powers, its value is given. [t is doubtful whether the three last modes of action may not with propriety be all resolved into revulsion, or included under that head. The modes of administration by which we apply our ordinary re- medies, are four, viz. 1st. By the primse vise or surface of the alimen- tary canal. 2d. By the cutaneous surface. 3d. By the pulmonary surface. 4th. By introduction into a vein, or insertion into a wound. There are besides these, some mechanical, and in a certain sense, chemical remedies, not directly referable to either of the above heads, as friction, percussion, acupuncture, electricity and galvanism. Medicaments may act when applied in either of the above modes.— 1st. Upon the extremities of the nerves immediately, and through the sensorial system upon the whole body.—2d. By introduction into the circulation and actual mixture with the mass of fluids. Instances of the first kind may be found in the instantaneous death which follows the swallowing a large quantity of alcohol—the same result is produced by touching the eye or tongue of an animal with strong prussic acid—and in the effects of stimulating volatiles upon the body through the olfactory nerves. The latter, I believe, is common in the agency of our ordinary me- dicines. The effects of medicine introduced into the stomach, are exactly similar or identical with those which they produce when ejected into a vein. Opium dissolved and thrown into a vein, produces sleep and stupor; ipecacuanha vomiting; jalap and castor oil purging ; and 30 arsenic more readily brings on gastric inflammation when Inserted into a wound, than when swallowed. It is only on these tissues or. systems, the vascular and sensorial, that medicine can act primarily. They affect the first by actual admixture with the circulatory fluids. The affect the sensorial system by a direct impulse or impression upon the extremities of the nerves, which we do not understand, and cannot describe. They are separable then fairly into two classes, as they affect one or the other of these systems. Friction, percussion, acupuncture, act upon the nerves directly subjected to their influence. These they irritate, vascular determina- tion ensues, (ubi irritatio ibi fluxus) and thus they prove remedial on the principle of revulsion. Acupuncture is maintained by many theo- rists to owe its efficacy to electric impression. Electricity and galvan- ism seem to exert as pervasive an influence over living, as upon inanimate matter, and act with wonderful force upon all the solids and fluids of the living body. They are impressive agents of high value and general adaptation. The operation of each and every medicament, is specifically direct- ed upon some particular organ of the body. Besides this specific operation, which it has a tendency to produce under all circumstances there are other influences which may be derived from it, depending either upon the quantity employed, or upon the condition of the recipient. 1st. The direct or specific operation of medicines we see in the emesis from tartrate of antimony and ipecac; in the sleep and stupor from opium, in the dilatation of the pupil from belladonna, &c. We may even point out more minutely distinctions as to the modes of effect, when their action is upon the same organ ; thus ergot causes the uterus to contract, affecting its fibrous structure; guaiac acts upon the secretory vessels, causing them to pour out their due fluids. Cathartics act vari- ously upon the bowels. This relevancy which constitutes the principal basis of the therapeu- tical employment of medicine, can only be known, empirically by observation and experience. There is nothing in the physical qualities or elementary composition of any agent, that indicates its probable influence upon the animal economy. Bebeerine and morphine offer the same constituents to minute chemical analysis, but the first acts like quinine and is not hypnotic at all. The mode of impression of any drug will depend upon its specific qualities and the specific sensibilities of the organ or tissue on which it is adapted to act-neither of which can be known but by experiment. 31 The accidental discovery of these modes of impression can only be expected to occur to the prepared and attentive observer; zeal and ingenuity may hope to profit by suggestions derived from attentive observation. 2d. The indirect or consecutive.—These may, or may not include 3d. The poisonous. Among the indirect effects of medicines, those namely which depend on dose and condition of subject, we may mention the emetic effects of castor oil, of calomel—catharsis from the latter, diaphoresis from antimonials. In regard to the effects of medicines, one important observation should be kept in mind by every practitioner ; that certain of the most power- ful and valuable articles of the materia medica are accumulative in their operation, and thus become dangerous. Thus mercurials shall sometimes, when administered in repeated doses, seem inactive, exhi- biting no obvious effects, until at once we have ptyalism, ulceration of the lining membrane of the mouth, and caries of the teeth ; the system having become, as it were, slowly saturated with it. Thus it is with arsenic, and thus also among others with digitalis. The first shall be given in vain, as it might appear for some days, when on a sudden there will be pain and disorder of the stomach, with great prostration, and swelling of the face and eyelids. Digitalis will, at times, act neither as diuretic, nor in any other way, until, its administration being persevered in, vertigo comes on, dim vision, intermittent pulse, palpitation, and perhaps coma and con- vulsions. 4 32 SPECIAL PATHOLOGY AND THERAPEUTICS. Some classification and arrangement are essentially necessary to assist the progress of learners in all sciences. I prefer to all others the Physiological Nosology, which distinguishes the tribes of disease, according to the seats which they occupy,—the functions which they disturb or impede. I shall treat of them as they affect—■ I. The Circulatory organs and their functions. II. The Digestive. III. The Respiratory. IV. The Sensorial. This class nearly coincides with the "Neu- roses" of Cullen, Parr, &c. V. The Motory, comprising the diseases of bones, joints, muscles, tendons, ligaments. VI. The Generative. VII. The Excretory, comprehending the cutaneous affections, those of the urinary organs, and the local diseases of the large intestines. Before attempting the cure of a disease, it is necessary that we should carefully distinguish it from every other ; the diagnosis, then, of every case, must be considered separately in this relation. Special Pathology implies the absolute individualization of each instance of disease ; for it is impossible that any two examples should be exactly alike, or any two patients be found in precisely the same morbid condition. The indications of treatment cannot therefore be precisely the same; some modification appropriate to each will be demanded. Therapeutics comprise the whole management of an attack of disease- the regimen, the physical and moral control, nursing, &c., as well as the administration of medicines. Indeed this general management is often of far more importance than the mere pharmaceutical applications. Voltaire's definition of the practice of physic as " the art of pouring 33 drugs of which we know little, into a body of which we know less," is an unjust reproach if applied to the modern scientific physician, of whom prudence is the special attribute, (nullum numen abest, si sit prudentia,) and who believes with Chomel, and acts upon that belief that " the first duty of the practitioner is to take care that he does his patient no injury in his efforts to benefit him." The diseases of the circulatory system are of paramount impor- tance, and require our earliest attention. Among them are to be found many of the most fatal maladies that assail our race; and the two most frequent of all known morbid conditions, inflammation and fever, are arranged here. Indeed they are so mingled and combined with the large mass of human diseases, that it would not be improper to affirm that few of them are susceptible of satisfactory discussion, with- out a previous inquiry into these very extensive and important subjects. Inflammation, which either as cause or effect, as coincident or consequence, is so generally combined with the principal forms of disease, is entitled to our immediate notice. Its seat I suppose to be in the capillary system—the nutrient and secretory arteries, the vasa vasorum. Its nature is unknown. There has been much useless argument to establish the uniform and essential contingency of the increase or diminution of excitement and action, in inflammation. It does not depend upon, nor consist in, degree of action; yet it would seem, that there is always, at least in the first instance, increased action. The smaller vessels, like the heart, are endowed with the capacity of active dilatation. We cannot otherwise account for the phenomena; for it is absurd to suppose the heart, or larger vessels, capable of elective propulsion or determination of blood to any particular part of the body. The minute vessels then expand in the production of inflammation, as they do in blushing, redness from friction and stimulants; but there is some superadded essential condi- tion, or blushing would be inflammation. " Determination of Blood" admits of explanation in three modes. The first I will call passive or revulsive, as being the effect of causes acting upon some distant part; as where blood expelled from the surface by cold, &c. is driven upon the internal viscera, whose vessels are thus distended. The second exists where the arteries supplying a part, becoming rigid by the undue excitement of their contractile force, give the current passing through them, as Arnott points out, an increased impulse. A leaden tube requires less vis a tergo to conduct a stream of fluid to a given point than a leather one ; and with the same will send 5 34 it farther or more forcibly. In the third, the part itself, the tissue or organ may assume or be impressed with greater affinity—chemical or vital, or chemico-vital—for the blood, and may solicit, or become ca- pable of receiving, either to transmit or to retain, a greater quantity. There are two conditions or states of a part, which precede or give rise to inflammation. The most common is Irritation—a term difficult to define. It is usually employed to express excitement of the nerves of a part either normally or morbidly ; but we are not sure that the irritability of the tissues is absolutely dependent on their nervous con- nections. Many of the most familiar modes of irritation produce mus- cular contraction—spasm, convulsion, not inflammation. They are the sources of reflex actions, the final cause of which is obvjous, such as sneezing, coughing, &c. ; and of others whose purpose is unknown, as irrepressible laughter from tickling, and hiccup from various modes of irritation of the stomach, chiefly. Irritation of glands and vascular tissues produces a fluxus or hyperoemia, which if protracted or exces. sive, gives rise to inflammation, The second is Congestion—where there has been, from whatever1 Cause, an undue proportion of the sanguineous fluid forced into the structure of any organ thus engorged, or unnaturally distended—as in the liver, spleen, and other internal viscera, from the concussions of intermittent fever, or the shock of cold applied to the surface. Such congestion is mechanical, passive, revulsive, venous, capillary; not attended with local change in the tissues affected, nor in the fluids collected in the part. Indeed, congestion seems to be sometimes the effect of a vascular paralysis; the vessels of the surface chiefly affected and of the lungs, admitting no circulation, the necessary vital changes of blood and tissues are suspended. Hence the danger and mortality of many forms of disease of which this is a prominent element__as of cholera asphyxia, and of congestive remittents and intermittents. It is almost superfluous to remark, however, that neither of these is of necessity followed by inflammation. The internal organ may dis- gorge itself and return to a natural condition ; the irritated part may be soothed into tranquility without any exhibition of vascular excite- ment; or this may be so temporary and transient as not to deserve the name of inflammation. The redness from slight friction on the surface or from acupuncture, is not inflammatory, any more than the vascular excitement of the whole system from wine or exercise, is properly fever. r v J Hyperoemia —sanguineous congestion or determination of blood shows itself in many modes. It is normal and active, as in the swell' ing of erectile tissues, blushing, redness from friction and the like' 35 weeping from mental emotion, salivation from sapid substances, &e. It is the passive effect often of repulsion of blood from distant parts, Usually a venous hypercemia ; a mere stagnation or little else, and Unproductive of change or hypertrophy. Inflammation is an active hyperemia, in which the minute, nutritives arterial tissue is concerned; Vvith tendency to new production* All inflammation is in nature morbid, as we know both from the symptoms and the results. Surgeons recognize a healthy inflamma- tion, but the phrase is rude and unscientific. Union of opposite sur- faces, by the organization of effused lymph or fibrine, is made inciden* tally useful in surgical operations, as for the cure of hydrocele, artificial anus, &c. ; but can no more be called healthy inflammation, than that which unites the pleura costalis with the pleura pulmonalis ; indeed, they are absolutely identical. Union by the first intention, has been attributed to inflammation, but incorrectly. The vessels of divided surfaces are placed in apposition, so that circulation goes on, and restoration is effected by the deposit of nutritious matter from the ves- sels. A finger or piece of flesh cut off and replaced, sometimes adheres. But in this case union must precede inflammation, or only one surface can inflame. Indeed, inflammation impedes the occurrence of union by first intention. It occurs always to a certain extent no doubt, but merely as a coincident effect of the violence applied to a living body. The local changes in inflammation are minutely described by many microscopists. Addison states that " the accumulation of the colorless cells of the blood in irritated and inflamed textures is an established fact," the globules move irregularly, slowly, oscillate to and fro, become stationary, and actually retrograde very often. Houston, having remarked upon the comparatively slow motion of the white globules in the healthy circulation, which, as he says, " lag slowly on, stealing along the sides of the vessels, while the smaller red ones glide easily in the centre of the stream," goes on in these words: " Under inflammation, this tendency to linger is increased. The white globules accumulate in the capillaries and stop up the stream, so that the mass of blood actually stagnates there; hence the rubor, tumor, calor, dolor. Whether this stoppage is mechanical, or from want of tone in the blood-vessels, or from increased disposition to at- traction between them and the globules, is doubtful." The general symptoms of inflammation are the same, whether its seat be internal or external—pain, redness, swelling, heat, throbbing. The pain differs in kind and degree, according to the structure of the part affected, its sensibility, and the general sensibility of the patient. It is in proportion to the suddenness and extent of the changes which take 36 place, being of course greater in acute than chronic cases. It results, probably, from the excitement of the minute vessels, which by their dilatation, produce tension and pressure on the nerves. Inflammation may be too hastily inferred to be present. The phe- nomena are simulated in some neurotic affections: extremes meet in the results of ancemia and hyperoemia—as in ulceration. This, frequently an effect of inflammation, also follows starvation, as in Magendie'sexperi- ments. May not the ulceration of Peyer's plates in' typhus, be entirely independent of inflammation—the result of atrophy or of the presence of typhode matter deposited. Pain is very intense in mere neuralgia. Throb- bing also, as in headaches, &c. Heat, the greatest known to be developed in the human body, is physiological, in parturition ; stated by Granville at 120. In some diseases not inflammatory, apoplexy, for example, and in some congestive malignant fevers, the morbid heat runs very high. The primary essential element—what is it ? Perhaps we may find it in some change of relation between the tissues and the blood by which they are supplied : in local inflammation, the change being in the tissue or part; in general inflammatory affections, being in the blood (as in erysipelas, &c.) The tissues everywhere must be endowed with specific properties and powers for the performance of specified functions, to secrete, excrete, deposite. The relation referred to is chemico-vital. Beyond a certain limit consistent with health, it must then be disturbed both by changes of innervation and of composition of the fluids. The redness and swelling are easily accounted for by reference to the vascular fullness and determination which exist. The heat of the part is somewhat heightened, as depending on the vascularity of the part, and the force and fullness of local circulation. It can scarcely be higher than the heat of the interior of the body, and is most notably in- creased at the farthest point from the heart. Throbbing results from the admission of a forcible current, impelled by the heart into vessels which were before too small to admit of such impulse, or which have spontaneously dilated to receive it. The local^ effects of inflammation are modified by the structure of the part in which it occurs, and by the nature of the cause which has pro- duced it. In illustration of the first, we may refer to what are called the terminations of inflammation of the serous tissue; these are most commonly adhesion and dropsy, sometimes purulent effusion__rarely ulceration. In inflammation of the mucous tissue, we have very com- monly purulent secretion and ulceration—rarely adhesion &c. In the skin, vesication and phlegmon ; in parenchymatous masses, abscess and schirrhus. The modifications from cause, are still more marked 37 and precise. In certain predispositions we have arthritis, cancer, &c.—each peculiar. From certain morbid agents, we have specific modes of inflammation, as upon the application of arsenic, tartrate of antimony, lytta, &c. Sphacelation seems to be determined for the most part by the intensity of the morbid excitement, rather than the nature of the cause. It may be defined as a species of disorganization, of which death is a necessary consequence. Disorganizations are effect- ed (as in scrofulous and schirrhous degeneration) without depriving the part of its vitality, and death may occur without disorganization. Sphacelus implies a union of the two circumstances. Inflammation produces certain notable changes in the fluids. 1. Hyperfibrination of the blood, of which we know not whether to pro- nounce it cause or effect, or how to account for it. 2. Buffiness or siziness, already spoken of, and 3. The formation of pus. This is a new production. Simon describes pus corpuscles, often found mingled with the blood, as well as effused on surfaces and collected in abscess- es, "to be half as large again as blood corpuscles; of a pale grey color ; their edge is granular or tuberculated ; their shape is round or oblong; they are slightly granular in the interior; indicating from 3 to 5 nuclei. Pus-cells contain all the specific principles or characteristic proper- ties, contagion, &c. of the disease by which they are produced ; as in small pox, vaccine, gonorrhoea, syphilis, &c. Inflammation may or may not be attended with the excitement of general febrile disorder. After wounds and injuries, especially in vitiated constitutions, and at an interval undetermined and varying, fever is apt to come on with shivering or without it, the skin becoming hot and dry, the pulse hard, frequent and quick, the face flushed, and the eyes red, with headache and perhaps delirium. This is one of the types of symptomatic fever, assuming a continued form, that is, with- out intermission or regular and definite remission ; it is closely anal- ogous to, if not identical with, the febrile derangement, connected with the long list of internal inflammatory diseases, hence called py- rectic, as pleurisy, gastritis, &c. In these latter, the fever supervenes usually with great promptness soon after the invasion of the disease. Hectic, the second of the types of symptomatic fever, is intermittent, and attends protracted inflammation, both internal and external. It shall receive special notice hereafter. It has been suggested that these forms of fever are excited by the changes in the blood dependent on inflammation, the excess of fibrine in the continued or early symptomatic fever, and the presence of pus in hectic fever. The question merits inquiry. We should not omit 38 to remark the striking difference between idiopathic and symptomatic fevers, in the fact that blood is always defibrinated in the former. In the general treatment of inflammation, we refer to three modes of remedial management. 1. By abstraction of excitement, venesection, leeches, cold, low diet, purgatives, emetics, nauseants, &c. It is under this head chiefly, that I would include the agency of opium as a remedy for inflammation. The first step in the lighting up of inflammatory disease is often a mere irritation, which is capable of being entirely subdued by the anodyne and soothing influences of this most valuable drug. In its farther progress, too, inflammation is liable to be aggravated by pain, which is the result of morbid excite- ment of the nerves of a part; and this can often be allayed promptly and entirely by opiates. The state of sleep which they so admirably induce, is singularly adapted to promote the subsidence of all undue actions of any of the organs, and especially of the brain, whose agita- tion readily disorders every fibre of the system, and whose restored tranquility is so often the harbinger of general repose. From opium also we may obtain, by proper management of its in- direct operations, very great benefit as a diaphoretic, and as a most impressive stimulant; but these effects are referred to under the follow- ing heads: 2. Revulsion, as by venesection ; purgatives, diaphoretics, stimu- lants, sinapisms, epispastics, &c. 3. By alterative influence, as in the mercurial treatment, and in the substitution of a new and transient form of inflammation, as when we apply a blister to erysipelatous surfaces, arsenic to a cancerous ulcer, and stimulants generally to indolent ulcers and chronic inflam- mations. In strict propriety, these are but modes of revulsive affection. Fever.—The phenomena of fever prove the co-existence of two prominent conditions in both the vascular and sensorial systems. There is evident concurrence in each of 1. Diminished energy—defective power, with 2. Undue action—morbid excitement. This latter expression implies that with the diminution of the amount of power, there is irregular distribution of the remaining power. The combination of these elements, perhaps in varying proportion in different cases, forms the proximate cause of fever. It is probable that the earliest disturbance occurs in the extreme ves- 39 sels, the nutrient, and secretory, and excretory, denominated the capil- lary system. It is also probable that in most fevers this disturbance arises from the entrance into and admixture with the blood of some morbid matter or poison, as in the contagious and malarial. We infer that the general modus operandi of such poisons is sedative or depressing. It cannot be denied, however, that in some cases, nay, perhaps classes of cases, they appear to be rather stimulant and irrita- tive, but such instances it may be observed constitute, after all, mere ex- ceptions to the general rule ; no disease being so liable as fever, to be modified both by the condition of the individual whom it affects, and the circumstances which may attend its production and spread. In the study of fevers we are at first struck more forcibly with the differences than the points of similarity between them. We are apt to think, as Andral said of Inflammation—that the word is too wide and covers too many conditions. Compare a habitual intermittent with a malignant typhus—congestive remittent or yellow fever. Yet there are always present the same elements, whose varying predominance may be said to separate fevers into two general classes—the neurotic and the humoral. The first, neurotic, are those in which irritation is the principal feature, productive of and connected with congestion, in- flammation and hoematic change. The second, those in which hoe- matic change is primary and predominant, productive of course of irritation, congestion and inflammation ; when strongly pronounced we call these latter malignant fevers. The causes differ relevantly. Among the first we find what are usually termed inflammatory fevers, arising from incidental causes of all kinds ; the latter are the effects of specific poisons, contagion espe- cially. The doses of these poisons as well as their special qualities modify or affect the results produced, as when malaria diluted, gives rise to intermittent; concentrated to malignant remittent. There is some analogy in the observed influence of alcohol, which in small amount exhilarates, intoxicates when largely taken, and in sufficient quantity proves instantly fatal. Entering the blood through the skin and lungs, they act upon the internal surfaces of the minute vessels, specifically affecting special organs. Separate tissues are disordered in various types, as the stomach in yellow fever, the intestinal glands in typhoid, &c. Fevers are properly divided into Idiopathic and Symptomatic. The distinction intended, is generally recognized in marked cases, as when we refer on the one hand to fever from local injury, succeeded by in- flammation, and on the other, to the regular recurrence of an habitual 40 quartan. The best definition perhaps, which can be offered, is that which connects symptomatic fever essentially with some obvious, regu- lar and early local inflammation ; idiopathic fevers being such as do not show uniformly such connection. The latter head will then comprise intermittents, with the exception of hectic ; remittents generally, and among the continued fevers, typhus, catarrhal fever and pneumonia typhoides. Examples of the true symptomatic fever, are given in pleuritis, hepatitis, phrenitis, gastritis, enteritis; the inflammatory fever which occurs immediately after a severe injury, and the irrita- tive or hectic, which comes on later. It has been much disputed, whether the first step in the formation of fever is the production of debility, or of irritation. The true nature of incipient febrile action is unknown. Many of the remote causes of fever, it is true, are of a stimulant, or irritating, or exciting quality, but not all. Typhus, the "famine fever" of Ireland, is the result of agents of opposite tendency, and large losses of blood are very apt to be followed by fever. Cullen's definition of fever is not correctly precise. Fevers do not always begin with a cold stage. When they have so commenced, the animal heat of the surface is not always augmented. The frequency of the pulse is sometimes diminished. Fever is difficult to define because of the number of concurrent ele- ments which go to constitute it. Lassitude, one of the most uniform incipient symptoms, shows early affection of the cerebro-spinal system; the disturbance of the circulation seems to consist primarily of obstruc- tion in the smaller vessels, perhaps from capillary paralysis, and reac- tive vehemence in the central organ. From or with the capillary pa- ralysis ensue defective generation of animal heat on the surface and in the tissues ; chill and rigor; cold and muscular trembling ; from the same cause universal derangement of nutritive, secretory and excre- tory action. Nothing is more strongly characteristic of fever, than the general diminution and depravation of the secretions of all the surfaces and glands; hence the thirst, the clammy mouth, the furred tongue, nau- seated stomach, constipated bowels, harsh dry skin, paucity of urine, which is highly colored, &c. The blood always undergoes more or less change in fevers. It is asserted to be always defibrinated in the idiopathic forms. Hence perhaps the tendency to hemorrhage in the latter stages of severe fevers. The ancient notion of the tendency of fever to run a certain course and subside spontaneously, is fallacious and must not be depended on. * 41 The congestions and inflammatory determinations which belong to the history of fever, tend on the contrary to the production of organic changes in the tissues, which, reacting, keep up fever, and prostrate the constitution. Hence, as these irritations, congestions and inflam- mations are at least in a certain measure controllable by proper re- medies, we must class fever among curable diseases. Not only in this way, indeed, is it removed, but we occasionally see it cut short by im- pressive measures, which relieve the system of it suddenly and at once, as venesection, the cold bath, emetics, cathartics, mercurials, &c. The perturbing methods of treatment are therefore preferable in their general results to the expectant management of fever. The doctrine of critical days requires notice. Crisis is defined as a sudden and notable change, occurring spontaneously in the course of fever, and exhibiting a remarkable influence on its character and ter- mination. The change may be either favorable or otherwise. Crises occur probably in all acute diseases. They may consist in mere revulsive determinations to some new part or organ relieving those first attacked; we may thus explain the alleged critical influence of epistaxis however trifling, the external vessels receiving the fluxus which had oppressed or irritated the brain. There are obvious criti- cal changes, exhibited in the urine and perspiration, much dwelt on recently, as in ancient times. The question is, whether these changes are to be expected on cer- tain calculable days. These days, if we collate the writings of the principal and most zealous supporters of the doctrine, are the 3d, 4th, 5th, 6th, 7th, 9th, 11th, 13th, 14th, 15th, 17th, 20th, and 21st—thirteen days in twenty-one ; the non.critical days are the 8th, 10th, 12th, 16th, 18th, and 19th—six in number. We cannot wonder then, if, as is as- serted, a majority of crises do occur on the so-called critical days. The regular observance of the types of fevers, all which refer origi- nally to the intermittent form, however obscurely, I think, has been the cause of the belief in critical days. The diurnal and septenary revolutions have been spoken of; to the combined influence of these I attribute the types of fever. Continued fevers usually have reference to the quotidian intermittent; remittents to the tertian, with its modifications, double and triple, and perhaps sometimes to the quartan. Remittents, when they become obscurely re- mittent by protraction, running, as the phrase is, into a continued type, exhibit in a still indistinct way, this reference to intermittent type, and these imperfectly marked references have been called crises. The remote causes of fever shall be enumerated under each specific head. 6 • 42 The effects of fever, the local derangements developed during its progress, and displayed in post-mortem examinations, vary both with predisposition and exciting causes. The brain, in its substance and upon the membranes which en- velope it, shows vascular engorgement, and sometimes the results of inflammation. The mucous membrane of the stomach and intestines, suffers various lesions from similar inflammatory determination, and other modes of derangement. The pleura and peritoneum are also attacked—the lungs and the mucous lining of the trachea. The liver, especially in warm climates, is often notably altered in color and appearance, being increased in size, in weight, &c. These local affections are not necessarily inflammatory; they are congestive, perhaps, as often. In Crampton's account of a Dublin epidemic, the following estimate is given, of the relative proportion in which the organs were altered in condition, or had undergone notable lesion. Out of 755 cases, 76 were of the abdominal viscera, 129 of the chest, 550 of the head. Similar tables are presented us by Tweedie and other British physicians. Among us, owing to influences of climate and determinations thereby given, the proportions would be reversed. Here the abdominal viscera are chiefly affected, (the stomach, intestines and liver,) next the head, lastly the chest. I believe the former never escape derangement in the warm months. Fevers divided into Intermittent, Remittent, and Continued. These types are fairly distinguishable, although there are cases in which the distinctive marks are very slight. The cause of the difference of type in fevers, is not known. It would seem to depend upon the nature of the morbid poison which gives rise to the disease, and which indeed impresses the whole train of results. Malaria produces intermittents, and remittents; con- tagion, a continuous fever. The period of incubation appears universally determined by the efficiency of applied cause, and this is the combined result of amount or concentration of dose and predisposition of subject. This latent period is therefore very various. The intercurrent period is, on the other hand, very exact; depending simply on one element—the type of the disease. An intermittent presents repeated paroxysms of fever, with intervals between of absence or apyrexia. A remittent is characterized by notable and regular exacerbations, 43 and diminutions of febrile excitement, there being no complete apyrexia, but an observable approach to that state. A continued fever is so denominated when there is no notable or prominent difference at regular periods in the degree of febrile inten- sity. The influence of diurnal revolution, is however generally ob- servable, there being slight morning remissions, and evening exacer- bations. Intermittents are divided into three stages—the cold, the hot, and the sweating. The whole time from the commencement of the cold stage of one paroxysm, to the commencement of another, including the apyrexia, is technically styled the period of an intermittent. 1. The quotidian occupies 24 hours in this way, returning daily. 2. The tertian 48, returning every second day. 3. The quartan 72, returning every third day. Each of these has its usual hour of access, and its relative duration and violence of stages. The quotidian comes on in the morning, has the shortest cold stage, but the longest exacerbation of febrile excite- ment, continuing about eighteen hours ; its apyrectic interval about six. The tertian comes on at or a little before noon ; its duration is about twelve hours ; its interval is long. The quartan attacks in the afternoon, with the longest cold stage has the shortest duration; continuing seldom more than nine hours. These are the original types, which are variously complicated ; we have the double tertian, the attacks on alternate days corresponding in time of access, violence, duration, &c. ; the triple tertian, two paroxysms on one day, and one on the alternate ; the double quartan and the triple quartan are also mentioned. The paroxysm of an intermittent described. The cold stage is marked by the following symptoms—languor, muscular feebleness, yawning, stretching, sighing, paleness of the face, with lividity of the lips and ends of the fingers, shrunken countenance with cutis anserina, a sense of chilliness increasing to trembling and shiverings of the whole body ; uneasiness at stomach, amounting to nausea sometimes, and vomiting ; pain in the head, and over the back and limbs ; pulse small, and feeble, and quick. Hot stage.—The chills alternate with flushes of heat, gradually per- vading the whole surface, which is glowing and dry ; pains in the head and limbs increase, with turgidness of the face and eyes; vomiting goes on, and bilious matter is thrown up mixed with mucus and other contents of the stomach; there is thirst, and the pulse has become fre- quent, full, and hard. 44 Some intermittents do not present the stage of ague or chill, but commence with the hot stage. Other irregularities are noted in the books, such as inversion of the three stages, &c. ; but these are very rare, if indeed they ever occur. Sweating stage.—After some time a moisture is felt upon the fore- head, breast, and arms, which progressively extends over the whole body, and the sweat flowing freely, the symptoms above enumerated go off, leaving the patient more or less exhausted. Masked or disguised intermittents present, instead of the above regu- lar succession of phenomena, some single symptom of great intensity, occasioned by morbid determination to, or affection of some part, as of the eye, the stomach, the brain, &c. We distinguish these by their periodical recurrence and regular abatement, and the previous exposure of the subject to the causes of intermittents. As to the nature of these " masked cases," (so called,) I entertain some doubt, however. Periodicity is so frequent an attribute of disease, that we need not refer it to any supposed connection with intermittent fever or its causes. Causes of intermittents.—Malaria is the principal, if not the exclu- sive cause of these fevers. They are said also to arise from alterna- tions of temperature, moist clothing, fatigue, &c. ; but such instances are very seldom if ever met with. The latent period may be so long protracted as to give rise to error here. The attack may be developed days, weeks, or even months after exposure to the malarious atmosphere. A table is given us by Dr. Halpin, of 14 men from Cavan, Ireland, exposed harvesting in the fens of Lincolnshire, but 3 of whom escaped. Only one of 11 was seized within a month after exposure—7 were attacked six months and one about a year after their return home. General prognosis.—Favorable, allowance being made for their obstinate tendency to recur, the season of the year—vernal being more easily curable than autumnal attacks—-and climate. In hot and moist countries, as on the coast of Africa, intermittents put on often a malig- nant and fatal character ; and in very damp districts of more northern latitudes, as in Holland and England, (Lincolnshire,) though less imme- diately destructive, they are tenacious and sometimes fatal. Few diseases engraft themselves so tenaciously on the system or generate so strong a disposition to their own return. Relapses are apt to happen at intervals relevant to the intercurrent period of the original type. They take place frequently on the approach of warm weather, although the whole winter has passed without a paroxysm, and the subject may have removed from the unhealthy district. This is 45 vaguely ascribed to habit merely, but although this may sometimes keep up the disease, yet I think we must attribute its return after long va- cant periods to some morbid condition of the organs and tissues which suffer during the attack, reacting and reproducing the general disor- der with which it is associated. Special prognosis.—Favorable, mildness of symptoms, postpone- ment of time of access, completeness of apyrexia. Unfavorable, extra- ordinary violence, anticipation of period of access, unpleasant feelings and uneasiness during apyrexia, coma in cold stage with difficult breathing, delirium in hot stage, great prostration of strength during the sweating stage, or at the subsidence of the paroxysm. Effects of intermittents. Patients sometimes die in the cold stage, from congestive determination to vital organs, the brain and lungs; they may sink exhausted (though this is rare) at the close of the sweat- ing stage, or when the vomiting has been severe. Enlargement of the liver and spleen are the most common consequences of the protraction of intermittents ; these may be either indolent or inflammatory ; dropsies, jaundice, hepatitis, dysentery, may also be mentioned here. Enlargement of the spleen is so general a coincident of malarious intermittent, that Piorry maintains it to be the cause of the whole train of symptoms. It occurs, he says, rapidly and subsides as promptly; disappearing under the use of tRe sulphate of quinine in a few seconds. This statement contains exaggeration and error. I have watched par- oxysms of intermittent, in which there was no notable enlargement of the spleen, though carefully looked for. I have seen patients long subject to intermittents, also apparently free from any such enlargement. There is no doubt however of the general fact; and to the morbid con- dition of this organ, at least in part, I am disposed to attribute the ten- dency to recurrence so very tenacious in certain instances. Treatment of intermittents. The indications are, 1. To arrest the paroxysm. 2. To palliate or relieve the symptoms which annoy the patient. 3. To prevent its recurrence. During the cold stage, external heat to the extremities and general surface, and sinapisms should be assiduously applied. If the stomach be oppressed, a quick emetic may be given. The tourniquet has been applied to the limbs by Kellie. The lancet has been used of late freely by Mcintosh and others. Its effect doubtful, if not dangerous. Opium is of all our remedies most generally useful, and is capable both of preventing and cutting short a paroxysm, when given in full dose with sufficient promptness. If the chill be severe and prolonged, in a debilitated subject, we may combine it with camphor, piperine, capsicum, and other stimulants. During the hot stage, if special determination to the head be present 46 in robust subjects, the lancet may be used ; cold affusion to the head, and the cold bath employed with advantage ; a cathartic may be given; and diaphoretics, assisted with cooling drinks. In intermittents of malignant character, the symptoms of over- whelming congestion and of typhoid prostration, must be met by a re- sort to stimulants of the highest power—sinapisms and other modes of external irritation, brandy, ether, and laudanum internally, in no timid doses. The stimulating diaphoretics, camphor, and the volatile alkali, with hot wine whey, and stimulating enemata, are also of use here. During the intermission.—Cinchona is our most important remedy. The only objection to its employment consists in the inflammatory de- termination kept up sometimes to some organ, as the liver, spleen, stomach, lungs, and brain. This being subdued, it should be freely re- sorted to. It is given in substance, in infusion, tincture, and extract. The sulphate of quinine, prepared from it, is a medicine of inestimable value, on account of the concentration of valuable febrifuge powers; dose, one to three grains, every two or three hours. Larger quantities excite the stomach and determine to the head, and are in ordinary cases unnecessary ; but we meet with instances of obstinate protraction, in which we may administer with the best effect very free doses, as from three to twenty grains. Our exhibition of this as of all other drugs should be regulated by the effect produced. We should not stop short of "quininism" as shown by buzzing in the ears, dimness of sight or vertigo, &c. The administration of quina should be commenced as soon as the sweating stage—the solution of the febrile paroxysm—is fairly estab- lished. In ordinary cases it is of itself abundantly sufficient to put an end to the attack. Bebeerine is perhaps the best substitute for quinine where the latter is for any definite reason contra-indicated. Salicine has been lauded highly, but is far less effectual than either of the above. Cornine, from the dogwood, is another article upon the long list employed here. Piperine shows its best influence in combination with quinine. It is too much a stimulant to be used throughout the apyrexia, but may be added with much advantage to the dose of quinine, just before the paroxysm is expected. It forms thus a very useful combination. Narcotine, or rather the muriate of narcotine, is highly eulogized by O'Shaughnessy and other East Indian physicians. I have found it like quinine, available in a long list of maladies recurrent periodically Serpentaria-not valuable alone, but its infusion is a good vehicle for cinchona. 47 Sulphur—second only to bark, in the cure of intermittents, and par- ticularly serviceable, as it may be given when bark ought not, in cases of imperfect apyrexia. Is well applied in all masked intermittents— when mingled with cinchona, forms an impressive combination. The carbonate and prussiate of iron, and the sulphate of zinc, are highly recommended. Arsenic—a very powerful remedy ; it should be cautiously ad- ministered ; best adapted to the more obstinate chronic habitual forms of intermittent. If we distinguish between the power to prevent a coming paroxysm and that of doing away the liability to recurrence of an attack, we shall find that while cinchona is immeasurably superior as a means of fulfilling the first indication, it is excelled by arsenic in its permanent influence over the predisposition to relapse. The above means failing, the patient should be subjected to a mild mercurial treatment, or sent to take a long journey or a sea voyage. Bilious Remittent Fever.—This title is well chosen, as expressive at once of the type of the disease, and of the derangement of the liver, and its secretory action, which uniformly attends. Cause.__Belongs especially to warm climates and seasons ; pro- duced almost exclusively by malaria aided by the occasional or ex- citing causes formerly enumerated, heat and alternations of temper- ature, moisture, &c. Strangers from colder countries, or from upland districts, are predisposed to its more violent forms, and should carefully avoid the adjuvant agencies which bring it on or aggravate it—should live temperately, but not abstemiously—shun extremes of temperature, dampness, dews, night-air, &c. Acclimation, if possible as regards malaria, which I doubt, is a very slow process, and cannot be assisted or hastened by any means known to us. By a prudent course of life, we may put off the invasion of endemic fevers, which are apt to assail new comers most severely. Bloodletting, purgatives and mercurials, are falsely represented as prophylactics. They actually predispose by reducing the system and rendering it susceptible. Symptom*.—Bilious fever commences sometimes with, and often without, a rigor or chill; then follow languor and weariness—gastric uneasiness—pains in the head, back, and limbs ;—the skin becomes hot and dry—pulse full, bounding, abrupt, and frequent, with restless- ness—vomiting, thirst—tongue at first white and lightly coated, soon 48 covered with a thick yellow or brown fur ; its edges red and indented, as if swollen and pressed against the teeth. Bowels constipated— stools, when obtained, greenish and acrid. The exacerbation continues from twelve to eighteen hours. Remission, or abatement of symptoms, then takes place in a greater or less degree. The pulse is slower and more regular ; the gastric dis- turbance not so urgent; the other sufferings of the patient diminish. The completeness of the remission, its approach to intermission, best shown by the fullness of the cutaneous transpiration. The urine is also secreted more freely, and contains a lateritious sediment. The return, or exacerbation, refers to the tertian period of access, at or a little before noon—observing the double tertian type in the cor- respondence of alternate days. Cases not unfrequently occur bearing analogy to the triple tertian, when we have on one day two exacerba- tions, and on the next, one. In the exacerbation, if the disease is not checked, the vomiting becomes more frequent—there is heat at the epigastrium, and pain on pressure—the headache is intolerable—the eyes cannot bear the light. In the farther progress of the case, the tongue is dark brown, black along its central line—is chapped or cracked. The bowels are cos- tive or the stools thin and watery. Respiration is more and more em- barrassed with sighing and restlessness—the pulse sinks, becoming small and feeble. There is great prostration, with muscular twitchings ; the fatal termination occurs in from seven to thirteen days—average about nine. Typhoid state or stage.—After many repeated exacerbations, the pa- tient sinks sometimes into a condition thus designated, in which the symptoms resemble those of typhus. This more frequently happens among old residents, the termination taking place more promptly (whether favorably or otherwise) in youth and strangers. The disease may be, in this modified form, prolonged to thirty and thirty-five days— average fifteen or twenty. General prognosis in bilious remittent, favorable. Proportion of deaths throughout the south and west, as small as in any part of the world. In our own city, not more than one in thirty or forty, perhaps even less. Individual prognosis.—Favorable when the remissions are distinct and prolonged, with tranquil sleep and sweating ; if the bowels are moved easily and the evacuations assume faecal appearance and quality ; if the stomach become quieter and the tongue cleaner and less red. Unfavorable, when the remission is short and imperfect; when the 19 stomach is specially irritable, when there is much wandering of mind or delirium ; inordinate frequency of pulse is a bad symptom—recoveries are rare when it transcends 130 or 140 ; so are great tenderness of epi- gastrium or tympanitic swelling, with or without vomiting, obstinacy of intestines, laborious breathing, coma, subsultus, fatuity. There is considerable liability to relapse. This is to be dreaded when digestion is weak, tongue furred or red, bowels irregular ; occurs more frequently on the 7th or 14th day. Effects of remittents.—If the patient continues to reside in a malarious district, remittents often run into intermittents of great tenacity. This is the mode of subsidence of these fevers, the remission being heightened and protracted into an intermission. Sometimes a conversion takes place during seeming convalescence ; or relapse occurs, into the form of tertian. Both [n this way and more immediately they are apt to give rise to jaundice, dyspepsia—pulmonary complaints, when there is predisposition—enlargement of liver and spleen, hepatitis, splenitis, dropsies. In the ordinary form of bilious remittent, the tendency to death is developed in local determinations, usually considered inflammatory, to the brain or the abdominal viscera. Neorotomy.—The vessels of the brain and its membranes are found engorged ; and those of the gastro-enteric mucous membrane, in similar condition: the spleen and liver enlarged, discolored, full of dark blood, heavy, softened and brittle: the bile discolored, vitiated, te- nacious, flocculent and granulated. A peculiar olive hue of the liver is represented by Stewardson as characteristic. I have not found it uniform. Treatment.—The first indication, both in point of importance and time, is the reduction of the force of morbid excitement, as directed upon particular organs or parts. This may be effected by the following means: Venesection—Not a general remedy. Adapted to cases of robust, plethoric strangers; and to attacks, in which at the invasion, or during the early stages of the attack, the local determinations are specially violent and painful, as when there is delirium, or mania, or coma, or great epigastric tenderness, &c. When resorted to, should be employed freely, the blood being permitted to flow until the pulse yields; and under the same circumstances, local bloodletting by cups and leeches, will be found useful after venesection. The cold bath may be considered a general remedy. Contra-indi- cated by feebleness from age or other circumstances, by a moist skin, by chilliness. Forbidden also by determination to the lungs, and 7 50 by the presence of diarrhoea. Should not be repeated if it produces a continued sense of coolness. Affusion preferable—next immersion. Its remedial value cannot be exaggerated. Emetics.—Not often called for. If the stomach be oppressed with imperfect vomiting, may be useful both by cleansing it, and by deter- mining to the skin and bowels. Should be abstained from, if there is pain at the epigastrium, increased on pressure. The antimonials are in general preferred. Ipecacuanha is safer, and more manageable. Cathartics.—Absolutely necessary in the treatment of fever. The good effect of cathartics in fever—strangely disputed by some autho- rities, is threefold ; 1st. They are good and safe means of depletion and palliation. 2d. They are revulsive. The extensive tract of mu- cous membrane is a safe seat of derivation from the head, &c. 3d. They are depuratory, affording in the large secretion from the surface they excite, a free and ready outlet for injurious and effete matter, mingled with and retained in the blood, from exposure to bad airs, and defect of ordinary excretions. Great care must be taken to choose the least irritating and most efficient. I would avoid the combination so generally used in domestic practice, of drastic purgatives with harsh emetics. I would select such articles as cause least nausea or griping. Calomel, pulv. rhei, and the epsom salt, may be given so combined and alternated, as to produce all the good effects which we can hope for, from the evacuation of the bowels, and the disgorgement of the liver and other abdominal viscera, and may be prescribed in such doses, and at such intervals, as to keep up a permanent and highly salutary determination to the intestinal canal. But it is not necessary to persevere in what is called active purging, and if the bowels yield readily, we should discontinue the exhibition of cathartics. Serious harm may be done by urging their use too far, especially if there be much nausea and vomiting, with great epigastric tenderness, and the stools are frequent, small and mucous, and attended with pain, or griping, or faintness, or vomiting. Yet, on the other hand, it is an error more mischievous, to neglect entirely this valuable class of me- dicines, and to leave the patient to suffer all the evils of abdominal congestion and engorgement, and the irritation of accumulated morbid secretions in the alvine canal. The mucous intestinal surface is one, I repeat, to which revulsive determination may be directed very safely, and to the great relief of more important and delicate organs. Its secretions may be increased to such an amount, too, without any injurious consequences, as to form a very impressive means of depletion. Diaphoretics may be administered in union or alternately with ca- 51 thartics. The saline and sedative are at first to be chosen, as the ni- trate of potassa with infus. rad. serp., acetate or citrate of potassa, acetate of ammonia, and nitrous ether. The use of these means should be continued through the remission, arid so timed as to produce their fullest effect just at the period of exacerbation—the room being kept dark, cool, silent, and well ventilated, and coal drinks and ice allowed. The vapor bath is a good adjuvant to diaphoretics internally adminis- tered. Thus we fulfill the first indication, palliating the violence of symp- toms and resisting the tendencies to disorganization. But we must be prepared to interfere farther, with the purpose of arresting the attack— notwithstanding the still lingering prejudice that u fever is not to be cut short." Why may not a remittent be checked in the incipient stage, as well as a*a intermittent and by the same treatment ? Venesec- tion has been known to effect this ; so has the cold t>ath. Here also our most efficient remedy is ckachona. Unfortunately it is oot always admissible or adapted, but experience has shown that the .objections t® its use are not as frequently present, or as weighty as was formerly be- lieved. A well marked remission offers a good opportunity for the administration of quinine, but it need not always be waited for. Un- less a hiffh decree of febrile eseiteraent, associated with some violent local determination, were present, I would advise the trial to be boldly though prudently made. Wright tells us that in the remittent fever of Florida, it was his usual custom to exhibit 20 grains sulphate of quinine, at any period of the paroxysm. " Tfoe practice was successful; not a single death having been reported during die season." If the exacerbation be often repeated, and the patient's strength seem about to yield, resort to the stimulating diaphoretics—camphor, the volatile alkali, tinct. opii camph., with infus. rad. serp. the combination of carb. potass, with the tinct. opii camphorata, the acet. and carb. of ammonia, the nit. ether and the infus. cinchonas; while a generous and stimulating diet is allowed, with wine in proper amount if necessary, the bowels in the meantime being gently acted upon by some mild cathartic ; I prefer to all others the combination of mere. dulc. with pulv. rhei in small doses and at proper intervals. Of local applications, I regard the blister and the leech to be alike of equivocal effect, and prefer the mustard poultice to either. The throat and mouth must be kept scrupulously clean. The ash-colored spots must be touched with the strong solution of nitrate of silver occa- sionally and the foul secretion washed off with the syringe, or, if the patient can use them, with gargles. These should be somewhat stim- ulating. The infus. cinchon. with myrrh or camphor, with the min- eral acids, is much to be confided in. The infusion of cayenne pepper is greatly in vogue, and often does good service. Besides this very useful local application as a gargle, it is perhaps our best internal stimulant, and should be administered freely. The infusion should be preferred as strong as the patient can take without suffering, and containing a small proportion of common salt. When its pungency cannot be borne, the pulv. capsic. should be prescribed in substance, made up into pills or covered in capsules of jelly. DISEASES OF THE RESPIRATORY SYSTEM. The knowledge of the objective phenomena which manifest the con- dition of the organs of respiration, is highly important to the practitioner. These physical signs are various in their character, and are to be ascer- tained by the following modes of investigation. I. Inspection of the outline, figure, and movements of the thorax. One side of the chest may be flattened, or enlarged; the intercostal spaces may be protruded ; it may remain still, and unaffected by the breathing. The subject may be chicken or cuirass breasted or other- wise malformed. II. The capacity of the thorax may be tested for comparison at different periods of chronic pulmonary disease, by mensuration ; or by expiration into a gas-holder or bell-glass turned down over water; or by counting seconds during inspiration or retention of the breath. III. Hyppocratic succussion, brisk agitation of the trunk by the 159 shoulders, is employed for the purpose of detecting fluctuation in the chest, such as occurs in pueumothorax and pueumohydrothorax. IV. Percussion—performed by striking upon the chest with the fin- ger, or the points of three or four together, smartly. If it be healthy and full of air, a notable reverberation or.hollow sound is produced, which differs in degree at different points ; if this reverberation does not occur, but a dull or flat sound follows the percussion,we infer the absence of air at the part, either because of the solidification of the lung, its con- taining an undue amount of blood or some other inelastic fluid, or because of some effusion within the pleura. On the other hand the resonance may be inordinately great at certain points; whence we infer emphysema, or the existence of a cavity. Normal resonance, moderate in degree, is always coexistent with the healthy sounds of respiration, and these are always impaired when the resonance is morbid. Percussion is mediate or immediate; each rib may be tapped by the finger-point; but the general examination is best made mediately, a " pleximeter" being interposed between the finger and the surface of the chest, espe- cially over the intercostal spaces. A flat piece of ivory is used for this purpose, a bit of leather, or of caoutchouc or a finger of the left hand ; which latter I prefer to all others. V. Auscultation. This is immediate, as when we lay the ear to the several regions of the thorax, and listen to the sounds within. It is mediate when we employ the stethoscope. This instrument is made of numerous varieties in form and substance. I prefer a light wood, apple or cedar, to either paper, ivory or caoutchouc. It should be short, in one piece, and the bore not less than one-third of an inch wide. The stethoscope is often very convenient, sometimes necessary to us; it enables us to localize and circumscribe the sounds heard. The ear should be made familiar with both mediate and immediate auscultation. The healthy sounds of breathing, the respiratory murmur, are de- scribed as vesicular over the cells, and bronchial along the course of the air tubes. Puerile respiration is an intenser vesicular murmur, such as attends the breathing of children. The morbid sounds, rales or rhonchi, are, the crepitous ; the mucous ; the gurgling or bubbling ; the cooing or purring ; the sibilant or whist- ling. It is difficult to describe sounds otherwise than by the use of suggestive phrases. The diffused murmur of healthy and tranquil breathing, and the gentle current heard flowing along the smooth bronchi and trachea are easily known after listening to them a few times attentively, and can only be thus known. Thus we obtain the standard for comparison and learn to appreciate new and unnatural sounds. The crepitous rale is well imitated by pressing between the 160 fingers a lock of dry hair so as to make it rustle. The mucous rale is often heard just before a loose cough in common catarrh. In gen- eral we may affirm the phrases to be well chosen and convey the meaning clearly enough, as when we speak of the metallic tinkling, and the amphoric breathing and cough heard when air is put in motion in a large cavity, resembling the noise made in blowing into a bottle. The terms used in reference to vocal sounds are, I think, less hap- pily descriptive. In health we notice the diffused thrill or vibratory murmur heard over the cells and corresponding with the vesicular breathing ; and bronchophony, a modified vibration, perceived over the course of the large air tubes. The morbid vocal sounds are entitled agophony and pectoriloquy, which, as I have said, are awkward enough designations ; but it is not easy to suggest better. Mgophony is to my ear very little like the bleating of a goat, (as the word imports,) indeed I know no sound re- sembling it, but that which children make by blowing on a piece of paper over a comb, and that not much. Pectoriloquy is known at once and easily when heard, but is described in the books vaguely and extravagantly. It is a sort of internal echo of the oral utterance, both being heard. Young physicians should be cautioned against undue or exclusive reliance on these physical signs. They aid us much in the attainment of a clear diagnosis; the prognosis drawn from them is somewhat less trustworthy. Croup—Laryngitis—Cynanche Trachealis.—Croup is one of the most common maladies of children, in whom it is rarely met with be- fore they have been weaned. Occurs seldom in mature life, though a few individuals remain subject to it. It consists in a well known and peculiar dyspnoea, attended with cough and febrile excitement. The voice is exceedingly husky, and the cough is characteristically harsh, stridulous and ringing. The access is usually towards evening, when the child presents the ordinary appearances of catarrh or common cold, with sneezing, &c. His breathing becomes rapidly more and more difficult, and fever comes on, with flushing of the face and suffused and watery eyes. He sits up in bed, and his struggles for breath are frightful. If not soon relieved, his face is swollen and turgid, and his countenance livid or very pale, whifl his eyes protrude and his skin is bedewed with sweat. Expectoration of a thick tenacious mu- cus diminishes his sufferings, and he sinks exhausted to sleep. His respiration is still hurried and croaking, and a mucous rattling is 161 soon heard over the whole thorax. Portions of a flaky membrane are sometimes coughed up, with great alleviation of his dyspnoea. His paroxysms recur, if art has not arrested his disease, and he sinks, worn out with his violent exertions to continue the process of respiration. Cause.—Exposure to the vicissitudes of weather, to changes of tem- perature, to cold and moisture, to particular winds, as with us the east and northeast, give rise to attacks of croup. In some children the pre- disposition is so strong that any exposure to night air will bring it on. It sometimes arises from the extension of inflammation or ulceration of the throat into the larynx. I have seen it, I think, produced by gastric disorder and irritation. Pathology.—Croup consists in an inflammation of the lining mem- brane of the larynx. The thickening of this swollen membrane may close the rima glottidis, or the effusion of thick tenacious mucus en- danger suffocation. But the greatest risk lies in the exudation of fibrine or plastic lymph upon the inflamed surface, to which it adheres, clogging up the passage of air through the glottis. A distinction is attempted here into true and false croup, the presence of the "membranaceous exudation" being regarded by some as specific, characteristic, diag- nostic. I look upon it as only one among the results—varying with circumstances—of the inflammation of the affected tissue ; depending partly upon its structure and partly upon the composition of the blood in early life. In the acute laryngitis of adults this exudation is not often met with. In these subjects the most frequent termination is in aedema of the glottis. Dr. G. Buck of New York and Valleix in France have called the attention of the profession to it. It is connected with erysipelatous and other inflammations of the throat, and its supervention clearly marked by the croupy voice, cough and dyspnoea. Dr. B. has relieved it in several instances by incisions on each sideof the glottis, made with a knife constructed for the purpose. Autopsy.—The mucous membrane of the larynx is thickened and high-colored. Adhering to parts of the surface in small flakes or coat- ing it entirely over, we find in many, though not uniformly, the plas- tic lymph above spoken of. I have seen it in a protracted case extend- ing downwards and forming long tubes within the bronchi. Bronchitis and pneumonia indeed are apt to supervene upon prolonged croup ; and the air tubes become clogged with a tenacious mucus and the lung to a considerable extent hepatized or solidified. Diphtherite or membranous sore-throat is apt to extend downwards into the larynx from the fauces. So also ulceration sometimes pro- gresses. I have a preparation of a larynx which exhibits at different 162 points of its surface, adherent flakes of lymph, and an extended ulcer. The prognosis is generally favorable. Croup, though always alarm- ing, is, if seen early, very much under medical control. The pre- sence of diphtherite or membranous exudation in the fauces is indi- cative of great danger. Cases connected with ulceration in the throat too are usually fatal. The extension of the inflammatory action down- wards into the bronchi and lungs, aggravate the severity and risk of the attack. The treatment.—We may often succeed in arresting the invasion of croup at its commencement, or during what we may call the catarrhal stage with which it so generally comes on, by administering a full dose of the tinct. opii camph., immersing the little subject in the warm or rather hot bath, and then covering him up warmly in bed. The ano- dyne and diaphoretic effects of these measures avert the threatening paroxysm, and he sleeps tranquilly, bathed in perspiration, and he awakes relieved. But if he be not seen early enough ; if dyspnoea be urgent, attended with the characteristic cough, an active emetic is necessary. The an- timomal is almost universally chosen. I prefer to combine it with ipe- cacuanha, and to administer it while the child is seated in the warm bath. If much febrile excitement be developed, with full hard pulse, flushed cheek and sparkling eye, with tokens of pain in the larynx, it may be well to premise V. .S., or to apply a few leeches to the throat. The emetic should be repeated, if its effect in relieving dyspnoea has been unsatisfactory, and the bowels moved by uniting with it some active cathartic. Calomel is much relied on, both as purgative and for its specific or alterative influence, and administered in large doses ; but I would not confide in it alone, or to the exclusion of other remedies. Seneka and squill are much and justly extolled as combining ob- vious and expectorant effects with their emetic property ; in protracted cases they may be exhibited repeatedly at intervals, with advantage. If the attack does not yield readily, and indeed at the very com- mencement if any spots or flakes of membranaceous exudation be visi- ble on examining the throat, we must resort to the employment of ni- trat. argent, in strong solution. Its introduction into the larynx was first successfully attempted by Dr. Horace Green of this city, by pas- sing through the glottis a bit of sponge moistened with a solution of the pure crystals of the strength of about 3ii in aq. § i. The plastic and semi- organized lymph is disorganized by the chemical union with it and 163 action upon it of the metallic salt, and the inflamed vessels beneath it contract and cease to effuse it. Ricord has well characterized this ac- tive remedy, as "the great modifier of diseases of mucous membranes." Invading croup is very often managed with success by domestic means, which, in country places where the physician is distant, ought to be known as at least retarding the progress of a rapid and danger- ous malady. A plaster of Scotch snuff is sometimes efficient in arresting an at- tack. It is highly eulogized by Godman. Hot water is applied by some to the throat. Hoi poultices with or without mustard are also revulsive and relaxing. The alkalies are much employed. Common ley-water is given internally and used as a hot bath. The vol. liniment, composed of equal parts of spt. corn, cervi with olive or lamp oil is ad- ministered with molasses. Indigo was once much used; it operates harshly by vomiting and purging. With regard to the operation of tracheotomy so much discussed, I would offer this rule. If, in the earlier period of an attack of croup, the patient was in imminent danger of suffocation from sudden closure of the glottis, either by swelling of the membrane or exudation of lymph, while yet the bronchi were permeable and the chest reso- nant, I would open the windpipe. But it is idle and useless to do this in a case more or less protracted, when the inflammation, engorge- ment, effusion, and exudation have extended along the trachea and into the thorax ; the patient now labors under bronchitis and pulmoni- cs as well as croup, and the operation can be productive of no advan- tage. Chronic Laryngitis.—Laryngeal Phthisis.—This form of disease has of late attracted much attention, and though it is not absolutely a new malady, as some suppose, is certainly more frequently met with in the last few years than formerly. It is known without difficulty. The sound of the voice is peculiar, or the aphonia is entire, the patient being able to speak only in a hoarse husky whisper, and with a painful and fatiguing effort. The larynx is the seat of uneasy sensations, and suffers when handled or pressed. There is a sibilant weak cough, usually dry and teasing ; in some cases there is expectoration of a thin tenacious mucus, sometimes of a little pus. Dysphagia is occa- sionally the most annoying symptom, from inflammation of the epi- glottis. There is dyspnoea and much panting, after muscular exertion. As the case progresses, the ordinary symptoms of phthisis supervene— emaciation, hectic, colliquative sweats, and diarrhcea. 164 Its causes are not clearly defined. It attacks most frequently the scrofulous constitution. Clergymen are observed to be subject to it, especially such as read discourses in public. Autopsy.—-The local changes after death are—1. Edema of the glottis. 2. Inflammation of the mucous membrane of the larynx, with redness and swelling. 3. Ulceration of this surface. 4. Ossifi- cation, caries and necrosis of the cartilages. It is rarely fatal, how- ever, without the extension of the morbid action downwards along the trachea and bronchi, and the supervention of pulmonary inflamma- tion with its usual results. Treatment.—In the first instance bloodletting, both general and local, is demanded, with the application of poultices and sinapisms to the throat. Emetics are often serviceable in relieving paroxysms of dyspnoea. Mercurials are strongly recommended by Trousseau and Belloc in France, who urge them to the production of ptyalism, and by M. Hall in England. I have not derived much benefit from them. Narcotics are always useful. The Dover's powder, if well borne, is to be preferred ; the salts of morphine are among the best palliatives. They may be applied to blistered surfaces with benefit. Inhalations of vapor, simple and mingled with ether, camphor, chlorine, &c, have been recommended. The nitrate of silver has been long in use as a gargle or local appli- cation to the fauces and pharynx for the relief of the troublesome dys- phagia, which it controlled better than any other remedy ; but to Dr. Green belongs the merit of introducing it freely and efficiently within the larynx. He uses for this purpose a bit of sponge strongly attached to a stick of bent whalebone, the insertion of which dipped in a solu- tion of nit. argent. 3ii to 3i in aq. dist. § i, is productive of far less irritation and annoyance than would readily be imagined, and is in many cases followed by highly beneficial results. Its employment should always be fairly tried. Laryngismus Stridulus.—Spasmodic Croup.—This is compara- tively a rare disease, confounded under the same name, but very dif- ferent in nature from croup properly so called. The dyspnoea, the only symptom common to the two affections, is in this transient, spon- taneously subsiding and recurrent; and accompanied with convulsive or spasmodic action of other muscles than those concerned in respira- tion. It attacks children almost .exclusively—and for the most part while teething. The patient's thumb is bent in upon the palm with the fingers closed over it; the toes and instep bent backward, the breath- 165 ing for a time suspended, suffocation seeming imminent; the eyes are open and turned upward; the nostrils dilated ; the limbs and trunk rigid. After a short struggle the attempt at inspiration becomes parti- ally successful, and a series of sharp, sibilant catches precede the in- halation of a full breath, which is attended with a shrill sound, very different from that of true croup, but equally characteristic, described as " crowing" or chuckling. The paroxysm lasts from a few seconds to two or three minutes ; it is sometimes accompanied with general con- vulsions, and has occasionally proved promptly fatal. I had under my care an adult above 50 years of age subject to well marked attacks of this character. Its cause is found, we are told, in exposure to alternations of weather during dentition, and in gastric and intestinal irritation. Autopsy reveals nothing to account for the symptoms. The treatment consists in a careful attention to all obvious or suspect- ed sources of disturbance. The gums should be scarified if swollen ; the bowels kept gently moved by proper cathartics, and anodyne dia- phoretics administered in moderate doses. The application of the ni- trate of silver to the fauces, pharynx and parts adjacent is recommend- ed on the ground that it tends to subdue any morbid irritability of the mucous surface, and the suggestion is reasonable and promising. Change of air is urged by Robertson as the true remedy and prophylactic. Bronchitis—Trachitis.—Inflammation of the mucous membrane which invests the air tubes, the trachea and bronchi, and the cells of the lungs. It is divided into acute and chronic. Acute bronchitis resembles closely, in the first instance, an attack of catarrhal fever, from which it is then only distinguished by a more special prominence of the tokens of local and thoracic irritation and inflammation. Its access is usually with a chill, accompanied by a sense of soreness and stricture in the trachea, and a tickling, dry, and frequent cough ; fever soon follows, with harsh hot skin, flushed face, thirst, pain in the back and limbs. In some cases the dyspnoea is ur- gent, with a distressing tension across the chest, and much pain in coughing. The patient cannot lie down, a crepitous rattle is heard and felt throughout the thorax ; but though oppressed with the accu- mulating mucus, he cannot expectorate. Resonance upon percussion is dull, and the respiratory murmur is impaired very generally over the thorax. If these symptoms be not promptly relieved, he may sink ex- hausted by his struggles ; or the expectoration becomes somewhat freer and fuller, and the disease subsides, or passes into a chronic condition. 166 Post-mortem examination'shows the mucous lining membrane highly injected and thickened, the tubes and air cells being filled with a se- cretion of varied appearance, sometimes a tenacious ropy mucus, again a thick purulent 'fluid, mingled occasionally with a serous, ichorous, or sanious effusion. The substance of the lungs partakes of the results of the inflammation, and its tissue is solidified, or as the phrase is, hepatized, and incapable of collapse. Cause.—Exposures to cold, moisture, and alternations of temperature, are familiarly known to produce bronchitis. It has been excited by inhalation of some of the irritating gases. It is more frequently met with among persons engaged in certain occupations, millers, cotton-ginners, needle-grinders, &c. The prognosis is readily inferred from the degree of dyspnoea, and the apparent ability of the patient to struggle with the impediment to his breathing, and to bring out from the air passages the offending mucus. Free expectoration is therefore favorable, and a hard dry ringing cough the reverse. Very old and infirm persons, and young children, suffer the most serious risks. Treatment.—Venesection is in some cases an indispensable remedy, and must be promptly carried to as great an extent as can be borne without injury. Emetics are serviceable, both as expectorants and diaphoretics, and are peremptorily demanded in the cases of infants and the very aged. They may be repeated from time to time. Ipecac, squill and seneka are preferable ; if these are not sufficiently active, tart, antim. may be added. Cathartics are useful. I select the saline, and com- bine them'with diaphoretics, as the infusion of serpentaria or seneka. Much has been said against the employment of cathartics in thoracic diseases, but these objections are speculative—experience shows them to be, in the early stages, notonly safe, but admirably beneficial. In the advanced periods of such cases they are not required, but the bowels should be kept regular and soluble throughout. Nauseating doses of antimony and other diaphoretics are much extolled. I am not fond of the practice, but prefer to use the same remedies in less amount so as to reduce the undue force of the circulation. When the febrile excitement is in some measure subdued, opium is an invaluable medicine. Dover's powder is a good combination, to ensure its effect as diaphoretic and anodyne. Of topical applications, after cupping I prefer warm poultices, with which I envelope the throat and cover the chest. Leeches imply too much exposure. To relieve the cough, demulcents are required ; mu- cilaginous mixtures with opium form the basis of the most valuable. Spermaceti, formerly so often prescribed, is now too much neglected. 167 In the asthenic bronchitis of the old and infirm—the peripneumonia notha of writers of the last age—stimulating diaphoretics and stimulants are demanded, and must be given freely. Camphor and ammonia are among the best. Opium must be prescribed with some caution. The strength must be supported with wine-whey, wine, &c. We cannot detract blood from such patients, but dry cupping will often be of ser- vice—the mustard poultice should be applied—and here also blisters will be found well adapted. Chronic bronchitis is usually a consequence of the acute form, but may occur as a primary affection, in which case it is developed slowly and insidiously. There is cough, with slight soreness of the trachea and thorax—a sense of stricture and tightness, increased on drawing a deep breath; the voice is somewhat hoarse. The cough becomes more harassing and severe; the expectoration, at first scanty, increases in amount, and changes from mere mucus to muco-purulent consistence, sometimes colored with a little blood. In a few cases hemoptysis may happen, but this is not frequent. Respiration is hurried, and panting attends any muscular exertion, or the ascent of a stair. The pulse is tense and frequent, and a febrile exacerbation shows itself at first in the evening, going on to a full development of hectic, with night sweats, emaciation and great loss of strength, diarrhcea, &c. Autopsy.—The bronchial mucous membrane is high colored and thickened, and occasionally eroded with ulcers. The lungs are found hepatized or solidified—the air-cells and tubes filled with muco.puru- lent matter, mingled with a frothy and bloody serum. Prognosis.—The unfavorable indications are chiefly drawn from the degree of dyspnoea in the early stages, and at a late period from the atrophy and emaciation which waste the patient. An extreme frequency of pulse is unfavorable—so is the absence of the respiratory murmur in a considerable portion of the lungs, with a loss of the proper degree of resonance on percussion. Diagnosis.—The distinction between chronic bronchitis and tuber- cular phthisis is often difficult. In the latter there is less crepitus or ride—less soreness of the trachea and thorax—more tendency generally to hemoptysis, and less expectoration in the early stages. In their latter progress we can draw no line between them, except from their previous history. Treatment.—-The lancet is sometimes required, but must be employed with caution. We derive most advantage from small bleedings re- peated. Leeches may be applied to the throat, and cups to the chest, with benefit. Even after we can no longer detract blood, dry cupping the thorax is useful, as revulsive. Emetics are much confided in, and 168 great stress laid on preference due to particular articles. Ipecac is generally chosen—some combine it with tart, antimon. and others with the sulph. cupri. The utility of emetics is unquestionable; they are expectorant, diaphoretic, and in most instances move the bowels suffi. ciently. To soothe pulmonary irritation and keep up a constant determi- nation to the skin, we may exhibit a combination of the nitrat. potass. with Dover's powder, allowing a full dose of anodyne nightly at bed- time. A choice of the numerous preparations from opium may be made to suit each particular case. I do not think any other of the narcotics, as the lactucarium, byoscyamus, &c, entitled to our confi- dence. The digitalis may do service when the pulse is particularly frequent. Squill is highly prized by some as an expectorant. The infusions of serpentaria and seneka, afford good bases for the mucilaginous, demulcent and anodyne solutions, administered to relieve the troublesome cough. In threatening cases, I would advise an alter- ative mercurial course. Calomel in small doses, or the blue pill, may be so given as to produce highly beneficial results, while it should not interfere with the proper employment of such other remedies as may be demanded. Inhalation of various airs and gases has been proposed; but after a fair trial, I have abandoned them. The vapor of ether, in which conium has been macerated, that of burning tar and of resin, iodine and chlorine, have been extolled. The several balsamics were formerly much in vogue. Myrrh, tolu, and copaiba, are the best of them. "Pine-gum pills" and "lightwood rum," are common domestic prescriptions in the south and southwestern states. Naphtha is advised. Codliver oil is in growing repute. Tonics may be made of great benefit, by a proper selection of the period for their exhibition, and the cases to which they are adapted. I would use them when the tokens of muscular debility and general relaxation were more prominent than those of local irritation or febrile excitement. The infusion of cinchona with mucilage, is lauded by Broussais and Hastings. The elixir vitriol and tinct. mur. ferri, are also useful. They aid in restraining nocturnal sweats. The persevering application of counter-irritants to the chest and arms, will be of great advantage. I prefer to blister successively one and another portion of the surface. The tartar emetic is a favorite irritant with many physicians, while others still prefer setons and caustic issues. The convalescent must take as much exercise in the open air as he can undergo, without fatigue. A long journey or a sea voyage should be advised, and an equable climate chosen. Flannel should be worn next to the skin, and all undue exposure avoided. 169 Pleuritis.—Inflammation of the serous investing membrane of the lungs. Pleurisy is a common and well known disease, usually met with in winter and spring, and frequent in occurrence in proportion to the abruptness of the changes of the weather in these unsettled sea- sons. It comes on with sharp pain in the thorax, at the side and most often perhaps on the right side ; the pain is fixed and circumscribed, constant but increased by a full inspiration ; the breathing is short and restrained, and the patient assumes a bent posture, leaning to the af- fected side. Fever soon supervenes, with quick, frequent, hard and full pulse ; the skin is hot and dry, and a cough comes on aggrava- ting intolerably the keen lancinating pain. If not soon relieved, the dyspnoea increases and the symptoms of pulmonic inflammation are added and become prominent; or the case is protracted into a chronic stage in which the results of the inflam- mation of the pleura vary somewhat. Effusion takes place within the cavity of this membrane, which exhibits itself by continuance of dysp- noea after the earlier acute symptoms have subsided ; it is aggravated into orthopnoea more annoying when the patient sleeps, and during the night. The affected side becomes fuller to the eye and does not fol- low the ordinary movements of respiration ; there is not only a total absence of resonance on percussion and respiratory murmur, but the heart itself is sometimes displaced by the accumulated fluid, if on the left side, and pressed over to the sternum and upwards; and all the phenomena detailed in the description of hydrothorax supervene. The causes of pleurisy are already pointed out; exposure to cold and moisture and sudden changes of temperature. External violence too may give rise to it; puncture by the spiculce of a fractured rib has occasioned it, and a fatal case is on record where the pleura was wounded by a needle employed in passing a ligature round the sub- clavian artery. The diagnosis of pleurisy is not difficult. The pain in the side is attended at first, if the case be uncomplicated, with little impairment of resonance on percussion ; the respiratory murmur is only deficient because the patient does not inspire freely. After a short time, the " frottement" sound is heard, produced by the rubbing together of the opposite surfaces of the pleura, roughened somewhat by the exudation of plastic lymph or fibrinous shreds. The case still advancing, effu- sion of serum gives a brief aegophony ; this is followed by great dull- ness of resonance, varying somewhat with the posture of the patient, and corresponding loss of respiratory murmur, owing to the still in- creasing amount of fluid only, if the case continue a simple one. But in fact it is apt to complicate itself into pleuropneumonia, the 22 170 superficial inflammation extending to the tissues beneath, where we shall have of necessity the symptoms of pneumonia vera added to those above enumerated. Prognosis.—In general, pleurisy may be regarded as a manageable disease, attended with little danger, if the patient is seen early. In the first stage the danger or risk may be inferred from the extent of the inflamed surface, the violence of access, the severity of the con- stitutional excitement supervening, and the apparent ability of the pa- tient to bear the requisite remedial measures. As the case progresses, the increase of dyspnoea into orthopnoea is unfavorable. By explora- tion of the thorax we derive minute information of the condition of the subject. All tokens of effusion are of course to be dreaded. Autopsy.—The most common result of inflammation of the pleura, often indeed observed in bodies dead of other forms of disease, is the adhesion of the opposite surfaces of the pleural sac or their connection by layers or strips of organized membrane. Effusion of pus, empy- ema, is occasionally met with ; that of serum is far more frequent. Treatment.—The lancet used promptly and boldly at the outset of the disease will often put an end to it at once. It is to be resorted to at all stages while the breathing is sharply painful and difficult, un- less the pulse is feeble, and the strength of the patient obviously fail- ing. Topical depletion by cups, which should be applied on and near the seat of pain, is next proper; after which large warm poultices should be assiduously laid about the side. A full and free dose of an ano- dyne diaphoretic will now complete the relief of the patient, who sleeps soundly, breathes quietly, and wakes restored to comfort. Dover's powder is perhaps preferable here to any other formula. If the attack be protracted, cathartics will be found useful, and the drastic and somewhat irritating should be chosen as most revulsive. No prejudices have less foundation than those which oppose the employment of purgatives in thoracic inflammation. They are adapted however, only to the early stages of febrile character in young and robust sub- jects. It is advantageous to combine them with an antimonial or other diaphoretic, as in the common formula of nitrat. potass., pulv. jalap et tart, antimon. I have seen little or no benefit from the exhibition of emetics so highly recommended by some practitioners. Among the vegetable diaphoretics, the infusions of seneka, and serpentaria, and of the asclepias decumbens (vulgarly called " pleurisy root") are de- servedly extolled. The combination of ipecac with opium in the pulv. doveri is an invaluable remedy ; a full dose of it, 12 to 20 grains, should be given nightly, and it may be usefully added at regular intervals to 171 such other medicines as are prescribed during the day. Demulcent drinks, rendered more efficient, by the addition of tinct. op. camph., tinct. tolut. and nitrous or chloric ether, may betaken to palliate cough. Epispastics should be applied over the affected part of the chest, if any pain should continue after the febrile excitement has been subdued and the pulse has lost somewhat of its force and tension. This abate- ment of inflammatory irritation constitutes the " blistering point" of English writers. Empyema or hydropleura may demand the opera- tion of paracentesis, to relieve the patient of the otherwise fatal accu- mulation of serum or pus. Bilious pleurisy.—In all low miasmatic regions, the thoracic affec- tions of spring and early winter are apt to be combined with and modi- fied by notable symptoms of gastric and hepatic disorder. This com- plication, known familiarly by the title just given, 1 am disposed to at- tribute to the persistent effect of malaria upon constitutions imbued with that poison ; an English writer of some authority speaks of it as owing to an undefined atmospheric and epidemic influence still present and acting. In this form of the disease, which is by no means rare in the south- ern country, less vigorous depletion by the lancet is required or admit- ted of, than in simple pleurisy. Emetics are more beneficial ; ca- thartics indispensable, and mercurials more applicable. The sulph. quinine is used with advantage, after the very first stage has passed. Vesicatories are well adapted and may be applied early. Convalescence requires great care and prudence. The clothing should be warm, and all exposure avoided. Pneumonia—Pulmonitis.—Inflammation of the lung proper—its parenchymatous and cellular tissue. This is among the most frequent of the diseases of our continent—the most common outlet perhaps of life. It is oftenest met with in winter and spring, but occurs in all seasons of the year. It attacks all ages—the infancy, maturity and decline of life. It seems to be the direct effect of exposure to cold and moisture. Symptoms.—Pneumonia comes on often with a chill, which soon ushers in the hot stage of fever, accompanied with dyspnoea, and un- easiness and oppression of some part of the chest, a pain rather obtuse than keen, increased by inspiration. The face is flushed, the pulse full and hard. Cough soon attends, at first dry, hacking and distress- ing ; a little mucus is next brought up, tinged with streaks of blood, then colored brown like iron-rust, then of a deeper hue, resembling to. 172 bacco or even prune juice. As the case progresses this is mingled with or substituted by a creamy or frothy matter, mucopurulent, or seropurulent; and in the worst instances grows thin, serosanguinolent, dark, and highly offensive. There is orthopnoea—panting; the pulse becomes small and weak and extremely frequent; the skin cold and clammy ; the countenance livid and shrunken ; the lips and tongue bluish or purple ; there is low muttering delirium ; cough and expec- toration cease, and death soon follows. Physical signs.—From the first there is impairment of respiratory murmur and loss of the resonance at the part affected. The lower lobe of the right lung is most frequently the seat of inflammation— next the lower lobe of the left. The upper lobes are not often at- tacked—the middle more commonly. The crepitous rale is heard at the spot in the early stage, but soon disappears, replaced by loud mu- cous rattle when the expectoration becomes free. When the lung be- comes impervious and solidified, there is no respiratory murmur, little or no rale ; bronchophony is heard, and much vibration felt when the patient speaks. Diagnosis.—We distinguish it from pleurisy by the early dullness and loss of murmur—by the absence of frottement sound and aegoph- ony—and by the fact that as the disease advances the dullness is never or very rarely so complete in the worst cases as it is in effusion ; and that it does not shift its place with the changing posture of the patient: from bronchitis, with which it soon complicates itself, by the rust colored and prune juice sputa and the signs of hepatization. Exploration of the chest should be carefully attended to in young chil- dren, in whom inflammation of the lung is as obscure as frequent. Prognosis.—In young and previously healthy subjects—ifthepneu- monia be single, limited to small space, at the base of the lung—if expectoration be early and free—favorable. In advanced age and in- fancy on the other hand—if a large portion of the lung be inflamed— still more if the pneumonia be double or of both sides—if dyspnoea be specially great—if the expectoration be difficult, very thin, serous, frothy, fetid, or stop suddenly—it is unfavorable. The return of crep- itous rale and of resonance and murmur when they have been lost, betoken improvement. So does a florid change in the lip and cheek. Autopsy.—The changes shown in the diseased lung vary relatively to time and other circumstances. Earliest we find sanguineous con- gestion, and infiltration of blood into the pulmonary tissue—" spleni- zation ;" then hepatization, the organ losing its light cellular texture, becoming solidified and granulated and of a livid brownish color; it f 173 shows, still later, purulent infiltration and collections of pus; it is sometimes found gangrenous and disintegrated. Treatment.—Venesection is a general remedy, whose importance is not sufficiently admitted by Louis, and understated even by Prof. Bart- lett in his elegant essay on " the Certainty of Medicine." In the early stages of pneumonia it is rarely, very rarely, justifiable to omit it. The detraction of blood, always cupped and buffy and fibrinous, should be free and efficient, carried to the relief of the breathing or the reduc- tion of the pulse ; when the relief given by it is not permanent, should be promptly repeated, unless in some manner definitely contra-indicated, as by general debility or failure of circulation. Topical depletion by cups or leeches may precede the application of large warm poultices about the chest or to the side. A saline cathartic combined with some diaphoretic, as the infus. R. senek. or serpentariae with sal epsom, should next be administered ; or if it be night the patient may be put to bed and a full dose of pulv. doveri, grs. 15, prescribed with mere. dulc. grs. 10, which will prove anodyne, diaphoretic, and purgative successively. Great confidence is placed by many in the contra-stimulant exhibition of tartarized antimony carried as far as tolerance of it can be estab- lished ; this is aided by combining with it small doses of tinct. opii, a very efficient formula. Or we may substitute with excellent effect a strong infusion of rad. senek. with large proportion of (3jto 3yj) pulv. ipecacuanha. Others prefer to continue the mercurial in small doses with nitrat. potass, and pulv. doveri. All these determine to the surface and bowels, and act on the blood by diminishing probably its plasticity and hyper-fibrination. A few press the mercurial to the point of light ptyalism, but this is rarely necessary. Contra-irritation by blistering is of great service at the proper period, when the first stage of active excitement has passed by. If the strength of the patient give way, he must be assiduously sus- tained by stimulants and tonics. Carb. ammonice, camphor and cin- chona in infusion and tincture are the best of these; while wine whey, wine, and milk punch are allowed in quantities carefully adapted to the circumstances of the case. The cough must be palliated by mucilages and demulcent drinks. Of these there is a great variety ; all of them being rendered more efficient by the addition of the tinct. opii camph. and other anodyne for- mula, with tinct. tolutan., tinct. sanguinarioe, benzoin, &c. Chronic Pneumonia—Apostematous Phthisis.—Dr. Duncan di- vided consumption into three kinds. 1. Catarrhal consumption, iden- • 174 tical with chronic bronchitis already treated of. 2. Apostematous consumption, our present subject; and 3. Tubercular consumption, which shall be considered next in order. Chronic pneumonia, with abscess, is not so rare a disease as it is re- presented to be by Laennec and some others. It is foremost among the sequelae of pleuro-pneumonia, and may perhaps follow catarrhal fever and bronchitis. I have seen it twice occur from gun-shot wound of the lung; in one case it was fatal, the other recovered after long protracted illness. Wounds of the lungs, however, often heal kindly. It may supervene upon asthma, and results from tenacious gastric and hepatic derangements, constituting the dyspeptic phthisis of W. Philip. Hemoptysis is said to produce it, but is in general only a coincident effect from the same cause. Some of the exanthemata, as measles and small pox, render the patient exceedingly liable to it. It has been brought on by the suppression of itch and other cutaneous eruptions. An obvious predisposition is supposed to be found in a flat or nar- row or otherwise ill-constructed thorax. Sedentary occupations, which exclude from fresh air and free exercise, predispose to it; so do all such trades as subject the respiratory organs to mechanical irritation, as with millers, needle-grinders, cotton-ginners, and coalmen. The formation of pulmonary abscess is attended by a fixed heavy pain in the thorax, pulsatory, or at intervals sharp and lancinating. There is dyspnoea which does not admit of muscular exertion, and is increased also on lying down, especially if the patient attempts to rest on the sound side ; but this rule is not without exceptions. The cough is severe, but at first without expectoration. The abscess sometimes empties itself through small openings and gradually, but in general bursts and discharges its contents freely and suddenly, pus being coughed up in quantities, varying from ounces to pounds. There is great relief at the time, and the expectoration continues abundant for a while after, consisting of pus mixed with mucus and sanious serum. Recovery sometimes happens at once from this state, but more com- monly hectic supervenes, in place of the inflammatory type of fever which had attended the formation of the abscess; there is great ema- ciation and muscular debility, the voice is weak and hoarse, and colli. quative sweats and diarrhoea terminate the tedious train of suffering. The pulse is at first tense and quick, and in some cases full; after the abscess is matured, it becomes very frequent and more contracted. The digestive system in many instances remains unimpaired until the last stages, diarrhcea then coming on, with redness and ulceration of the lips, cheeks, gums and tongue. The prognosis is unfavorable, holding perhaps a middle rank be- 175 tween bronchitis and tubercular phthisis. When a case occurs in a person of well-formed chest, previously healthy, and from a transient and notable cause, there is good hope of restoration. The worst symptoms are great emaciation and debility. By careful exploration of the chest, we can ascertain the extent of the pulmonary disorganization, to which the danger is pretty regularly proportioned. The duration of apostematous consumption is very various, from a few weeks to many months. Autopsy.—Laennec and Andral declare it to be quite uncommon to find pus in a circumscribed cavity in the lung in this form of pulmo- nary disease, the frequent mention of abscesses by other pathologists being attributed to their having mistaken tubercular vomicae (to be here- after spoken of) for abscesses. They describe purulent infiltration as supervening upon hepatization, the color being changed from red to gray and the matter being diffused through the lungs, the texture of which is broken down and softened. There is, however, good proof that encysted or circumscribed abscess does occur. A large one is described by Laennec himself. Nor can we otherwise account for the fact of large and sudden evacuation of pus, after pulmonic inflamma- tion, cough, &c, have existed for some time. Such cavities are lined by a false membrane, or layer of organized fibrine. Diagnosis.—Apostematous phthisis is attended with more pain and dyspnoea than chronic bronchitis or tubercular phthisis, and with less expectoration than the former, for some time from the commencement. If a considerable amount of purulent matter be suddenly discharged, we infer that it must have collected in an abscess. The physical signs of this state of the lungs are, the lessening of the capacity of the thorax, the dull sound upon percussion over the pained part, and the loss of respiratory murmur there, and after the abscess is empty, pecto- riloquy. Treatment.—While pain urges, and until the failure of pulse and strength absolutely prohibit, venesection to small amount should be repeated occasionally. Cupping the affected side of the chest, at first with, and then without the scarificator, will be of much service. Large warm poultices are also useful. Blisters applied in long suc- cession are among our best remedies. When in any way unsuited, the ung. ex tart, antimon. may be substituted. Emetics have been much employed by different physicians, and with very different views. Some suppose them specially adapted to procure resolution and absorption of any deposit; others use them persevering. ly as the most efficient revulsive. Some prefer ipecac alone; others prescribe it in combination with the sulphates of zinc and of copper. 176 The antimonials have been highly eulogized, by some as the best emetics, by others, for the property of reducing the pulse and exciting protracted nausea ; while Laennec and many continental physicians look upon the tart, antimon. as gifted with a specific remedial influence, and give it in large and increasing doses as a contra-stimulant. These consider it as most beneficial when alone and uncombined. In this coun- try, it is often exhibited in combination with nitrat. potass., to reduce vascular excitement and determine to the surface, or with the infusion of seneka and serpentaria. With similar views and as exerting a tran- quilizing influence of great advantage, I employ the Dover's powder, both before and after purulent expectoration has appeared. Mercury, in small doses, is occasionally administered with much benefit; but it is not adapted to all cases, nor should it be carried to the extent of an irritating ptyalism. In the first stages, it is useful in moving the bowels gently, and subduing any gastric or hepatic disorder that may be present. Digitalis has been the subject of extravagant eulogy; but I do not consider its remedial influence as well marked or striking. It is best adapted to cases where great frequency of pulse exists, and the tokens of inflammatory excitement are not particularly high. The prussic acid has been in like manner extolled, and some authentic reports made in its favor; but it has not retained the confidence of the profes- sion. After the abscess has been ruptured, as will be known by the sputa and pectoriloquy, if the expectoration be free and without pain, we may derive advantage from the infusion of cinchona, with which mucilages and anodynes may be united. The mineral acids are also serviceable as tonics here. On the other hand, if there still remain tension across the chest, with a harsh cough, it may be necessary to take blood from the arm, and apply the cups and poultices or vesicato- ries, and even to administer an emetic, which will often give great re- lief. If diarrhcea should come on, it must be restrained by the acet. plumbi, kino, or such other astringent as is best adapted ; while we in- dulge the patient with free doses of opium, which will aid in checking the alvine disturbance, while it subdues, in an unequalled degree, the pulmonary irritation and cough. Among the numerous formulae pre- pared by modern chemists from its constituent principles, some one will surely be found without objection. The other anodynes may be used —thridace, lupuline, hyoscyamus, conium—but I have little confidence in any of them. With a view to promote the healing of the abscess or ulcer, inhalations of gases and even of finely pulverized bark, and other remedies, have been advised. Iodine has been tried, chlorine, the vapor of tar, of resin—several of the gases less stimulating than common air, 177 as mixtures of hydrogen, nitrogen, carbonic oxide, &c. The balsamics are also in ancient repute for the same purposes. If any good be done by such prescriptions, it must be in an indirect way. Our best hope is in keeping the constitution at its highest point of tone and vigor. As soon as the patient can bear it, exercise in the open air must be ad- vised. He should take a journey or sea voyage. Flannel should be worn next to the skin, and a diet chosen for him, nourishing but un- stimulating. Tubercular Phthisis.—This insidious and fatal form of pulmonary inflammation derives its name, as well as its other characteristic pecu- liarities, from the presence of tubercles in the lungs. It is therefore proper here to enter into the consideration of their nature and origin. Tubercle is variously described by authors. In the condition most commonly met with, it is a pale yellow or yellowish gray, opaque, in- organic substance, somewhat resembling cheese in appearance, soft and friable. Carswell regards the mucous and serous surfaces and the blood " as the exclusive seats of tuberculous matter"—it is principally found deposited in the first of these positions. It is composed of albu- men, gelatine and fibrine, with a very small proportion of muriate of soda, and phosphate and carbonate of lime. The majority of patho- logists suppose it to be deposited in this solid form—Cruvelhier asserts it to be at first fluid. Laennec contends that a tubercle grows by in- tussusception, but the opinion of Andral prevails, that it increases by the successive deposite of molecules around the primary granule. When deposited, "each granule," says Morton, " retains its appropriate tunic of cellular tissue." The deposition may go on until the mass shall occupy an entire lobe of the lung. The softening of a tubercle is not well explained. Laennec and others contend that it always commences in the centre—a view hardly consistent with the acknowledged inorga- nic state of the mass. It seems more probable that it results from in- flammation of the interstitial cellular tunic above spoken of, upon whose surfaces pus is effused, mingles with and macerates the tuber- culous matter. Tubercles are not constant in their form. They are often rounded and contained in a sort of circumscribed cavity, in a cyst, the inner surface of which secretes purulent fluid. But tubercle, it is well known, is not confined to the lung ; it is met with in many and various locations, and is so often connected with the other phenomena of strumous disorder, that it is by many supposed to be exclusively the product of scrofulous constitutions. Whether this be absolutely true or not, it is certain that scrofula constitutes an obvious 23 178 and strong predisposition to the formation of tubercle, and that tuber- cular phthisis is hereditary and of lamentably common occurrence in strumous families. It is a question of great importance, whether tubercle is ever the result of common inflammation, in a constitution previously sound. The opinion that it can be thus developed, is held by Andral and others ; but I am inclined to think, that inflammation is only to be regarded as the exciting cause of the series of symptoms which constitute phthisis. The deposition of tubercle I believe to be independent of, and often unattended by, inflammation in any form or degree. When this depo- sition has taken place, it may go on, and by its bulk excite inflamma- tion round it, and thus develope phthisis ; or it may remain an inert body and indolent, until inflammation of the surrounding parts shall be excited by some extraneous cause, when its interstitial cellular invest- ment shall secrete pus, and by this process soften the tubercular mass —pleuritis, pneumonia, and bronchitis being thus converted into tuber- cular phthisis. Phthisis, by a large proportion of writers of a past age, and in many countries now, was and is considered as communicable or contagious; and within my own observation so many circumstances have occurred which seem to confirm the doctrine, that with Cullen, " I dare not assert that consumption is not contagious." Symptoms.—The access of this fatal malady is often extremely gra- dual and obscure. The patient is scarcely disposed to complain, though harassed by a dry hacking cough, with occasional pain in the chest, heavy and deep seated. There is languor and debility, and after a time notable emaciation, though the appetite is unimpaired and the digestion good. Hemoptysis will now and then follow a fit of coughing, though the hemorrhage is not apt to be very large. As the case progresses, the respiration becomes hurried, with frequent pulse ; on ascending a stair, the patient pants and his countenance is pale or livid ; he cannot lie down at night without uneasiness, or is confined to one side or to his back; there is oppression or tension of the thorax, with a disposition to stoop or lean forward ; hectic ensues, with its long train of derangement and suffering, colliquative sweats and diarrhcea, the tongue and mouth being covered with aphthous ulcers, though the inclination for sapid food may hold out to the last; and the patient ultimately sinks, after an indefinite protraction of his tedious disease, into absolute atrophy or marasmus. Prognosis very unfavorable—recovery scarcely to be hoped for. It can hardly be possible that a single tubercle, or even one mass of tuber- cles, exists alone—if so, there might be a softening and expectoration of 179 them, and the patient would be in a state described under the head of apostematous phthisis, after the rupture of the abscess. It might heal. But the formation of tubercle in the lung is generally a mere portion of the universal diathesis or constitutional derangement, and similar de- position goes on or is repeated from time to time. It is consoling, how- ever, to know that in many instances, an indefinite protraction of life is attainable by judicious and proper management. Diagnosis.—The unfavorable prognosis which a melancholy ex- perience enforces from us, requires from us great care in distinguish- ing this, from more hopeful forms of disease. The pathognomonic signs are not very clear. The slowly progressive gradual increase of the symptoms will attract our notice. We will inquire if the patient be of strumous family, or have exhibited in early life any scrofulous development; or if his parents or ancestry have died of consumption. His expectoration will not be abundant, or mixed with much mucus from the first, as in bronchitis; nor suddenly augmented, with pus, as in the bursting of a vomica. The pain will not be at any time as acute, in any part, as it is from the commencement of pleuro-pneumo- nia, although it will in its progress be actually complicated with this affection ; nor will there ever be so general a soreness of the respira- tory tubes, as in the former. There is in these cases too, a tenacious cheerfulness and resolution, and hope of recovery, proverbially noticeable. It lasts until the im- pairment of the digestive function, which is often delayed to the very latest moment of life. The physical signs are rather negative than positive in the first stages ; the absence of respiratory murmur may be remarked in more than one spot of the thorax, and after a time pec- toriloquy will be distinctly observable. We should be aware that tubercular phthisis may go on to a fatal termination without pain in the thorax, or dyspnoea in notable degree, or cough. I once saw a patient die, the nature of whose case (from the absence of these symptoms) was not detected, the right lobe of whose lung was found, after death, a mere mass of tuberculous matter. I attended, in the last weeks of his life, an eminent literary gentleman whose physicians had treated him for chronic hepatitis and diarrhcea. He was surprised at learning that his lungs were at all diseased, as he had labored under no difficulty of respiration, and almost no cough, but desired that his body should be examined. In complying with his request I found his liver little, if at all affected, and his lungs full of tubercles. The relations of phthisis with other diseases should be noticed here. Its connection with other and more obvious forms of scrofula has been mentioned. Children who have been specially subject to epistaxis, are 180 apt to fall into phthisis after puberty. Hemoptysis is also a coincident effect of the same malformation and defect of organization which pre- disposes to phthisis. Fistula in ano is very often observed in subjects predisposed to phthisis, and even after phthisis has commenced ; in this case it may sus- pend or protract the progress of the latter indefinitely. There is said by authors to be a similar connection or alternation between mania and phthisis, but I have had no occasion to remark any thing of the kind. Intermittent fever has also been supposed to exert a suspensive or pro. tracting power over phthisis. I doubt this—nay, I have seen our ordi- nary malaria fevers repeatedly develope phthisis, and excite it in sub- jects predisposed. It is well known that the condition of pregnancy will almost invariably suspend, even in its advanced stages, the further progress of phthisis, and that the feeblest patient will almost certainly live until she is delivered. Lactation does not, however, continue the privilege, and such a patient will sink sooner if. permitted to nurse her child. Treatment.—The elements of the disease are, 1. A vice of nutrition, whence the morbid deposite: 2. The local pulmonic inflammation occa- sioned thereby : and 3. The constitutional or sympathetic results, hectic atrophy, &c. For the first, a remedy has been hitherto sought in vain. We scarce- ly know its existence until the second has been added in greater or less degree, which then we set ourselves earnestly to palliate or arrest. The means for effecting this are such as have been already dwelt on, V. S., antimonials, digitalis, opiates, &c. These antiphlogistic and depletory measures must however be cau- tiously carried out, on account of the chronic and persistent nature of the diseased condition, as well as the imperfect capacity of the consti- tution to bear them. Meanwhile we must endeavor to correct the morbid element upon which depends the whole train of symptoms. To improve the nutri- tive function, naphtha and codliver oil have of late been much employ- ed ; and some high authorities offer strong testimony in their favor. Prussic acid is supposed to do service in a similar way. The alco- holic lotion of Marshall Hall, when efficacious, must act in the same manner. To remove the mechanical irritation of the inorganic deposite of the pulmonary tissue is a difficult matter. Emetics have been alleged to promote its absorption directly. From the analogy of its usefulness in other forms of scrofula with tuberculous deposite, iodine is the subject still of hopeful experi- 181 ment. I have been pleased with the apparent benefit derived in some well marked cases from the use of the deutiodide of mercury and potassium. In no disease can the general subject of prophylaxis be of greater consequence. Children of scrofulous or consumptive parents, or who have suffered much from epistaxis, or who exhibit notable malforma- tion of the thorax, should select for their future occupation through life, such employments or situations as shall admit of, or require, the full development of muscular power, by active exercise in the fresh air. Phthisis can neither be prevented nor cured, nor even long protracted, otherwise than by exercise constantly and habitually taken under the open sky. Asthma.—Defined to be a species of dyspnoea, paroxysmal, sponta- neously remitting and recurrent. Divided by writers generally into two forms—the dry, nervous or spasmodic, and humid or humoral asthma—the distinction referring to the presence or absence of mucous rale and expectoration. A paroxysm of asthma usually comes on at night—is often preceded by flatulence, a loose griping stool, heartburn and other symptoms of indigestion. The patient awakes from his first sleep with a sense of uneasiness and constriction of the chest, difficulty of breathing and cough. He is forced to sit up, nor can he bear the weight or pressure of any clothing or fastenings about his neck or body. Respiration is effected with wheezing and panting, and great muscular effort. At first the cough is dry, but after a time a frothy mucus is brought up, occasionally tinged with blood—this is attended with relief. In the worst cases there is neither cough nor expectoration. These symptoms, depending on the affection of the respiratory organs, are uniform; those which arise from the sympathetic disturbance of the general functions, vary with the condition of the patient. In the robust and plethoric, and in recent cases, the pulse is full, hard and frequent— the countenance flushed and turgid—the eyes suffused and prominent, with much tension and pain of the chest. On the other hand, when the disease has become habitual, and the patient is feeble, the face is pale or livid, the surface cold and moist, the pulse small and weak, and the tokens of gastric derangement more marked and prom:nmt. The duration of a paroxysm is uncertain ; it remits usually at the ap- proach of morning, the dyspnoea continuing, however, in some degree, through the day, with more or less cough, and the exacerbation again 182 recurring at night; these changes go on for a few days before the en- tire subsidence of the attack ; it has endured for weeks. The general prognosis is favorable as regards the danger of a fatal issue—few die; it is unfavorable as regards the hope of a cure— few recover. Besides the impairment of the constitution universally, which must follow the repetition of paroxysms of asthma, it sometimes developes hydrothorax, chronic bronchitis, and phthisis pulmonalis. Autopsy.—Asthma is found accidentally connected with a great many lesions of the viscera of the thorax, but is clearly proved to be essentially independent of any of them. The most frequent organic change in the asthmatic, is emphysema of the lung ; the cells being found distended, several of them dilated into one cavity, and incapable of collapse. Even this, however, is far from being constant; and numerous cases are recorded, in which there was no notable deviation from the natural state of the lung. The pathology of asthma is doubtful and obscure. The difficulty of breathing is twofold, and urges both during expiration and inspiration. It is hence plausibly suggested, either that the muscular fibres of the bronchi are everywhere rigid, refusing both to contract and to dilate; or, that in some portions of the air tubes, these fibres are spasmodic- ally contracted, resisting both the entrance and exit of air. It is not unfrequently combined with inflammation and organic lesion, as in bronchitis and emphysema ; but the complication is merely a coinci- dence. It may exist fatally without a trace of either. Causes.—A predisposition is obviously derived from vicious con- formation of the thorax, or of some of the organs contained in it, either accidental or hereditary. A first attack generates a strong ten- dency to recurrence. Paroxysms are excited by exposures to change of temperature, or to cold and moisture, to the bad air of crowded apartments, to certain of the gases, and to some odors. They come on after full meals, late suppers especially, violent muscular exertion, loud singing and speaking, and supervene on repelled eruptions. It seldom appears early in life ; I have, however, seen a well marked case in childhood. Treatment.—During the paroxysm, it may be necessary to employ the lancet, if the pulse be full and hard, and the patient robust. It is especially called for in the early stages of cases which present marks of thoracic engorgement or inflammation. Cupping the chest is also a useful measure, under these circumstances. But we must be cautious not to detract blood in the opposite conditions, when the patient is fee- ble and the asthma habitual. Emetics are highly beneficial in many cases ; given at the beginning of the attack, they often cut it short, 183 and if this fail, may be repeated after a time ; they are among our best expectorants, and are indispensably necessary when the patient \ has indulged in a full meal just before going to bed. It is well, too, to have the bowels opened by a purgative enema. Many of the nar- cotics enjoy great repute for the relief of asthmatic dyspnoea. To- bacco, stramonium, lobelia inflata, the spider's web, coffee and opium, have their eulogists. I prefer the last mentioned, and in combination with camphor, ether, or ipecac have seen it of immediate and striking advantage. Inhalations of various gases have been tried, but with no very obvious good results. I am inclined to hope for benefit from the inhalation of ether, chloroform and other anesthetics. They are re- laxant and subdue irritation. Galvanism deserves general employ- ment and confidence. My experiments with it have been successful and gratifying. In the prophylactic management of the asthmatic, we must depend more upon regimen than medicine. If any disorder of the digestive system, or any chronic pulmonary disease exist, we must endeavor to remove it. Casey describes the influence of iodide of potassium as highly beneficial in asthma, having exhibited it successfully in a large number of cases. Its use as a preventive here is altogether empirical, however. We must aim to restore the patient to full and perfect vigor of constitution, by air and exercise. We must attend to the place of his abode, for there are particular localities in which asth- matics suffer much, though in regard to the situation best fitted for each, no general rule can be laid down. The matter must, therefore, be decided by experience. Pertussis—Tussis Convulsivus—Bex convulsiva, Kink-cough, Chin- cough, Hooping cough.—These are all significant appellations for the well known disease now to be spoken of. It is one of the specific contagions, often becomes epidemic, does not attack usually more than once the same individual, although this rule is liable to exceptions. Hence it is most frequently met with in young children. It invades for the most part as a common cold or mild catarrhal fever. After a certain duration the paroxysms of coughing become more and more violent, and protracted and convulsive. Rapid and repeated expira- tions are made with vehemence, and then a sonorous inspiration, whence the common name, hooping cough. These paroxysms termi- nate with large expectoration or vomiting. The intervals between them are shorter or longer, and more or less perfect and free from un- easiness, in proportion to the violence of the attack. There is gener- 184 ally a considerable secretion of mucus in the air passages, with a loud rale. Pulmonary inflammation sometimes arises, with fever and great dyspnoea. In other cases there is notable and prominent disorder of the digestive system, with diarrhcea, &c. Not unfrequently, too, there is much determination to the head, with convulsions. The causes which occasion or render more violent a paroxysm, are a full or indigestible meal, any forcible muscular exertion, mental emotion, exposure to cold and moisture, &c. The average duration of hooping cough may be calculated at from six to eight weeks; it may be prolonged indefinitely by a renewal of catarrhal affections, with which it readily associates itself. It is said also to assume some- times a periodical character, which gives it a tedious protraction. Prognosis generally favorable. The greatest proportion of deaths happens among very young infants, who may die suffocated by en- gorgement of the air cells and tubes with mucus that they are unable to expectorate, and children who are teething—a complication which often gives rise to convulsions. The supervention of any of the more ordinary forms of pulmonic inflammation, is attended with danger ; the diar- rhcea, which is sometimes present, may become unnlanageable and fatal. Autopsy.—The traces found in post-mortem examinations of this disease, are not regular or uniform. It sometimes happens that no lesions or morbid changes can be pointed out. Most generally, how- ever, the bronchial mucous membrane is irregularly reddened and in- jected in patches ; while, at the same time, there are marks of deter- mination to the head and engorgement of the brain. The pathology of hooping cough is not clearly made out. Many de- ny the existence of inflammation as an essential condition ; the major- ity, however, believe it to be an inflammatory affection of the bron- chial membrane. Some very respectable authorities refer all the phenomena to cerebral and nervous disorder. Others still regard both cerebral and pulmonary inflammation as necessarily present, and in some manner connected. Desruelles calls it a " broncho-cephalite." It cannot be a simple bronchitis, as we infer from the spasmodic or convulsive character of the cough which attends, and the peculiar manner of coughing. Watt considers it a pulmonary exanthem. Treatment.—It is made a question whether we have the power to cure an attack of this singular malady ; and while some, denying this power, use their efforts merely to palliate the symptoms, others are engaged in the search after specific remedies, of which a large num. ber is already accumulated. I would advise, as the great majority of cases are in the first instance attended with pulmonary disorder and in- flammation, that they be treated as catarrhal fever or acute bronchitis, 185 by general and local bloodletting, if severe ; by emetics, purgatives and expectorants. The sulph. zinc has been supposed to deserve a special preference among emetics, and of the expectorants, squill and ipecac. The narcotics and antispasmodics are much used when the first stage has passed. I am much in the habit of combining with the campho-, rated tinct. opii, the tinct. mosch. fact., which I add to a solution of the carb. potassae. The warm bath should be employed at night, and counter-irritation by mustard poultices frequently resorted to. Assa- fcetida is much extolled among the antispasmodics. Prussic acid is supposed by some to be almost antidotal ; and in the same way the acet. plumbi, nit. argenti and cochineal, are prescribed, without any definite idea of the modus operandi. Of the tonics, cinchona and ar- senic are justly preferred, and are well adapted to the relief of pro- tracted attacks. DISEASES OF THE SENSORIAL SYSTEM. The organs of this important system are the brain, the spinal cord, and the nerves—the diseases of which must be considered in succession. Their functions are varied and numerous, and essential both to organic and animal life. Intellection, including sensation, volition and all forms of mental action and passion ; motivity, in both the voluntary and involuntary muscular fibres; secretion, nutrition, circulation and indeed all the specific actions of all the viscera and tissues, are abso- lutely dependent upon, or inevitably modified by their condition. Some portions of the intracranial mass, the " hemispherical gan- glia," are exclusively devoted to intellection ; the offices of "the true spinal cord" are purely physical; the nerves seem mere conductors of sensations, volitions, and impulses direct and reflex, between the nervous centres and their extremities. These centres are supposed to be sources of nervous power, which is analogous to, but not identical with galvanism, and like it is a " polar force." This is generated probably too by the organic or nutritive action of all the tissues. The grey vesicular, and the white tubular matter exist together in the brain, spinal cord, and ganglia; the nerves consist of the white only. Nervous matter is composed of albumen in combination with phos- phorus and certain fatty substances. The disorders of the various departments of the sensorial system must of course express themselves by prominent impairment of the spe- cial function of the portion affected ; this is not always clearly known, 24 186 however, and the connection between them all is so close that the lines of demarcation cannot yet be drawn with absolute certainty in many in- stances. I therefore still follow the usual arrangement, and treat first of the diseases of the brain and Us membranes. Cephalalgia—Headache is one of the most frequent and painful of human maladies. It attends most febrile ailments, depending on the irritation, congestion and inflammation of those affections, and is sym- pathetic of, or caused by many gastric derangements. When idiopathic, it seems to consist of a peculiar erethism of the brain, which may be extensive, spreading over the head ; or limited to one side—hemicrania ; or confined to a single narrow spot. Most persons habitually subject to it have it usually at some particular point. Its causes are direct and indirect; prolonged and intense impressions 'of light and sound ; strong thought, violent emotion or passion ; solar heat, or the warmth of a crowded apartment are among the first—so is the motion of a ship, or a swing—so too, want of sleep—the effect of tobacco, opium, wine, and other stimulants and narcotics. The indirect are found in the disturbances of the digestive system, chiefly acidity of stomach, constipation, &c. The idiosyncracies of the subject and the contingencies with which it is connected, modify it somewhat and give it a qualifying title—as nervous, sick headache, hysteric headache, &c. It becomes by repetition almost habitual in many, and returns upon the application of the slightest causes. Treatment.—Its natural cure or termination is in profound sleep ; yet the employment of narcotics is producive of less benefit than would here be expected. Great care should be taken to avoid its obvious or apparent causes. When this cannot be done the system should be gradually accustomed to them, guarding against any unfavorable circumstances of predis- posing character—such as indigestion, costiveness and the like. Camphor and belladonna have been supposed to exert some specific good effects in the relief of constitutional headaches, and may be employed in small doses. The best remedy is found in the annealing or hardening influence of long and frequent journeys, in which discom- fort to moderate extent is incurred. 187 Phrenitis—Meningitis—Encephalitis.—Inflammation of the brain and its investing membranes, is divided into acute and chronic. The lat- ter is plausibly alleged to be the proximate cause of most of the diversi- fied forms of mental alienation or insanity, which varies in its history and symptoms in relation to the varying seats and nature of the cere- bral affection. Acute phrenitis is not often met with as occurring idiopathically or independently, but many of its phenomena arise sympathetically, in the course of other diseases ; and in the class of fevers, this is so generally the fact, that Clutterbuck and others have maintained cere- bral inflammation to be the primary location and essential condition of fever properly so called. Acute inflammation of any portion of the brane and its membranes, commences with pain in the head, with a sense of fullness, heat, and throbbing ; the eyes are red and suffused, and intolerant of light; the face is flushed and turgid ; there is pain in the back of the neck, and down the spine; the scalp is occasionally tender to the touch; the stomach is in some cases oppressed, with retching and vomiting ; the pulse is full, hard, and bounding ; there is great anxiety and mental dejection, or even from the first wild delirium, which at any rate sel- dom fails to supervene early in the progress of the attack ; the hearing is acute, and ordinary sounds occasion distress; there is pervigilium; the tongue is whitish and lightly furred, and the skin hot and dry. If the disease advance unchecked, the patient sinks into a soporose state ; the eyes grow less and less sensible to light ; there is perhaps strabis- mus or a fixed state of the pupil, at first contracted closely, and after- wards widely dilated ; the hearing is impaired ; there is sighing, grind- ing of the teeth, tremulous debility ; respiration and deglutition become difficult, and coma or convulsions precede death. The predisposition is said to be sometimes hereditarily transmitted. It is found to exist in men of irritable and violent temper, and morbid susceptibility to mental emotion ; in persons of sanguineous tempera- ment ; those accustomed to free and luxurious living ; and in the pro- found student and ardent cultivator of literature. The exciting causes are insolation, blows on the head, gusts of ve- hement or prolonged passion, and intemperance or excess. Autopsy.—The appearances after death vary with the duration of the case. The vessels of the brain and its membranes are turgid— lymph is found adhering to the surfaces of the latter, and connecting them hy adhesions—serum is often effused over the surfaces and in the ventricles, and pus not unfrequently found mingled with it in con- siderable quantity. It is not settled whether " softening" of the brain, 188 " ramollissement," is a result of inflammation or not; I am disposed to regard it as a special vice of nutrition. "Induration" attends rather upon chronic than acute cerebral disorders. Prognosis is generally unfavorable. We draw the most gloomy in- ferences from the supervention of great debility, while the local excite- ment is unabated, and from the tokens of effusion and mechanical pres- sure, as paralysis, strabismus, deafness, stupor, coma, convulsions. Treatment.—Bloodletting is universally acknowledged to be indis- pensable. Some open the temporal artery—some the jugular vein. That vessel is to be selected from which we can obtain the fullest and freest flow of blood. The head should be elevated, and persevering affusions of cold water thrown on it from some height. The scalp should be shaved ; cups or leeches may be applied to the skull and be- hind the ears ; but our best reliance is on the lancet and cold affusion, which I prefer to pounded ice, &c. The most active purgative doses should be given—a combination of the resinous and saline, I think, should be preferred, and used freely and as long as the strength will bear. In the meantime the chamber should be kept cool and dark, and absolute silence enjoined. The head of the patient should be elevated, and abundant cold drinks allowed him. He must be perfectly control- led, and by such means as admit of no struggle or resistance. The convalescence must be for some time guarded most carefully. The diet should be low, the mind kept free from care and anxiety, lax- atives administered occasionally, and a total abandonment of such habits as may have predisposed to or excited the attack strictly enjoined. Chronic Phrenitis.—Chiefly shown in the varied disturbances of the intellectual functions, which are known under the head of Insanity. It is important to draw correct distinctions here, and separate from in- sanity proper—which I regard as uniformly depending upon cerebral inflammation, the numerous modes of mental aberration arising sym- pathetically in the progress of many forms of disease, as transient and incidental conditions, and implying none of the circumstances of phre- nitis. The irregular and undefinable states of intellection resembling in- sanity in the absence of control, are not easily distinguished from each other, but must not be confounded—dreaming, reverie, absence of mind, somnambulism, exalted passion, enthusiasm, intoxication modi- fied by the different agents which produce it, delirium, melancholy, fatuity, idiocy and senile imbecility. It is impossible to define insanity —difficult by any form of words to describe it, so as to separate it from 189 either of the above conditions, and yet there is little danger of mistak- irig them. In fevers we have delirium—in hysteria, there is fatuity or imbecility—in intoxication there may be almost every variety of mental disorder, disturbance and confusion—yet these are not insanity properly so called. Neither is the amentia or the amnesia attendant on epilepsy, apoplexy, and paralysis. Causes of chronic phrenitis, divided into the moral and physical— the predisposing and exciting. Of physical causes, the predisposing are, 1. Hereditary transmission of constitutional peculiarities. 2. In- temperance or excess of any kind. The exciting are, 1. The causes formerly enumerated of acute phrenitis, or acute phrenitis itself im- perfectly cured. 2. Gastric and intestinal disorders which, through the close and universal sympathies affecting the brain, act upon that delicate organ. 3. Genital or sexual irritations which derange, in pecu- liar and inexplicable modes, the various portions of the cerebral tissue. 4. Metastasis of various morbid affections, as on the sudden disap- pearance of cutaneous eruptions, of gout, &c. Of moral causes, the principal predisposing is found in education, in- cluding within that comprehensive term all that conduces to the forma- tion of the character and habits. The imitation of parental peculiari- ties, eccentricities, and oddities, may thus be enhanced in the child into a forcible predisposition to some mode of insanity. The exciting moral causes are obvious. The frequent and violent indulgence of passion, the fostering particular trains of thought and emotion, whether pleasant or painful, irritate and inflame the organ of thought. Very sudden and great changes of condition, as from wealth to poverty, or vice versa, produce similar effects. Pathology.—Bayle refers insanity to inflammation of the meninges, but Foville says, that " as the traces of inflammation are more constant in the brain than in the membranes, we must regard the former as the essential—the latter as the incidental condition." Necroscopy indeed reveals to us a great diversity of morbid altera- tions. The membranes are thickened, injected, adherent both on their opposite surfaces and to the cerebral substance. This substance is injected, thickened—"occasionally," says Foville, "intensely red. The surface or superficial stratum of the cortical substance is firmer and denser than natural." Gall and Desmoulins have observed what they call " atrophy of the convolutions—more frequent in the frontal regions; sometimes an actual absorption, leaving chasms filled by se- rositv." Esquirol has described the presence of a multitude of small cavities in the brain, " from the size of a millet seed to that of a not, containing fluid." 190 Diagnosis.—Insanity, as the sign, token, or consequence of chronic phrenitis, does not necessarily imply the loss or impairment of any of the intellectual powers; for the brain is a double organ, and it is rare that the corresponding parts on both sides shall be diseased. It con- sists in and depends upon the loss of the power of precise association, through which the mental operations are conducted to definite and cal- culable results. This inconsistency, irrelevancy, or dis-association, whether merely speculative or practical—this uncertainty of relation and succession in the intellectual actions, is the only uniform and es- sential symptom of insanity. Mental derangement, as the effect or manifestation of chronic inflam- mation of the brain, may be divided into the following varieties. 1. Incoherence.—Some of the cases under this head exhibit a ceaseless activity of the mind, marked by the absence of all the principles and powers of regulation. Even the instinct and natural propensities seem often subverted, and the patient is forgetful or ignorant of the meaning of words, or the connection between thought and action. 2. Mania, which has been often called moral insanity. Here the destructive and mischievous propensities are highly excited, with great cunning and contrivance in adapting means to ends. Among these were the demo- niacs—the possessed of ancient times. Here also the subjects of eroto- mania, and the desperately profane and blasphemous, are generally to be classed. 3. Melancholy. 4. Hallucination, the form of insanity bordering most closely on delirium. Some of these hallucinations have been incorrectly, as I think, attributed to false impressions made on the organs of sense. 5. Monomania—a perversion of the judgment on one subject or set of subjects, and consequent perverted course of conduct or behavior in relation to them. This is often complicated with the former. Insanity as to a single subject is much dwelt on in medical jurisprudence. I believe it to be a very rare condition, if indeed it ever exist. With the disorders of intellect, there are always combined the ob- vious marks of physical disease. We find headache complained of by a great many—morbid vigilance, with restlessness. In many, the senses are morbidly acute. In a great majority they receive almost no impressions but such as are unpleasant and annoying. Convulsions, paralysis, apoplexy, not unfrequently supervene, in the progress of cases of chronic phrenitis. The tongue is foul and the breath fetid in most instances ; sometimes a viscid offensive saliva is excreted in great quantity. There is deprivation of appetite, and costiveness. The pulse is generally quick, frequent and tense ; in some melancholies it is slow. There is much inattention to changes of temperature, but 191 the hands and feet are apt to be cold. An unpleasant odor often ex- hales from the entire surface of the body. The prognosis is unfavorable. The tables published in regard to the proportion of cures in different lunatic asylums are somewhat apt to mislead. Proper distinctions are not made between the infinitely diver- sified conditions of mental aberration resulting from various causes. Hysteric folly, delirium tremens, somnambulism, puerperal mania, &c. are easily and in very large proportions curable, and these are confounded with true insanity or chronic phrenitis. In our treatment we must be guided by the state of the general system. If entonic, we must bleed both from the arm and by leeches and cups from the head and neighboring parts. Venesection is, however, much less frequently and energetically employed now than formerly, and is not perhaps often requisite or serviceable. Pur- gatives are also useful here ; they should not be urged at any time into hasty operation, but a revulsive influence should be long exerted on the intestines. The nauseating and depressing effect of antimonials may be made of much benefit, if perseveringly kept up. Mercurials are sometimes serviceable. I do not depend on them in general, but they may be experimented with. They are best adapted to cases which exhibit notable disturbance of the digestive system. The importance of sleep both as preventive and curative of insanity can scarcely be overrated. Opium is called for by restlessness with pervigilium, the patient suffering much for want of tranquil and re- freshing sleep. In such cases, and those which exhibit, during the waking state, peculiar agitation, irritability, and other marks of gen- eral distress, I do not hesitate to administer anodynes freely, premi- sing such precautions as may seem requisite—employing the necessary means of depletion and revulsion, keeping the bowels properly open, &c. Digitalis has been often found of advantage. Cold applications to the head are frequently required. I prefer the occasional affusion of cold water from a height on the head, to the constant application of cold in any way, as it often annoys and irritates the patient. I advise almost always the removal of the patient, when the insan- ity threatens to become permanent, to some well managed asylum. In such institutions only can we find and avail ourselves of the requi- site means of physical restraint and moral control, not only necessary to prevent the patient from injuring himself and others, but positively and in a very high degree salutary in their influence, and remedial in their ultimate effects. In atonic cases we must be careful to support the strength of the patient. He must be warmly clad, supplied with nutritious and agree- 192 able food, and occasionally, though with much caution, indulged pro re nata in the use of diffusible stimulants. Of these, ammonia, cam- phor, and opium are to be preferred. Tonics are sometimes servicea- ble, and I have derived advantage from the exhibition of the sulph. quinine, with camphor in small doses, or minute quantities of some of the salts of morphine. Mania a Potu.—Delirium Tremens—Brain Fever of Drunkards— La Folie des Ivrognes, 8cc.—Among the numerous appellations of this remarkable malady, I prefer to retain the first of those set down, as strikinMy significant of the cause to which it is attributable. Until we have clearly designated its true pathology, we shall not be able to give it a title absolutely correct'and entirely unobjectionable. It is not properly a fever. The line between delirium and mania is not dis- tinctly drawn, and there can be no special impropriety in using the latter phrase, where there is so much mental derangement, with con- stant hallucination. Besides this, it runs so readily into phrenitis, acute and chronic, as to give good ground for this selection. Indeed, although I confess its pathology to be extremely obscure and ill-defined, yet I am rather disposed to regard it as a peculiar form of phrenitis, modified— 1st. Bv the causes which produce it; and 2d. By the morbid condition of other organs, with which it is universally connected. The cause to which it is exclusively ascribed, is intemperance in the use of ardent spirits—distilled alcoholic liquors. The influence of these agents is slowly developed in the production of mania a potu, which requires time, and which ultimately shows itself in various forms, according to the several diseases of other organs which may exist in each case. Some have maintained the necessity of a transient discon- tinuance of the use of ardent spirit, and a consequent exhaustion or prostration of nervous energy from the subtraction of accustomed stim- uli. The fact, however, is not so. I have repeatedly seen attacks of the several modifications of mania a potu, supervening during the actual progress of a "frolic," or while the sot was living in his usual manner. Symptoms.—In a majority of instances, the stomach has yielded long previously to the morbid effects of stimulating potations, and the liver and all the other chylopoietic viscera have suffered. There is total loss of appetite, with occasional retching and vomiting, especially in the morning ; the bowels are irregular, usually loose with acrid bilious discharges; the hand and tongue are tremulous ; the latter thickly fur- red, with fetid breath, or smooth and fiery red. The mind is deeply de- 193 pressed, and the state ofintoxication into which the patient plunges for relief from this dejection, is often more gloomy and remorseful. At last, the patient wanders—he mutters incoherently and with incessant restlessness ; or if he sinks exhausted into a brief and unquiet slumber, starts from it in terror which cannot be soothed. The pulse is weak and very frequent, his skin cool and clammy, his eye red and suffused. Convulsions may occur, but are not usually met with when the stomach is still disturbed with the frequent retching, so prominent a symptom of this form of the malady. In some patients the brain suffers more immediately, and with much less gastric disturbance previously, or at the time. Some fit ofintoxi- cation, deeper and more prolonged than ordinary, terminates in a horrid convulsion, followed by another and another. The unhappy subject may thus die at once ; or he sinks into a state of exhaustion, with cold skin, pulse indescribably rapid, and so feeble as scarcely to be felt, with countenance haggard and eyes half shut., After lying thus for some time, his muscular strength suddenly returns, and he becomes capable of prodigious exertions ; he is haunted by some frightful hallucination, and becomes extremely dangerous to those about him, whom, in his frenzied anxiety to escape, he will assault and pursue with vehement malignity. This condition may run into acute phrenitis, and some- times terminates in permanent insanity. Others again with less obvious affection of the digestive system, and no acute cerebral disorder, sink into absolute imbecility, both mental and physical, mingled with a peculiar shade of gloom and despondency. The skin in such cases is hot and dry ; the pulse is small, corded and frequent ; the patient takes almost no food, and scarcely sleeps— seems always restless and uneasy ; he affects solitude, often mutters to himself,,and appears alarmed causelessly. In almost all, there is a notable predisposition to suicide. The autopsy of mania a potu developes nothing uniform or charac- teristic. A variety of lesions have been noted, but are not regular. The " anatomy of drunkenness" shows marks of extensive diseaseof the stomach, the liver, and the brain ; the progress of the several changes or steps of disorganization, is proportioned to the duration of sottish habits. But all these changes may have taken place, without the pro- duction of this particular form of disease. The prognosis is generally favorable. Few die in mania a potu, and those few rather of the derangements of the constitution, which are the coincident effects of the caus? which has produced the attack. The tokens of a specially unfavorable case are, obstinate pervigilium, which always threatens convulsions—a repetition of the convulsions, 25 194 with brief interval—or the occurrence of coma. It is also unfavorable to find the pulse rising and becoming fuller and slower, while the mind continues perturbed. We have here to dread permanent insanity. The treatment must be modified to suit the condition of the patient. Venesection is seldom necessary or justifiable. It may be required to obtain a respite from convulsions. When a iransitus has taken place to the condition of acute phrenitis, the lancet must be freely employ- ed ; this is marked by fullness and hardness and comparative slowness of pulse, by the cessation of trembling of the limbs and tongue, and by a change of the manner of the patient, who is now fierce and reso- lute, and no longer full of tremorand vacillation. If there be no doubt on this point, the hair may be cut close, and leeches and cups applied to the temples and back of the neck. But such cases, it should be kept in mind, are not common, and this mode of depletion is not to be often resorted to. Cold affusion may be of advantage when the face is flushed and the skin is hot and dry : under opposite circumstances I would not advise it. Emetics have been highly eulogized, but they are of doubt- ful effect. When the stomach is nauseated, with retching and ineffec- tual vomiting, with foul tongue and fetid breath, they may do service. They may also be occasionally employed to arouse the susceptibility to the action of other remedies, when we have found ordinary doses incapable of affecting the patient. Cathartics are often beneficial. Calomel, in large doses, is the best. The saline may be added, if the patient be strong and robust. In general, however, it is not advi- sable to employ cathartics freely. Opium is, unquestionably, our most important remedy. It is applicable to all cases of mania a potu, and has only been subjected to doubt, by having been erroneously pre- scribed, when the case has run into phrenitis of ordinary character. I prefer the tincture, and prescribe it with unyielding perseverance, in large closes until the patient sleeps. I do not like to combine with it any other stimulant. Camphor and ether are the least objectionable, if an addition be necessary. Nor can I assent to the propriety of ex- hibiting large masses of solid opium, which may not dissolve at all when most needed, and may lie inactive in the stomach, until a period when its solution and consequent absorption and active influence may be pro- ductive of injury rather than benefit. Digitalis is proposed as a sub- stitute for opium, and the tincture is administered in large doses, from one to three drachms, every four or six hours. Thus exhibited, I have seen it unquestionably useful. Chloroform and other anesthetics have lately been resorted to, and as is stated, with the most obvious benefit; the patient being rendered soporose and tranquil by their inhalation. The management of the patient is a matter of much importance. He 195 should be kept under the most perfect control, by a sufficient number of resolute attendants, or, which is often better, by solitary confinement. His diet, if he will take any, may be nourishing and well seasoned. His convalescence must be carefully guarded. His mind must not be disturbed with care or business. Tonics may be of use to him, but all stimulants (except those already mentioned) must be positively refused. The prophylaxis of mania a potu—the reformation of the drunkard, is a topic of infinite interest. The peculiar craving or longing after ardent spirit is, in the sot, the consequence of morbid condition of the stomach chiefly. To remedy this, it is proposed to combine sulphu- ric acid with the accustomed drink, and the effect is said, in some cases at least, to be strikingly advantageous. By others, it is suggested to mingle with the several forms of distilled liquors, the tart, antimon. or ipecac or other emetic, in such amount as to nauseate long and vomit severely. These attempts may sometimes succeed ; but in gene- ral, they either totally fail or produce only a transient influence. No- thing is to be hoped from any measure short of perfect abstinence; nor is anything to be feared from the abrupt enforcement of the injunction. I would scarcely allow, in any case, the use of a substituted stimulant; but if such an indulgence seemed necessary in a given instance, opium and camphor would suffice abundantly, and the dose being rapidly di- minished, might soon be safely withheld. Apoplexy may be defined to consist in a loss or remarkable impair- ment of the power of motion, with insensibility and stupor. The pa- tient cannot be roused, and gives little or no token of consciousness. The action of the heart is usually little disturbed at first, but soon be- comes feeble, and after a time ceases. Respiration is performed with some labor and effort, and with stertor generally, the difficulty in- creasing as the circulation is more impeded. Causes.—A predisposition to apoplexy is found in a full plethoric condition of body—habits of undue indulgence in the pleasures of the table and venereal gratifications—in mental excitability, liability to gusts of anger, and other violent emotions. Yet it is not the luxurious only who are thus predisposed ; similar tendencies are often found in the ill-fated, badly nourished poor. As age advances, the predis- position seems to increase. It is commonly believed to be connected too with a particular form, of which "rotundity, corpulence, with thickness and shortness of the neck," is the description. The exciting causes, which affect the predisposed are numerous ; all stimulants, a full meal, especially if the subject place himself soon 196 i after in the recumbent posture ; insolation, vehement muscular exertions, ligatures round the neck, fits of passion, stooping down for any length of time—all circumstances in short, which either render active the cerebral circulation, determining to the brain, as the phrase is, or which impede the return of blood from the head. Apoplexy is said to be often connected with hypertrophy of the heart, and to follow the sudden disappearance of regular gout, and the suppression of accus- tomed evacuations. Diagnosis.—Apoplexy resembles profound sleep, but the sleeper may be aroused ; it is distinguished from syncope, in doubtful cases, by the respiration, which is almost always noisy and laborious—gen- erally by the pulse also, which is full and slow, and the countenance, which is, in the majority of instances, flushed; from epilepsy, by the absence of distortion or convulsions; from asphyxia, by the previous history of the case, and in the same manner from the torpor of extreme cold, which closely resembles it. It is very difficult to distinguish it from intoxication, and it is often most perfectly simulated by the hys- teric paroxysm. There is also a sympathetic loss of sense and mo- tion from gastric disorder, not easily separated from it. The prognosis is generally unfavorable—perfect recovery from it is not frequent; hemiplegia is a very common result of the attack ; there is a strong tendency to recurrence of the paroxysm. The best hope of restoration is in the young and temperate, subjects marked by no special bad habit, or other token of predisposition, and attacked under circumstances of transient influence, as from insolation. In the old, and infirm, and intemperate, the prospect is gloomy. When one side is in any degree agitated, and the other remains mo- tionless, we predict paralysis of the latter. If the pulse sink, the res- piration becomes louder, with puffing of the cheeks, and relaxation of the sphincters occur, we expect a promptly fatal termination. Autopsy.—The appearances vary somewhat, but in a vast majority of cases betoken impediment to the performance of the functions of the brain, or actual lesion of cerebral structure. Hemorrhage is of fre- quent occurrence. Blood may be poured out upon the surface of the membranes, or within the ventricles, or in the very substance of the brain, with laceration. Serum or seropurulent fluid may be found in the ventricles or upon the membranes. Tumescence of the cere- bral vessels is rarely wanting in greater or less degree. Exceptions are however recorded, on good authority, in which none of the above marks of disease within the head were discovered. Pathology.—Apoplexy is properly the abolition or suspension of the sensorial functions, occasioned by pressure on the brain. Mechanical 197 pressure, as by fracture and depression of the skull, gives rise to a train of symptoms precisely the same. This pressure may be— 1. Extravascular, i. e. from fluids poured out, blood, serum, &c.; or it may be—2. Intravascular, from mere fullness or turgid state of the cerebral vessels; which latter condition may disappear at the time of death, leaving no trace. Treatment.—This must vary with the condition and circumstances of the patient, which in different cases will be strongly contrasted. Apoplexy has, in relation to these diversities, been divided into two forms, sanguineous and serous, meningeal and cerebral, entonic and atonic—phrases significant, and applied with some foundation in pro- priety. These modifications are explained by the constitutional pecu- liarities of the subject, by the nature of the cause which has affected him, by the degree of lesion of the brain, and the particular locality of the lesion. 1. A majority of the cases present the following symptoms: The pulse is full and strong, though slower than natural, the face is flushed or turgid, the eyes prominent, the pupils somewhat dilated, though not altogether insensible to the influence of light, therespiration stertorous, the surface is of natural temperature, the features flabby, and the jaw somewhat fallen. There have been for the most part, certain premon- itory indications before the fit, such as flashing of light before the eves, tinnitus and other noises within the ears, fullness or throbbing, or pain in the head and vertigo, with somnolency ; and sometimes a failure of strength of the arm and leg of one side, or a sense of numb- ness in them or in the tongue, for paralysis may precede as well as follow apoplexy. In this state of things, the lancet should be promptly used and fear- lessly, and blood drawn from a large vein or veins, to an amount suffi- cient to make a definite impression upon the force of the circulation. Apply cold affusions on the head, the hair being cut close or shaved. Active cathartics and enemata must be employed for their revulsive effect; the drastics will be chosen on account of the impaired suscep- tibility. Counter-irritation by sinapisms to the extremities, and epis- pasties, will be of service. Emetics are equivocal remedies, and should not be administered, unless when the patient has been attacked immediately after a full meal. The best means of promoting the ulti- mate recovery of the patient, and of confirming a cure once begun, is to keep up a regular and free determination to the bowels, by the use of efficient purgatives in repeated doses. 2. The patient is sometimes pale or livid, with a cold moist skin, and a pulse feeble and intermittent. Here the lancet is forbidden. Cold 198 water must be applied over the head, by affusion or with a sponge, and cups to the back of the neck and between the shoulders, or leeches behind the ears or around the anus. Volatiles should be held occa- sionally to the nostrils, and mustard laid upon the extremities and epi- gastrium. Stimulating enemata ought to be given without delay, and epispastics laid upon the spine and other parts of the surface. If the pulse rise under this treatment, we may administer purgatives cau- tiously, and keep up determination to the skin and kidneys by diapho- retics and diuretics. Of the former the antimonials are preferred by some. The nitrate or acetate of potass will act serviceably upon the kidney's. Paralysis.—Under this head I shall notice several diseases, usually recognized as distinct. 1. Hemiplegia, or palsy of one side of the body, closely connected with our last subject, as being an affection of the brain, primarily, and always the result of pressure on some part of that organ. 2. Paraplegia, palsy of the lower part of the body, trans- versely divided ; the result in a vast majority of cases, of lesion in the spinal cord, though it has occurred independently of it. 3. Paralysis agitans ; and 4. Paralysis vacillans, or chorea sancti viti. Apoplexy in its worst grade has been considered a complete and total paralysis, but there are degrees even in apoplectic seizure, and the various divisions above stated, are obviously forms of partial paral- ysis. We may have palsy of a single limb, nay, of a single muscle, or of a few muscles. In colica pictonum, there is palsy of one or both hands. The arm has been palsied, while the hand, if supported, was capable of writing. A palsy of one side of the face is not very rare. The tongue is sometimes palsied. In what I have called P. agitans, there may be a constant trembling of the hand, or more frequently, an incessant shaking of the head. This is common with the aged, but I have met with it also in the young and robust. In apoplexy and hemi- plegia, the brain is evidently the seat of injury. The mind is disturbed more or less, and both sensation and motion are impaired. In the three latter forms of paralysis, the mind usually remains unaffected and the sensibility of the parts is not changed, the nerves of motion having suf- fered exclusively. This may either result from some cause acting upon the nervous ramifications which supply the parts, or may depend upon lesion of the portion of spinal or cerebral substance from which these spring. Ramollissement of any part of the brain is attended with paralysis 199 usually partial, and some mental failure. The " partio-general" paral- ysis of the insane, so well described by Earle, is of this character. Paraplegia, which in a great majority of instances arises from obvious injury or disease of the spine, has been ascribed in a few to cerebral derangement, and has occurred as a sympathetic effect of gas- tric and intestinal disorder, without any perceptible change in the condition either of the brain or spinal cord. In Chorea sancti viti, paralysis vacillans—styled by some P. agitans, incorrectly—the tremor or agitation is not constant, but exhibits itself only at the moment when an effort is made at voluntary motion. The volition fails in part, and the muscles called upon act with vacillation and irregularity, but not -feebly. There can be little doubt, I think, that the cerebellum, the organ of association of action, is here affected as well as the nerves, and when the case is severe and protracted, the whole brain may become disordered, the patient becomes fatuous, and there is ten- dency to convulsions. 1. Hemiplegia is nearly allied to apoplexy, which it may either pre- cede or follow. As the consequence of the apoplectic seizure, it has al- ready been spoken of. Its approach may often be observed and foretold. I have more than once marked in the apoplectic, the exact moment of its oc- currence, denoted by a slight quivering of the muscles of the face, trunk and limbs, which in an instant relax and subside into a passive condition. It often invades gradually. The patient first complains of a numb- ness and tingling of one arm and leg, is apt to trip or stumble, and to let fall what he attempts to hold; there is noise in the ears, and the eye of one side cannot be closely shut; there is some distortion of the mouth, and articulation is impeded. The mind is usually disturbed ; the memory generally fails, though not invariably, and some terror at- tends the feeling of so great a calamity. When fully developed, hemi- plegia implies an incapacity to stand or walk, or close or raise the hand ; but the power of sensation and voluntary motion in the side af- fected, though greatly'impaired, is seldom if ever totally lost, and in numerous cases the sensibility has remained, or been morbidly enhanced, while motion was impossible, and vice versa ; in one remarkable in- stance, there was loss of power on one side while the feeling of that side continued, and loss of sensibility on the other, the voluntary move- ments of which were not impaired. These facts are explained, by reference to the independent origin of the two sets of nerves. Sometimes the case runs rapidly on into apoplexy, occupying from a few hours to a few days, the prostration of muscular power increas- ing, and the mind becoming more and more disturbed, until insensibil- ity and coma supervene. t 200 Many patients, however, drag out a miserable, protracted existence of months and years of unabated suffering. The nutritive action of the vessels of the affected limbs is imperfect, they shrink and are emaciated, their natural heat being lessened ; harshness and dryness of the surface ensues, the ordinary transpiration ceasing ; the fingers are pale and waxen, and sometimes contracted ; the countenance is distorted by the traction of the mouth to the sound side, the saliva escapes over the chin, the tongue is thick,,and when protruded turns to the paralytic side, and the speech is confused and indistinct. There is sometimes severe pain, and sometimes spasmodic muscular contractions on the af- fected side. Amnesia is usually present in various degrees. The memory of words is oftener lost than the remembrance of things or facts. The names of familiar objects are sought for in vain, or incor- rect names obstinately applied, and words pronounced by the tongue which the will had not contemplated. The emaciation and debility in- crease, until the patient sinks, worn out and exhausted by a long train of evils, in which every function has successively suffered. In a few cases a gradual improvement takes place, and a restora- tion of some of the capacities for action and enjoyment, but such recov- eries are rare. They are attended with formication and tingling of the limb, and sometimes painful swelling, while the power of motion in- creases slowly and the mind gains strength. According to my own observation, this recovery of motive power scarcely ever takes place ex- cept in the lower limb ; the paralytic hand is very seldom restored in hemiplegia. The causes of hemiplegia are those of apoplexy, already enumerated —plethora from luxury and excess among the rich, and the apparently contrasted though closely analogous condition arising from imperfect supply of food in the poor; insolation, and intemperance in drinking. The prognosis is unfavorable. It is proved that absorption of ex- travasated blood, which by its presence in the brain has produced hemiplegia, may take place; but the process is slow and uncertain, and the constitution in the meanwhile sinks under the general impair- ment of function. Laceration and disorganization of the cerebral tissue hardly admit of restoration. Autopsy.—The most common circumstance noted in the examination of hemiplegics, is the presence of" a clot of blood in some part of the brain. It is usually, perhaps always, enveloped in a cyst, and has undergone more or less change from absorption. The process is slow ; the clot has been found undiminished in size, and filling the cyst, two years after the attack. • Sometimes the cyst is found empty, with its sides collapsed—at others, it contains serum. Tokens of inflammation • 20] of a portion of brain are found ; there is induration of substance, or softening, a change the nature of which is not well understood. Ab- scess or effusion of pus, of serum—various morbid growths, tumors and tubercular deposites, have been seen within the brain or connected with the membranes. The pathology of hemiplegia is readily deducible from what has been stated above. It is the result of pressure upon some part of the brain, and the degree and kind of effect are in relation to the locality and extent of the lesion which interrupts the sensorial function. The pressure on which it depends may be, though rarely, intravascular. The treatment must be varied, as in apoplexy, to suit the condition of the patient. If he be young and robust, the pulse full and strong, the face flushed, with pain and throbbing of the head, he must be bled largely, and cold water poured upon the head from a height. Purga- tives of active and irritating character must be promptly administered, and their effect hastened by the aid of enemata. In the opposite state of the system, when the countenance is pale, the pulse feeble, the skin cold and moist, volatiles must be applied to the nostrils, sinapisms and epispastics to the limbs and trunk, and the head sponged with vinegar and water. Enemata may be given, and leeches or cups put to the temples and back of the neck. If reaction ensues, we should deplete, but with caution. In the protracted state of hemiplegia, the persevering employment of purgatives has done service, and some of the cathartic mineral springs are celebrated for cures effected. Determination to the head must°be combated by keeping the head shaved, and occasionally apply- ing a few leeches behind the ears, a blister to the back of the neck or between the shoulders, or inserting an issue or a seton in that neigh- borhood. Farther revulsion is attempted by frictions with turpentine, mustard, &c, which are supposed to excite locally the enfeebled mus- cles and nerves. With the same view, the skin of the limbs affected is irritated with tartar emetic, rubbed with rough tow and hard brushes, stung with nettles and burnt with moxa. Both the cold and hot baths are much eulogized. But the most useful means in my hands have been galvanism and electricity. Dr. G. Bird affirms that " in paralysis from persistent cerebrospinal lesion, when recent, electricity will do harm; he has known a fatal apoplectic fit from it : and that when paralysis is attended by rigid flexure of thumb and fingers, it does no good. When in old cases the original cause is removed by time and treatment, electricity is most hopeful, especially the electro-magnetic form ; we must persevere how- ever." 26 \ 202 The tonics are much employed, especially the metallic—the nitrate of silver, bismuth, zinc, arsenic. Strychnine has been highly recom- mended, and is supposed to possess specific and peculiar properties, which adapt it to the relief of the hemiplegic. I have also seen some advantage gained by the careful use of veratrine, both externally and internally employed ; the difficulty of deglutition which so much dis- tresses some paralytics, being much diminished after frictions, with the ungt. veratri about the jaws and throat. Paraplegia is one of the most obstinate and hopeless of human mala- dies. The spine should be carefully examined, and at any joint ex- hibiting fullness or tenderness on pressure, leeches or cups should be repeatedly applied. Yet it is said that paralysis is apt to follow the true myelitis or softening of the spinal cord, which is not attended by hyper-sensitiveness. Tenderness of the spine belongs rather to arachnitis spinalis, in which we have tetanic rigidity of the muscles and spinal neuralgia. The use of purgatives cannot well be dispensed with, as the bowels are generally much constipated. Iodine and its combinations, with mer- cury at first and afterwards with iron, deserve a trial as tonic and alte- rative, while the region of the spine is subjected to constant counter- irritation. This course, with the patient employment of electricity and galvanism, furnish perhaps our most reasonable hopes of improvement. Under this head we may consider the paralysis of the bladder, con- nected so uniformly with paraplegia, and so often annoying subjects in advanced life. Ergot is highly eulogised here, especially by Day, who recommends it in free doses, 3i of the strong tinct. ter die in an effervescing draught of cit. ammonioe. Electro-magnetism is also found serviceable. Paralysis agitans, if in the old, is incurable. In the young it is con- nected with various other derangements of health, and will require the treatment to be accordingly modified. In females, it seems dependent upon habitual constipation, and sometimes upon irregularity of the cat- amenia. Under both circumstances I have succeeded in removing it by employing a combination of some resinous purgative with the rust of iron. Chorea sancti viti—paralysis vacillans—belongs generally to child- hood and early life. It is produced sometimes by the irritation of worms. I have seen it arise during convalescence from other maladies, as scar- latina, catarrhal fever, &c. I knew it supervene upon the introduc- tion of a needle into a part of the body, and after a duration of some months, suddenly cease on the needle finding its way out of a distant part. It often invades however without obvious cause. h 203 The pathology of chorea is obscure, and serves to show the close con- nection existing often between paralysis and convulsion. At first the agitation of the muscles is only to be observed at the moment of volition. Where it has been long protracted the intellection of the patient is im- paired. Hence I regard its primary and principal seat to be in the brain ; although there may be disturbance throughout the whole of the cerebro-spinal axis. The cerebellum too is doubtless implicated. Autopsy has not shown any constant lesion. The disease has been connected with various appearances of cerebral turgescence, inflam- mation, and effusion. Treatment has been almost purely empirical, yet not unsuccessful. Purgatives given for some time, followed by tonics, the mineral articles being preferred ; the cold bath, electricity, antispasmodics and narco- tics, are all eulogized on good authority, and are doubtless useful. Of the tonics, zinc and arsenic are most relied on. The cimicifuga racemosa is also a favorite remedy. I have prescribed camphor and opium in minute doses, with great effect. In obstinate cases I have seen the best effects follow from galvanism and electricity. Sparks were drawn daily or every second day from the spine ; in girls labor- ing under amenorrhoea, across the pelvis ; transmitted along the limbs it is said to do harm, but when partial, sparks may be drawn with bene- fit over the affected muscles. Epilepsy.—This terrible disease is of paroxysmal and recurrent character, the patient usually enjoying good health in the interval, but liable to an occasional attack upon the application of exciting causes of great number and variety, and in bad cases spontaneously, or with- out the influence of any obvious cause. The paroxysm consists in a sudden loss of consciousness and sensibility, attended, when fully developed, by convulsive agitation of the body and limbs. Convulsion is described as an alternate, involuntary and rapid contraction and relaxa- tion of the muscles of voluntary motion. There is much irregularity, both as to. the muscles affected, and the force and quickness of their contraction. In a fit or paroxysm of epilepsy, as ordinarily occurring, the patient falls, and is agitated with convulsions. The countenance is flushed or livid and horribly distorted, the head drawn forcibly backward, the eyes turned upward and inward, and the lids incessantly in motion. The mouth is rapidly opened and shut, with inarticulate sounds and 204 moaning, expressive of great suffering; the tongue is mangled by the gnashing of the teeth, and the lips are covered with foam. The limbs are tossed violently or drawn together, with the hands tightly closed ; the trunk is twisted to and fro, and the resistance of the sphincters be- ing overcome by the contraction of the abdominal muscles, the contents of the bladder and rectum are evacuated. After a time these convulsions subside, and the patient lies passive, languid and soporose; his intelli- gence gradually returns, or is at once recovered, after waking from this slumber, but there is no memory or consciousness of what has happened ; great debility, and usually some headache, remain for a few hours. Epileptics often receive a species of warning, which admonishes them of the approach of a fit. In some, this consists in the throbbing of the head, tinnitus, &c, which precede apoplexy. In others, there is an indescribable affection of one or more of the organs of sense, either smell, taste, or sight; to perceive a particular odor is not uncommon, and a patient of my own was always aware of what she denoted " a green taste" just before an attack. Others feel in some part of the body a sensation usually spoken of as "cold creeping vapor," which originating there, moves upward towards the head. This is known as " the epileptic aura ;" but the accounts given of it by different patients are dissimilar. Some speak of it as a titillation, others as severely painful, others as indifferent or but slightly uncomfortable. The paroxysm of epilepsy is not always fully developed, as above des- cribed, the sensorial and muscular system being affected in various modes and degrees. There may be for a moment, or a very few moments, total unconsciousness—a mist, as it were, coming over the mind, while the muscles remain undisturbed. On the other hand, the intellect may be clear while the aura is felt, and the muscles, if not agitated, refuse to obey the will. One class of muscles may be exclusively and strongly contracted, which is spoken of as the tetanoid form of epilepsy ; or the whole muscular system may become at once rigid and fixed in the mode and degree or state of action existing at the precise moment of seizure—a state well known as catalepsy, and of which I have met with two well marked instances. All these varieties may, at different periods, exhibit themselves in the same individual case. The autopsy of epileptics discloses no uniform lesion or derangement. Many affections of the encephalon and spinal cord have been noted, but they are found in comparatively few subjects; and on the other hand, are often observed unconnected with epilepsy. Among them may be mentioned, ossific and other tumors attached to the inner table of the skull, and to the membranes of the brain, and purulent and other effu- sions upon the surface of these membranes, and in the vertebral canal. r. 205 The pathology of epilepsy is extremely obscure and ill-understood. The nature of the intermittent disturbance of the sensorial system and function, upon which it depends, is absolutely unknown. The causes of epilepsy are varied and numerous. The predisposi- tion is transmitted hereditarily, .and in certain families many of the members become its subjects. In persons thus predisposed, almost every derangement of any organ or function may become an efficient exciting cause. I would distinguish epilepsy, in reference to the first notable link in the chain of circumstances which give rise to it, into Idiopathic and Sympathic. It is Idiopathic when it occurs without obvious derangement of any other function than the sensorial, and when we can reasonably refer it to some known agent, capable of directly impressing the sensorial system, as for example, mental emotion of many kinds, and the strong principle of imitation. It is Sympathic when, on the other hand, we trace the sensorial dis- order to an indirect or secondary influence exerted upon the brain and nerves, through the diseased condition of some of the other organs or systems : as— 1. The digestive. Dentition and worms produce, by their irritation, many attacks of epileptic convulsion in young children. Intemperance is a frequent cause among adults, though it may be questioned whether in this example, the primary impression be made upon the stomach or the brain. Hepatic disorder has been accused of bringing on epilepsy. 2. The genital. In women, epilepsy is often connected with derange- ment of sexual health. Masturbation will give rise to it, in both males and females. Venereal excesses have proved fatal by inducing epilepsy. 3. Metastatic epilepsies. Under this head I would include such as precede and follow the exanthemata—such as supervene upon the sud- den disappearance of inflammations and. the removal of tumors. I have more than once seen such convulsions follow the sudden disap- pearance of dropsical swellings. 4. Epilepsies connected with "the aura." This strange sensation has sometimes an obvious cause, in the condition of the part where it commences. The part is sometimes tender on pressure, and some- times it invites pressure. Where no disease can be traced on exami- nation, I am still disposed to believe there is a morbid local affection of the nerve distributed there. The prognosis, in the first species, or idiopathic epilepsy, is unfavo- rable, except where it is clearly owing to some transient excitement of the feelings, or when it is founded on the instinct of imitation. In the sympathic, we distinguish the several forms. Attacks occasioned by 206 the irritation of worms, or dentition, or even by intemperance, are for the most part readily curable, upon the removal of these transient causes. So also of those which I have termed metastatic, which are not usually obstinate. But epilepsies, arising from genital derange- ments, take promptly a tenacious character, and are difficult to expel; and in the modification specified under the fourth head, we have little room for hope, unless we can appreciate and remedy the disorder of the part primarily affected with the aura, or can detect and remove with the knife the diseased portion of the nerve—means of relief very rarely within our reach. In general, all the forms of epilepsy are difficult of cure, in proportion to their duration. Spontaneous cures of epilepsy occur now and then, but are not well understood. In almost all cases, it is in our power to render the paroxysms less frequent, and perhaps to diminish their violence. But few die in the paroxysm. It is af- firmed to have brought on hemiplegia and apoplexy, and by repetition, to. tend to reduce the patient into a state of idiocy and fatuity. Many epileptics, however, live long and enjoy unabated vigor and clearness of intellect. Treatment.—During a fit, loosen all clothing about the neck and body—elevate the head, and sponge or wash it with cold water—place a soft bit of stick, or roll of cotton, between the teeth, to preserve the tongue from injury, and give the patient fresh air. The lancet may be of use, but is not often required. I would bleed if the patient was young and robust, of apoplectic make, with face flushed and turgid, and laboring under some strong excitement of transient nature. Owing to the extreme obscurity of the pathology of epilepsy, and our total ignorance of the conditions upon which it immediately de- pends, our efforts for its removal, it must be confessed, are rather ten- tative than directed by scientific or definite indications. The practice in the case may therefore be considered, without impropriety, under the heads of the palliative and empirical. The palliative management of the epileptic is sometimes successful beyond our hopes ; not only lessening the number of the attacks of convulsion, and subduing its violence, but even in some happy instan- ces arresting the disease altogether. The diet should be strictly regu- lated—temperate though not abstemious, nourishing but not stimulating. The hair should be cut close, or even shaved off. If at any time the head throb or ache, or the face be flushed, venesection should be re- sorted to, or cups and leeches applied. Vigorous and constant exer- cise should be enjoined—studious and sedentary habits abandoned. The administration of cathartics is often beneficial; the most remarka- ble cure which I have ever seen, was effected by perseverance for years 207 in the habitual employment of gentle purgatives. In sympathetic epi- lepsies, besides this general palliative course, we must endeavor to eradicate or remove the primary affection, wherever seated. A care- ful examination of the source of the aura should be instituted, with the view to the counteraction of its influence, in whatever method might be practicable. The empirical treatment of this justly dreaded malady, consists in the administration of certain remedies, whose modus operandi in the case is totally unknown, but whose reputation is the result of tradition and experience simply. I have not succeeded with any of these anti- epileptics, though some of them are in high repute, and have been favor- ably reported of by physicians of name and authority. They are the nitrate of silver, the salts of zinc, of copper, and of arsenic, digitalis, and the mistletoe of the oak. Successful experiments have been also made with galvanism and electricity. These powerful agents, espe- cially the former, would seem capable of advantageous application here, and deserve repeated trial from the profession. Neuralgia.—The physiology of the nervous system is too obscure to admit of a clear understanding of its morbid conditions. The very language which we use in treating of its pathology, is vague and indefi- nite. Thus neuralgia is the term chosen to denote a painful affection of certain nerves, as if all pain were not essentially nervous ; it is intended here however, to exclude the idea of inflammation or structural lesion of the parts supplied by the diseased nerve or its ultimate expansion. Under this head, I propose to consider, briefly, three varieties of morbid affection, closely allied in nature, and analogous in symptoms and re- sults. 1. Spinal irritation. 2. Tic douleureux. 3. Visceral neu- ralgia. 1. Spinal irritation must not be confounded with true spinitis, to which however it may give rise. It has been accused as the obscure source of a long list of maladies, even intermittent fever having been ascribed to it. In ordinary cases, which are much more common in females than males, and in youth than advanced life, the patient- complains at first of occasional uneasiness in the back and loins, is easily fatigued, indolent, and unwilling to walk, or stand, or sit erect. Then come on aching along the course of the crural and sciatic nerves, and a feeling of weariness in the lower limbs. The general health yields under"he influence of this constant uneasiness, want of exer- cise and disturbed rest ; and a long series of sympathetic affections ensue, terminating in hectic and atrophy, the digestive and genital sy*. % 208 terns suffering prominently. If seated high up, irritation of the spinal cord may produce neuralgic suffering of the upper extremities. This will usually follow the course of the ulnar nerve, darting along it to the tips of the fingers, and recurring at every movement. It is not always easy to diagnose this affection from spinal arachni- tis. In both there is great tenderness on pressure; the latter is how- ever apt to xbe associated with tetanic rigidity of muscles and febrile state of the system, which symptoms are wanting in neuralgia. 2. Tic douleureux is a painful affection of the extreme expansion of some external nerve. Good makes three species—faciei, pedis, mam- mae—the first being most common. I have seen two instances of the second. The third is happily rare. Tic douleureux is paroxysmal, spontaneously recurrent—observing, though not very exactly, the law of periodicity ; the pangs suffered during an attack are intense, and of singularly depressing character. 3. Visceral neuralgia.—This is also a paroxysmal and recurrent af- fection. The ganglionic system of nerves is the principal (though perhaps not the exclusive) seat of suffering here, and the anguish of the wretched patient is indescribable. One of its most common forms is known as "nephritic colic ;" the kidney, lower intestines, and testes, being assailed with pains of most " atrocious" intensity. All the vis- cera may be thus attacked. Gastralgia is probably often a gastric neuralgia. Dysmenorrhcea, usually a uterine neuralgia. Some of the varieties of headache are doubtless of the same character, and perhaps some of the cardiac and diaphragmatic affections, so obscure, and so full of pain and danger. The causes of neuralgia are not clearly made out. Macculloch and others after him attribute it to malaria, but it is not more frequent in malarious districts than elsewhere. It is more plausibly alleged to be connected with previous dyspepsia, and sometimes with gout. Treatment.—All forms of this disease are intractable and tenacious. We may generally relieve a paroxysm with the prompt and unhesita- ting administration of opium, or some of its preparations. The doses should be as large as the stomach will bear, and for quickness of effect, J prefer the solution, either of the drug entire, or of some of the salts of morphine. The warm bath will aid their action, and so it is assert- ed will the combination with them of camphor, musk, and assafoetida. In the intervals, guaiacum and colchicum are advised by some, while others rely upon the tonics, selecting arsenic and iron. While there is any tenderness upon pressure locally, either of any portion of the spine (which we should never omit to examine carefully) or any other p^rt of the body, cups or leeches should be applied there, and counter- 209 irritation assiduously attempted by sinapisms, blisters, issues, and by the ammoniated lotion of Granville, which last I have found specially well adapted. DISEASES OF THE MOTORY SYSTEM. Gout—Podagra—Arthritis.—We have to consider gout, like scrof- ula, in a twofold point of view. It constitutes or depends upon a pe- culiar diathesis, of which its several local developments are the exter- nal manifestations. Regular attacks of gout, however, affect the joints exclusively, whence the propriety of the term arthritis and the ar- rangement of it here. The gouty diathesis or constitution may be transmitted hereditarily, determining a predisposition to its local manifestations so strong that they cannot be escaped, the subject being attacked in childhood or^early youth. In the generation of the diathesis, full or luxurious living is the most influential agent; this is much aided by habits of indolence and refinement. Climate has probably an effect in inducing this state of the system, as in Great Britain, where gout prevails as extensively among the upper classes of society, as scrofula among the lower. The nature of this predisposition is not at all understood. It is usu- ally connected with a plethoric habit, and attended by a proverbial exemption from other forms of disease. The exciting causes which tend to develope it and give rise to an arthritic paroxysm, are numerous and diversified. Intemperance- nay, a temperate use of stimulants, even a single glass of wine, will occasion it in the predisposed—so will any indigestible or stimulating food, fatigue, loss of sleep. Local injury of a joint, as a twist or strain of the ankle, is sometimes followed by a fit of gout. Gout is divided into entonic and atonic—regular, misplaced, and retrocedent. It is entonic when the local inflammation is attended with febrile excitement and increased force of vascular action. It is atonic when the pulse and strength are below the usual standard— when instead of febrile excitement and local pain, we have general un- easiness and disturbance, with little inflammation of a joint or limb. Regular -out attacks a joint and is there fixed, the constitutional dis- order being proportioned to the local affection, and disappearing as if abates. Retrocedent gout consists in a metastasis of such local affec tion from the joint first attacked to some one of the internal organs. 2*7 210 Misplaced gout is said to occur, when, at or about the usual period of the recurrence of a paroxysm, or under the influence of the causes which tend to produce it, an arthritic subject becomes affected with much internal disorder. The pathology of gout is confessedly obscure and uncertain. The prevailing opinion of the day, refers the symptoms in all their variety to disorder of the digestive system. In this view I do not concur. The nature of the diathesis, especially when hereditarily derived, is utterly unknown. The local inflammation is of peculiar character, and terminates only in resolution or deposition of earthy matter, never in effusion of pus or serum, or in gangrene. The diagnosis of gout is easy in cases of long standing. A first fit may be mistaken for rheumatism. It is distinguished by its intensity, and its exclusive invasion of the smaller joints, very generally the ball of the great toe. The prognosis in regular entonic gout is decidedly favorable. In atonic irregular attacks it is the reverse ; these are often suddenly fatal, whether the stomach, the heart, or the brain be the part affected. A paroxysm of regular gout begins with a swelling of the ball of the great toe, which is extremely tender to the touch, with great tension and redness of the skin, the veins being full and the arteries throbbing. The pain, which is insupportably severe, extends upward towards the ankle and calf of the leg, and is much increased on letting the foot hang. Motion is impossible. There is fever, with headache and un- easiness of stomach ; the pain is described as very distinct and pecu- liar, and attended with a sense of numbness and paralysis of the part. The inflammation occasionally changes from one foot to the other, or extends to the knee. After a duration of a few days, these symptoms subside, leaving the patient in good health. At first the intervals are long, and the paroxysms do not recur for a year or six months, but by repetition their duration is lengthened and their frequency increased, until the local inflammation becomes almost permanent, when we may have the deposition of urate of soda and phosphate of lime, so charac- teristic of gout. The symptoms of retrocedent and misplaced gout depend upon the organ attacked. When the viscera of the thorax and abdomen are af- fected, there appear the usual signs of gastritis, enteritis, pneumonia, &c. When the brain is the seat of the evil,-it assumes rather the form of apoplexy than phrenitis ; and when the heart is assailed, the case is angina pectoris, or perhaps more correctly a cardiac neuralgia. When with these arthritic affections there coexists an infirm, debili- tated condition of the patient—atonic gout—the pulse is feeble and 211 wavering, the skin cold and clammy, the pain intolerably oppressive, and described as spasmodic, with constriction of the chest or stomach. When these pains are transitory though severe, and shift from place to place, now assailing the trunk and now the limbs, now one organ or part, and now another, it is the " flying gout" of the books. Treatment.—During the paroxysm, in young and robust subjects, and in the earlier attacks, it will be proper to resort to venesection ; but not in the opposite class of cases. Purgatives are almost always use- ful and necessary; I prefer the combination of a resinous with a sa- line, adding some aromatic. Emetics are very seldom indicated ; I would employ them when the stomach was loaded with a recent full meal, at the commencement of a fit. Opiates are much objected to by some, but in all prolonged paroxysms I am in the habit of prescribing the Dover's powder freely at night, and with excellent benefit. The tincture of colchicum and eau medicinale, maintained by many to be the same, are on the one hand highly eulogized, as not only safe, but admirably successful : while on the other, they are accused of fatal tendency. I have seen them both employed; there was some advan- tage gained, yet. not much, and no evil resulted. Wilson's tincture, a celebrated secret remedy, perhaps a compound of colchicum and ver- atrum, is certainly possessed of remarkable power, and will often con- trol and arrest the invading fit of gout. Local management.—Leeches are generally serviceable; they di- minish the pain, if they do not shorten the paroxysm. Some patients are relieved by a soft tepid poultice, while others derive comfort from cold astringent applications, as the solution of acetate of lead, sulph. zinci, &c. I have not seen the good effects promised from opiate fric- tions and blistering. Percussion and bandaging are recommended by Balfour and others, but my patients cannot bear the part thus handled. With regard to the cold bath, so much a subject of dispute, I would resort to it if, in a young and robust patient, after proper depletion, the pain and inflammation were obstinately prolonged. Under other cir- cumstances I would consider it unsafe, and dread its giving rise to retrocedent or metastatic gout. During the interval.—Temperance and exercise are the best prophy- lactics. The diet should be nourishing, but unstimulating. A threat- ened attack should be opposed by the use of laxatives and tonics. The tinct. guaiac. combines these properties ; I have seen it often ser- viceable. The alkalies and bitters have enjoyed a high repute, but since the Portland powder lost its reputation, are not so much used as formerly. The irregular forms of gout, the misplaced and retrocedent, must be 212 treated on general principles. If entonic, the local affections will be highly inflammatory, and will require the prompt and free employment of the lancet, leeches or cups, purgatives, and blisters to or near the part assailed. If atonic, on the other hand, an immediate resort to opium and stimulants is necessary. The tinct. opii may be given in large doses, with ether and other diffusible stimuli, while we apply the quickest revulsives to relieve the affected organ—mustard, hot turpen- tine, moxa, &c. Rheumatism.—This disease is especially interesting to the physi- cian, from the frequency of its occurrence, the intensity of suffering which it often causes, and the readiness with which, in the majority of cases, these sufferings are relieved by proper management. Rheumatism may be divided into acute, subacute and chronic. The elements which constitute it, vary in prominence. In the first, the in- flammatory, in the last, the neurotic symptoms prevail; in the second they are mingled more equally. Acute rheumatism presents violent local affection, some part being red, swollen, painful ; the larger joints, muscular and tendinous struc- tures are attacked, the suffering is great; fever runs high with noc- turnal exacerbations. The blood is buffy and cupped and fibrinous ; the sweat is disagreeably acid ; the urine highly acid, containing, says Jones, " crystals of oxalate of lime ;" the skin is very red. Suppu- ration is rare ; I have seen it occur twice. Prognosis favorable generally : duration from 7 to 12 days. 2. Subacute rheumatism, the most common form, is not marked by chill or vehement constitutional disturbance. Fever usually attends, most pronounced by night. The seat of the local inflammation is chiefly in the aponeuroses—may shift from place to place. Prognosis rather favorable than otherwises-metastasis is chiefly to be dreaded. The heart most often attacked in this way. Duration indefinite. Relapses frequent. Suppuration rare^—deformity and im- pairment of motion of limb and joint not uncommon. 3. Chronic rheumatism, an obscure and varying malady. There may or may not be pain in the joints, but they are swollen and de- formed, and become anchylosed ; the muscles imbecile and atrophied ; the heads of the bones enlarged and hardened or softened ; there may or may not be fever; an exacerbation may generally be noted at night. Prognosis unfavorable. Duration protracted. Recovery not often perfect. Relapses frequent. The predisposing causes are not well known, although it is evident, 213 that certain persons are much more susceptible of seizure than others. One attack renders the subject more liable to a second. The exciting or occasional causes are more obvious ; sudden alterna- tions of temperature, and exposure to cold and moisture, are the chief. So clear is this connection that a partial exposure will produce a local rheumatism, as in the familiar instance of stiff-neck from sitting near a partially opened window or door. The diagnosis of rheumatism is usually easy. It is not liable to be mistaken for any other disease than gout, the characteristics of which are well marked. Acute rheumatism chiefly affects young adults and middle aged per- sons. I have seen it however exquisitely developed in a child of three years, and in old people. Both sexes seem equally liable to it. Chronic rheumatism chiefly attacks persons in advancing years and of otherwise impaired constitutions. Treatment of the two first forms of rheumatism—the acute and sub- acute. In the robust and strong it is as well to employ the lancet, but this instrument has been used with great imprudence by many, in the hope to extinguish the disease at once. A certain degree of caution is required, or injury will ensue; and although it is undoubtedly proper to relieve hypersemia (if it exist) in the plethoric, and to reduce the vascular excitement which prevails by bloodletting, yet it should be remembered, that there is something peculiar in the nature of the in- flammatory affection, which refuses to yield to mere abstraction of blood; and that this remedial measure when carried too far, has changed a transient or acute, into an obstinate chronic or passive rheu- matism. Bouillaud, who bleeds most freely, reports the largest propor- tion of metastases to the heart, and does not promise any prompter re- lief than Hope and Latham, who rely on opium and calomel. I do not in the majority of patients, press the mercurial far. Purgatives are undoubtedly useful. I employ the saline in the first stages alone ; as the case progresses, in combination with diaphoretics. Diaphoretics, indeed, have been regarded as specifically adapted to the management of rheumatism. The antimonials are much prescribed. Colchicum is highly recommended here as in gout. It is said to combine, when given in proper doses, a purgative with a diaphoretic effect, and is greatly depended on by many practitioners. I make much use of serpentaria—at first, with enough of the epsom salt in solution to operate freely upon the bowels—afterwards with some form of opiate. The Dover's powder is invaluably beneficial, when the earlier violence of excitement has been subdued by the lancet and cathartics, and in larjre doses will often remove promptly all traces of the disease. In 214 protracted cases, the acetate of ammonia, with camphor and opium, is highly efficacious ; sulphur is also well adapted to relieve. In com- bination with these, we may frequently administer infus. cinchonas with striking advantage. Briquet substitutes for it the sulph. quinine, which he employs in large doses—from 5 grs. upwards. The nitrate of potass, is prescribed as specific in very free amount, from 3x to § ij daily. Lemon juice is recently eulogized as specific. The local management of rheumatism deserves attention. Leeches or cups should be applied, and the flow of blood kept up by warm fo- mentations or soft poultices, which will relax and relieve irritation and tension ; at a later stage of the attack, sinapisms may be applied, and embrocations of a volatile or stimulating nature made use of. The vapor bath is serviceable. I mention only to disapprove of cold appli- cations in the acute forms. Chronic rheumatism is a state of disease difficult to describe. It may be the result of an intractable attack of the acute variety. There is a subsidence of fever and of general excitement; the appetite and strength of the patient are in a great measure restored ; and the ap- pearances of local inflammation diminish or disappear, with the excep- tion of the swelling, which continues or may increase, the joint being incapable of motion. In general there is no acuteness of pain, but the part is ill at ease, and some cases are attended with excruciating sufferings, which no lapse of time subdues, and in others, fever per- sists of the low irritative type. The muscles which move the affected limbs emaciate—the joints become large, hard, stiff and misshapen, with a pale and waxen hue of the skin covering them. Chronic rheu- matism, when not the consequence of the acute form, is said to select usually women and feeble men ; but the most remarkable instance of it which I have ever met with, was in a stout and robust man, a phy- sician, in the prime of life, healthy and athletic. The case is worthy of description, as exhibiting very strongly the characteristic peculiari- ties of chronic rheumatism. The subject of it was sent for on a warm night in autumn, to see a patient some miles from home; he rode hastily thither, prescribed, and then, bathed in perspiration, lay down to sleep under a window in a strong current of air. On awaking, he found himself incapable of moving without severe distress, every limb and joint being stiff and sore. A brother practitioner being called, bled him 40 ounces, from which time he had no pain. He was still unable to move, and in a few hours after was bled 20 ounces more. He never recovered the use of his hands, but was able to walk slowly and feebly. His joints were swollen, pale and stiff—he emaciated gradually—his fingers were slightly bent, and had the appearance of waxen prepara- 215 tions. His appetite and digestion were good, and he had no obvious febrile exacerbations, though his nights were often restless and uncom- fortable. In this state of helplessness he remained some years, with a clear intellect and cheerful spirit. Having removed to a distance, I know not the manner of his death. Lumbago and Sciatica are two forms of chronic rheumatism, well known and of frequent occurrence in the aged. In these affections of the hip and loins, there is usually much pain and incapacity for mo- tion, but with little fever or general disorder. Some have doubted whether they are correctly to be considered as rheumatic, and have regarded them as affections of the large nervous trunks; but it is diffi- cult if not impossible to draw such lines of distinction as are here aimed at; for many cases of painful affection of distant joints, with swelling, readily recognized as chronic rheumatism of ordinary charac- ter, seem connected with or dependent on affections pf the nervous trunks, and are relieved by cupping or leeching the part of the spine whence they arise. Treatment.—In chronic rheumatism I would advise an avoidance of the lancet. The stimulating diaphoretics are our best remedies— guaiacum, camphor, ammonia and opium. Stimulants alone are much employed, and sometimes with good effect. The tinct. cantharid., tur- pentine, savin, and balsam copaiba, are strongly eulogized. Sulphur is often beneficial, and in feeble subjects may be well combined with infus. cinchon. and serpentaria. The colchicum autumnale is sup- posed to be well adapted here also. The phytolacca dccandra is thought to be similarly useful. The Lisbon diet drink is a formula much employed, and combines some of our best diaphoretics. Experi- ments have been successfully made with the prussic acid, in very ob- stinate cases. Endermic medication, by vapor baths, fumigations of sulphurous acid, chlorine, phosphorus, ether, has been much in vogue. The natural hot baths have effected numerous cures in our own coun- try ; the springs of mountainous Virginia, and of Buncombe, in North Carolina, are much resorted to, and hot and sulphurous waters are drunk with remarkable benefit. Local applications have not been neglected, and the number and variety of those recommended at different times, and by different per- sons, for the cure of this very obstinate disease, are great. Leeches and cups are used occasionally with great advantage. To Dr. Mitchell of Philadelphia, we owe the suggestion of the preference due to the spine, as the place of application—at the part whence arise the nerves supplying the joint affected. Epispastics, the pustular irritation of tart. antimon., moxibustion, the persevering employment of strong friction 216 over, and forcible motion of the stiff articulation, have all restored patients. Acupuncture has often given striking relief, and so have electricity and galvanism. The local employment of chloroform has been found productive of great relief in chronic rheumatism, and especially in lumbago and sciatica. The diet, during the protracted existence of chronic rheumatism, should be nourishing and generous. Motion of the stiffened limb should be resolutely and frequently attempted. If there be any obvious susceptibility to cold, it will be a useful precaution to envelope the trunk and limbs in flannel, or even to apply to the latter the flannel roller-bandage. Friction and percussion and the cold douche have been useful. DISEASES OF THE EXCERNENT SYSTEM. Of all the classes of the physiological nosologists, this has been found most difficult to delineate and circumscribe. The business of excretion seems to be divided among many of the .organs, which assist inciden- tally in its performance, while engaged in other functions. Thus the lungs, the liver, and the intestines throw off much effete matter, while busied in digestion, absorption, and assimilation. The kidneys are per- haps the only organs exclusively secretory ; we know of no other func- tion in which they are employed than mere elimination. Next to them, the skin perhaps deserves to be considered in this point of view. Ex- cretion is the most important office of the cutaneous integument, al- though by no means the only one. The diseases which affect this extended surface are numerous, di- versified, and often highly severe; they are of frequent occurrence, and in every respect deserve our particular attention. Among the chief of the maladies in which the skin is especially im- plicated, are the Exanthemata or eruptive fevers—a group of diseases, so called from the fact, that a cutaneous eruption, preceded or attend- ed by fever, forms the prominent point in their history. The characteristic peculiarities of the exanthemata are the following. 1. They are pyrectic or febrile. 2. Eruptive—the skin is affected by a special form of inflammation. 3. Self-limiting—they come to an end at a defined period. 4. Contagious. 5. Self-protective; they do not attack a second time. Variola, rubeola, scarlatina, exhibit all these characters—and probably pestis, urticaria, varicella, dengue, erysipe- 217 las, pemphigus, are not proved to be self-protective nor self-limiting. Analogies are pointed out which dispose certain writers of authority to class among the exanthems—typhus (Perry,) yellow fever (Hilden- brand,) cholera (Horner,) pertussis (Watt.) These are contended to be self-protective, contagious, febrile, eruptive; the mucous membrane being the seat of the eruption. They are not self-limiting. Vaccine has its own exclusive history—but like glanders and hydro- phobia, does not belong to the list of human maladies-; being introduced from the lower animals. The most familiar of the exanthems combine many circumstances of close analogy. A certain febrile disorder with notable gastric de- rangement precedes, by a pretty regular interval, a specific cutane- ous eruption of definite character. The period at which this character- istic eruption makes its appearance, though subject to occasional and slight modifications, is well known ; it is transient in its duration, run- ning a limited course, and then declining and passing away. Small- pox throws forth its eruption on the third day from the invasion of the disease—arrives at its height on the tenth, and then declines. The rubeolous eruption appears on the fourth and declines after the seventh. Scarlatina shows itself on the surface on the second, and fades from the fifth." They are contagious always, and often become epidemic also. They affect the human constitution but once—a rule which, however, is proved to be subject to occasional exceptions. In the instances of smallpox, and measles, the gastric disorder is notably diminished as soon as the eruption has appeared upon the skin ; in scarlatina this relief is less observable. The pathology of the exanthemata is specially obscure, although there is no want of theory or hypothesis on the subject. The nature of the connection, so uniform and essential, between irritation of the mucous membrane of the respiratory and digestive apparatus, and in- flammation of the skin of varied appearance and character, is entirely unknown. It is very common to represent the cutaneous affection as a metastasis of diseased action from the mucous tissue, which is as- sumed to be the seat of primary irritation, and first assailed, but this is incorrect. The mucous surface is not always, if ever, restored to a healthy condition at the time of the eruption ; but the nature of the dis- eased action is altered. It is now affected similarly with the skin, and continues to be so until the latter is restored to health. In smallpox, pustules form upon it; in measles the red patches are first seen on the palate ; in scarlatina, the tongue, throat and gastric surface, are last 28 218 to lose their extreme susceptibility to painful impressions, their height- ened color and obvious inflammatory condition. The whole mass of fluids seems to be, in some manner, vitiated in these eruptive fevers, of which the best proof is found in the fact thai they are conveyed to the foetus in utero, when the pregnant mother is attacked. Such instances happen not unfrequently in variola, and, al- though more rarely, in measles also. Variola—Smallpox.—A well known contagious, eruptive, inflam- matory disease, It has been supposed to be indistinctly mentioned in ancient writings, as prevailing among the easterns, but we have no definite description of it until the sixth century. Smallpox is usually treated of under the separate heads of distinct and confluent; which terms, however, refer not to any specific differ- ence, but merely to the degrees of violence of the attack, with the amount and extent of the attendant eruption. Variola commences, like the inflammatory fevers, with a rigor or shivering, followed by heat, pains in the head, back and limbs, gastric oppression, nausea and often vomiting, restlessness, anxiety, and mus- cular debility. Sometimes there is soreness of the throat, with pain in the side and chest, cough and dyspnoea. In young children the inva- sion is not unfrequently marked by convulsions. These symptoms continue for three days ; on the fourth usually, (it may be twenty-four hours sooner or later,) the skin of the face and breast exhibits an erup. tion, consisting of small papulae, slightly projecting and of red color, which afterwards spread over the arms and the rest of the surface, From the time of its appearance, the febrile symptoms decline, and in a great measure subside. These pimples or papula? assume in a day or two the vesicular form, becoming distended with a thin serous fluid ; they increase in number and size, and on or about the seventh and eighth are of a circular shape, with a depression in the centre, of the great majority. On the ninth and tenth, the contained fluid is turbid and purulent. In proportion as these pustules abound, the case is distinct or confluent. In the latter form of smallpox, they oftpn run togeth- er, so as to make a complete mask for the face, and on certain parts of the body, those for instance which lie always in contact with the bed, run into large patches and crusts. Where they are not in contact, the skin between'and around them is inflamed, red and elevated. There is ophthalmia, and the face and eye-lids are swollen, the mouth and throat are sore, and the patient spits largely a tenacious saliva. About the eleventh day, there is an abatement of the inflammation, both pus- 219 tular and cutaneous. The pustules, or many of them, crack, and the contained fluid oozes out; they flatten, and by the fourteenth have be- gun to dry and condense into a hard crust. From the twentieth, these crusts fall off, leaving in a great majority of cases, a permanent de- pression or pit in the skin. The case may thus terminate without farther danger or inconve- nience, and such is the history of a mild or distinct attack ; but when the pustules are very numerous or confluent, we may have them spreading over and destroying the eye, extending into the throat and trachea, occasioning suffocation or severe pulmonary inflammation, and in such instances a secondary fever arises, depending, probably, on the great degree of constitutional irritation, occasioned by so extensive and violent an inflammation of the mucous and cutaneous surfaces. This secondary fever invades at variable periods, from the eighth to the elev- enth day. The tongue and mouth become dry ; the pulse is very fre- quent and rather tense, but often feeble ; the breathing is difficult ; drowsiness comes on, increasing into coma, and the patient sinks ex- hausted with intolerable sufferings. The prognosis is favorable in distinct smallpox; in the confluent form it is the reverse. Bad cases may be known from the first, by an imperfect eruption, the vesicles rising very little, being rather livid than florid, and filling, or as the phrase is, maturating badly. If at any time the pustules flatten, and the skin becomes pale or livid, the danger is great, especially if the pulse and strength fail, and the mind is observed to wander. The occurrence of any urgent internal deter- mination is to be dreaded, whether to the brain, as shown by delirium, coma, &c, or to the respiratory organs, with pain in the side or chest, cough and dyspnoea. The sequelae of smallpox are often very serious. Deformity and blindness, with sometimes a permanent ophthalmia, a chronic diarrhcea, anasarca, occasionally follow it. The voice is in some permanently changed, and rendered disagreeable, by injury done to the soft palate. Scrofula is said to be excited to severe and rapid development, and the predisposition to pulmonary disease generally, but more especially tubercular or scrofulous phthisis. Autopsy.—The variolous eruption is found not only on the skin, the vascular network of rete mucosum being the seat of the pustules, but extends to the mucous tissue lining the mouth, fauces, pharynx, tra- chea, larynx, and rectum, and upon the conjunctiva. The structure and formation of the pustule in these positions, is not well made out. In the cutaneous integument it is multicellular. Thepit is occasioned by the sloughing of a circular portion of the cutis vera. 220 In many subjects the brain and its membranes are found dark with vascular congestion. In others the lungs are engorged and hepatized, and the pleura inflamed. Treatment.—During the eruptive fever of smallpox, if we are aware of the nature of the case, there is little temptation to interfere, when the attack is mild. I know not that there is any risk or evil, in the ordinary management of fever of equal intensity applied here. If at the time of access there are exhibited determinations to the head, lungs, stomach, &c, violent and severe, the lancet may be used, and its effect aided by mild purgatives. The mercurials are supposed to exert here a peculiar efficacy, but of this I am not satisfied. Great gastric op- pression, with foul tongue and fetid breath, require an emetic, espe- cially if the retching be insufficient, and fail to empty the stomach of its crude contents and morbid secretions. Mild emesis can scarcely do harm, and is serviceable besides, by favoring a centrifugal deter- mination of the fluids. It often relieves the infantile convulsions which precede the eruption. The purgatives which 1 have advised to be used with moderation during the eruptive fever, must be abstained from when the papulae are forming upon the skin ; after this, the bowels should be kept free by laxative enemata. The use of the warm bath, should be one of our earliest measures in the management of the unwashed and ill clad of the lower class. It is beneficial to children attacked with convulsions, who maybe relieved with the lancet cautiously employed, if the pulse be full and hard and the face flushed ; and on the other hand, if pale and feeble, may be tranquilized with small doses of the tinct. op. camph. The apartment of the sick should be well aired, and perfectly clean. He should lie on a firm mattrass, and if able, sit up occasionally. The cool regi- men, so vastly preferable to the heating system anciently in vogue, must not, however, be carried to an extreme. It will, if urged, do harm, when the pulmonary symptoms are prominent. Nor do negroes in general bear it well, unless much modified. Light mucilaginous drinks should form the only nourishment. The sore-throat should be gargled often with tepid water, and the inflamed eyes washed from time to time with milk and other mild collyria, and carefully protected from light and other irritants. To prevent the pitting, so much feared, many expedients are pro- posed. I have not confidence in any one of them. The resort to them in confluent and really severe cases is1 trifling, and in distinct smallpox there is little deformity left. Collodion may deserve a trial. In the secondary fever, most advantage is derived from the mildly 221 stimulating diaphoretics, as the infus. rad. serp., with slight additions of ether, camphor, or ammonia. I employ opium unhesitatingly and freely, when it is required to relieve the cough, dyspnoea, restlessness> and other sufferings of the patient. It does not seem contra-indicated by any circumstances but those which show a tendency to coma. I prescribe the Dover's powder or the camphorated tincture. In protracted cases, when the strength yields, cinchona is of much service. The infusion may be combined with other remedies. Exten- sive crusts are rubbed off occasionally by the motions of the patient in bed, leaving painful sores. These must be dusted with cinchona or finely powdered chalk, the pressure of the body frequently changed by the attendants, and extreme cleanliness inculcated. If the "striking in" of the eruption, as the phrase is, occur, the pus- tules flatten and become indistinct, with failing pulse, and cold and livid surface, it is necessary to stimulate promptly and energetically, both by internal and external means. The treatment of the convalescent requires much attention. He is covered with a new and highly susceptible integument, and is special- ly liable to the ill effects of exposure and alternations, from which he must be guarded strictly by proper clothing. His diet should, for a long time, be plain and unstimulating, though nutritious. Variolous contagion is both palpable and impalpable. It may be communicated palpably by contact with the diseased person or with fomites, and by inoculation," or the direct insertion of smallpox matter into a wound. It is also capable of diffusing itself impalpably through the atmosphere. At what stage of the case a sick body becomes thus a focus of contagion, is not clearly known—perhaps from the seventh day, when a peculiar odor or effluvium begins to be given off. It is strange to see so much stress laid upon the etymological meaning of the word contagion. Contact is undoubtedly necessary with the cause of disease, "causae non agunt, ubi non sunt." It is often unnecessary to come in contact with the sick person from whom the contagious efflu- vium, the cause, emanates. The latent period, the interval between infection and invasion, is also doubtful; it is usually rated at from nine to fourteen days. The effects of inoculation show themselves earlier—about the fourth day. Smallpox attacks the same person but once—a rule clear and posi- tive, though not without exceptions. This exemption gave great im- portance to the practice of inoculation, which enabled the subject to select his own Jime and circumstances for suffering the disease. It is difficult to account for the immense difference in violence and mortali- ty between the casual and inoculated smallpox. 222 Variola is liable to many modifications in history and character, some of which have been pointed out and separated in common lan- guage by special denominations, while the strong similarity which they present to each other and to the common stock of all, is indicated in the use of a word now become familiar everywhere, Varioloid. All the old writers speak of irregular forms of smallpox. Syden- ham is particular in detailing the varieties which the disease offered, in the several years of its epidemic occurrence under his own notice. Lieutaud speaks of a " spurious smallpox," occasionally taken for the legitimate. Parr tells us that "the varieties of smallpox are nu- merous." Others tell us of water-pock, of wind-pock, stone-pock, &c. in almost unnumbered diversity. It was only among the English, and not by them until the time of Heberden, that varicella (chickenpox,) was distinguished from smallpox. Morton of the time of Sydenham, speaks of it as mild smallpox. His cotemporary must so have regarded it, if he met with it at all. And though Heberden, Willan, Rayerand Mcintosh talk very positively of the distinctions between the two, yet other writers have not been able to mark them so clearly. Thomson, for instance, maintains varicella, in all its varieties, to be a modified smallpox, and while Willan recognizes it only as presented in the se- rous or vesiculous form, Rayer acknowledges, that it occasionally as- sumes a pustulous condition. With regard to the grade, which is made the source of distinction between distinct and confluent smallpox, it should be remembered that Ring has given us a case of confluent chickenpox, and that Mcintosh has recorded two fatal cases, one in a child, the other in an adult. Heberden speaks of a malignant sort of chickenpox, in which " the continuance of the pain and fever, after the eruption, and the degree of both these, though there be not above twenty pustules, are, as far as I have seen, what never happens in the smallpox." Chickenpox has been known to pit the skin, and distinct smallpox often fails to do this. If we receive the diagnosis of Mcin- tosh and others, who discern chickenpox by the succession of crops and pustules, what shall we say to Heberden's acknowledgment of his having seen four cases of its unequivocal occurrence in smallpox ? These are "the only instances," he says, and his language is striking, " which have happened to me, something like what is often talked of— a second crop." It seems to me that the above observations, in making which I have referred in preference to the older writers, exhibit plainly enough the difficulty of distinguishing smallpox from its kindred affec- tions, if their actual identity be not established. The term varioloid is a new one, first used by Thomson, in his " account of the varioloid 223 epidemic," which prevailed at Edinburgh, in 1811. Cross gives an excellent history of a similar epidemic, (which however, he terms smallpox,) as occurring at Norwich. The same pestilence, it is as- serted, raged about the same time in France, Italy, and Germany, from which last source it was brought into America in 1818, making its first invasion in Baltimore, Md., and Lancaster, Penn. It was first noticed in Charleston, S. C, in January, 1824. Varioloid has been assumed to differ essentially from variola, (small- pox,) because first, it affects persons known to have previously passed through attacks of regular smallpox ; secondly, it affects persons pre- viously vaccinated; and thirdly, it presents certain peculiarities of his- tory and character, which serve as distinguishing marks. The first of these alleged reasons is obviously of no force. It was long since observed, that smallpox sometimes failed to destroy the lia- bility to its own recurrence, and instances of its repetition are to be found in all the old writers. " Petrus Borellus," says Heberden, " re- cords the case of a woman who had this distemper seven times, and catching it again, died of the eighth attack." Dr. Oppert of Berlin, relates the case of a girl, who, at six years of age, had confluent small- pox. Seventeen years after, she was again attacked, and died of the disease. A similar case is authentically stated to have occurred in this city. If it is replied that these cases are too few in number to af- fect the general rule, that smallpox invades the constitution but once, we readily acknowledge the correctness of the assertion, and proceed to apply the inference to the case before us. During the prevalence of the epidemic of 1823-24, in Philadelphia, (call it varioloid or small- pox,) but sixteen persons are reported, by Drs. Bell and Mitchell, as attacked with it, who had previously smallpox. A similar list may be made out of cases of the same kind occurring here, while the pesti- lence prevailed among us, so limited in number however, as to prove most conclusively, that variola protects, at least in a certain degree, from varioloid disease. With regard to the second point mentioned above, it is only neces- sary to observe, that no well informed physician of the present day re- tains any confidence in the absolute preventive power of vaccine against the invasion of smallpox, however much he may be disposed to confide in its unfailing modifying influence. But of this, more hereafter. Thirdly, the principal peculiarities which are supposed to charac- terize the varioloid, and to offer specific marks by which we may dis- cern it, are, so far as we have been able to collect, the following: First, the eruption comes forth in successive crops. 224 Secondly, the pocks or pustules, when formed, are conoidal, without a central depression. Thirdly, they are vesicular, and not multicellular, as smallpox. Fourthly, they are smaller than the variolous. Fifthly, they contain lymph and not purulent matter. Sixthly, they dry and fall off without pitting. Seventhly, their progress and maturation are unattended with secondary fever. To all these we would rejoin, that the circumstances above des- cribed are by no means regular or connected in their occurrence ; and that if they were, they would not imply sufficient distinctness to con- stitute a separate form of disease. For, First, in the smallpox, the eruption is sometimes incomplete at first, the pustules appearing to thicken as the disease progresses ; and it is well known to all nurses, to be easy to increase, locally, the number of pocks, by exposure of part of the body to long continued heat, as by lying on it, wrapping it, or exposing it to the heat of a fire. Secondly, thirdly, and fourthly, the size and configuration of the pustules, vary much in the most clearly defined cases of smallpox. Upon the same individual, some will be seen large, and others small— some conoidal, and others depressed in the centre. The internal con- struction of the pustules will be found to differ in a corresponding manner ; the conoidal are vesicular—those which present the depres- sion in the centre are, like the vaccine, multicellular, that is, divided into many separate cells or spaces. If we have not grossly deceived ourselves on many occasions, we have further noted that the pock changed its appearance in this regard during its progress; at first vesicular and conoidal, it exhibited afterwards a depression at the apex, becoming flattened and multicellular. But upon this, as it is by no means important to the argument, we shall lay no further stress, content if we can draw the attention of the profession to it by our remark. Fifthly, as to the assertion, so often repeated, that it is characteristic of the varioloid vesicle to contain lymph or serum, and not pus or matter, as the common phrase is, I affirm on the other hand, that the smallpox virus is limpid and colorless. The most experienced inocu- lators, as for example, Parr and the two Suttons, always preferred clear transparent lymph. It is in the latter stages of the pock, after common inflammation supervened upon that which is specific and peculiar, that we find purulent matter; arid the few cases of varioloid or modified smallpox, which run on into this stage, exhibit just as distinctly the formation of pus. If the inflammation of the skin be 225 stopped at an early stage, we prevent this; and such, as I shall here. after show, is the most important of the train of effects attributed to the vaccine. Sixthly, John Hunter has somewhere declared, that in each pock of the variolous eruption, a slough of the cutis vera takes place, answer- ing in dimensions to the size and form of the pustules. This sloughing forms the pit or depression left by smallpox, and the circumstance is assumed by him and others—'Ring, for example, and Dr. Adams—to be peculiar to and diagnostic of smallpox, and to depend, not upon the intensity of the inflammation, but on its specific nature. Thus they propose to separate varicella or chickenpox, from variola or smallpox. It is easy, however, to demonstrate the fallaciousness of this test, sup- ported as it is by the authority of such high names. A pit is not made by every smallpox pustule. In distinct smallpox, and in inoculated persons, there is frequently left no maik or trace of the location of a pock. Goethe, when a child, at Frankfort, was attacked by smallpox there —long ill—but had the good fortune to escape without being disfigured. Mary, Queen of Scots, so remarkable for her exquisitely fascinating beauty, had the smallpox in her early childhood—but, says her bio- grapher, " it must have been of a particularly gentle kind, having left behind no visible trace." Nor can it be doubted, that the chickenpox and the (so called) vario- loid, occasionally, though seldom, produce similar sloughs or depres- sions, and so leave marks on the faces of those who have gone through an attack. Seventhly, secondary fever is often wanting in the mild cases of dis- tinct smallpox, and very rarely occurs in the inoculated. Dr. Parr indeed mentions the absence of it as a peculiar character of inocu- lated smallpox. It is clear, then, that no inference can be drawn from its absence, of a nature favorable to our opponents. It arises like the secretion of pus from the irritation of the cutaneous surface, and is proportioned in degree to that irritation. It is, therefore, met with now and then, both in varicella and varioloid. I believe varioloid to be identical in nature with smallpox, because they are promiscuously capable of producing each other. The modi- fications which have been noted and discussed, I attribute in a vast ma- jority of the instances presenting themselves at the present day, to the influence of vaccine, of which I shall speak presently. In others, (for they are confessedly irregular,) to certain indefinable and varied pecu- liarities of constitution, or habit, or condition of body in the affected subject. J 29 226 Under this head of varioloid, I unhesitatingly coincide with Dr. Thomson in comprising varicella (chickenpox.) This gentleman entered upon the course of observations, upon the Edinburgh epidemic, made by him with so much care and nicety, a thorough believer in the opinions of Heberden and Willan, with regard to the separate and in- dependent nature of chickenpox. His candor, however, did not long permit him to remain the advocate of this view of the matter. " Dur- ing the epidemic, I had occasion," he says, " to observe natural small- pox, modified smallpox, and the disease which I had been accustomed to regard as chickenpox, coexisting in the same situations, and ap- pearing in their progress to produce one another. In three families in particular, situated at a onsiderable distance from one another, and between which, except through their medical attendants, no sort of in- tercourse had existed, my attention was strongly excited by observing chickenpox arise in unvaccinated children, from the contagion of ma- lignant smallpox. The occurrence of this event, in circumstances which left no room for doubt, because there appeared to be no possible source of fallacy in the observation, led me to conceive that all the various appearances of the epidemic, in the different classes of persons whom it attacked, might be produced by the operation of one and the same contagion." Phenomena precisely similar have occurred under my own observa- tion, in the several invasions of this eruptive disease, call it what you will. Such of my patients as had not been previously vaccinated, or had not had the smallpox, exhibited for the most part the regular symptoms of variola, as it is found described in the books and recog- nized by the best authorities. Those, on the other hand, who had been protected by either of the above means, had the disease modified vari- ously, and in different degrees of mildness—some of them scarcely, others not at all, distinguishable from varicella. That the same con- tagion is capable of producing these several forms of variolous disease, whether regular or in any manner modified, is not only proved by their occurring thus together spontaneously, or in the natural way, but has been definitely established by repeated inoculation with the matter of the modified vesicle, varioloid or varicelloid, in which regular well- marked smallpox was the result of the insertion of the virus. Among such examples the case of Dr. Hennen's son, of Edinburgh, is most worthy of being detailed. This boy, from whatever source infected, was seized with an eruptive disease, concerning which Dr. Thomson thus explicitly expresses himself: " If I had been requested to point out the case, which seemed to me to correspond most accurately with the descriptions of chickenpox, I 227 should certainly have fixed upon the eruption of Dr. Hennen's boy." It was the circumstance of Dr. Hennen's viewing the disease in his son, as a well marked example of chickenpox, that led him to think of instituting the experiments which produced such interesting results. These results may be stated briefly, as follows : In four children inoculated from the above case, the disease was mild, and of short dura- tion—varioloid or varicelloid ; in two, it exhibited the appearance of smallpox. In three men who caught the infection from sleeping in the same rooms with these inoculated children, the disease was " un- commonly severe"—not to be distinguished from smallpox; and in a fourth, under the same circumstances, " the mildest variety ever de- scribed of chickenpox." Upon these grounds, then, I cannot help reprobating the introduction of a new term, the application of which is not only unnecessary, but calculated to confuse and lead into error. The modifications which have been assumed to constitute a separate disease, dignified with the specific appellation of varioloid, are each and all of them to be found described by the old writers, under various names. Thus we have from Dr. Huxham, "an account of an anomalous form of smallpox at Plymouth, in 1741." Thus we meet among the old writers with the phrases, horn pock, stone pock, water pock, wind pock, crystalline pock, swine pock, sheep pock, chicken pock, and numerous others, by which they intended to point out the undefined, but not uncommon varieties, which the variolous eruption occasionally assumed. I have already remarked that chickenpox was familiarly recognized as one of these varieties until the time of Heberden, who separated it under the name of varicella or variola pusilla, in which he was followed by Willan. I now add, that Dr. Bateman, closely as he was attached to Dr. Willan's views in general, found reason to doubt their correctness in this particular, as appears from an extract of a letter, written by him to Dr. Howitz, of Copenhagen, in which he says, "I am much inclined to concur with you in the supposition, that chickenpox is, in fact, modified smallpox." These varieties and irregularities formerly noted of variolous dis- ease, arose from peculiarities of constitution probably, in some instan- ces; in others, from local or general condition of atmosphere, habits, manners, &c, and perhaps in most, from causes entirely unknown and unassignable. To all these is now added, a more general and an uniform disturbing cause—the influence, namely, of the vaccine ; and hence, at the present day, these variations and modifications are more regular, and better defined than they were of old, as well as infinitely more frequent. 228 Vaccinia, the vaccine, derives its origin from the cow, (yacca.) It was first made known to the medical profession in 1798, by the justly celebrated Dr. Jenner, whom we rank unhesitatingly among the greatest benefactors of the human race. The history of vaccine is an exemplification of the acuteness of the remark of Southey, in his Omniana, " that most things are known before they are discovered." Prela, physician to the Pops in 1825, contends, plausibly, from pas- sages in Pliny and Celsus, that the vaccine was known to the ancients, under the name of boa. It had been long observed, in Gloucestershire and Dorsetshire, two of the dairy counties of England, that their cows were occasionally affected with a species of ulceration about the udder, which communicated to the hands of the milkers a pustular eruption. The occurrence of this eruption was noticed to have con- ferred upon such persons a security against the casual infection of smallpox, and such was the "general opinion," says Parr, "that the inoculator, who attempted to convey the smallpox to one who had been thus previously affected with vaccine, was ridiculed." There was no difficulty in following up so plain a hint, and the artificial communication of this disease, as a preventive of variola, was tried first by a farmer of that country, and afterwards by Dr. Jenner, with the most satisfactory results. The early writings of the latter on this subject were received with scorn, and his papers refused publica- tion among the Philosophical Transactions. It however forced its way into notice ; the value of the discovery was, after vehement and angry debate, established on the most authentic basis, and the zeal of its promulgator amply rewarded by ihe British parliament. Since that time the vaccine has been extended all over the globe, and all nations of mankind have exulted in the benefits thus bestowed upon them. To the present time it has enjoyed the undoubting confidence of the profession, and at once superseded, and almost entirely suppressed, the practice of inoculation. Vaccination is performed by introducing, under the cuticle, a small portion of lymph, taken from a vesicle about the eighth, ninth or tenth day, while yet the fluid distending the vesicle is transparent and col- orless. The puncture remains unchanged until the third or fourth day, when slight elevation and inflammation are perceptible, which in- crease slowly. About the sixth, it assumes a regular circular form, with a depression in the centre. The vesicle is completely developed on the eighth or ninth day, and attains the average diameter of one- third of an inch. An areola now surrounds it of an intensely florid red color, and some febrile excitement of the system is perceptible, with stiffness, pain, and slight swelling under the arm, if the vaccina- 229 tion be performed about the usual spot, above the elbow. The diame- ter of the areola differs from one to two inches. It is attended with a degree of roughness, hardness and intumescence of the skin over which it spreads—circumstances which denote its existence and extent in the black. The vesicle is multicellular, that is, composed internally of numerous spaces or little cells, which communicate freely with each other. The fluid within these cells begins to dry away on the eleventh or twelfth day, having previously lost its transparency, and become milk or straw colored ; the areola at the same time declines, and grad- ually disappears. x\bout the twenty-sixth day, a hard round scab of mahogany color, smooth on the outside and remarkably hollowed in the centre, falls off, leaving a permanent cicatrix or scar of peculiar and characteristic aspect—its surface being marked with minute pits or depressions, similar to those on the head of a thimble, " denoting," probably, " the number of cells of which the vesicle has been compo- sed." It has been observed that, in variolous inoculation, the vesicle forming at the point of insertion has been attended by the eruption of others in different parts of the body; but as respects vaccine, it is a fact of very rare occurrence. Two such instances, however, have been communicated to me. I shall not attempt to describe any of the numerous deviations from the above history, which are to be met with in the irregularly diversi- fied forms of what are called " spurious vesicles." Suffice it to say, that any striking or obvious departure from the ordinary phenomena, in the progress of a vaccine pustule, should make us cautious of con- tiding a patient to its protective influence. Vaccine, like every other disease, may undergo certain modifications from the condition of the recipient, an infinite majority of which are slight and unessential, not affecting its character and influence, nor impairing its genuineness. Others there are, however, though few in number, which change the nature of the specific action, either locally, or in its effect upon the system, and thus render it " spurious." Of the local modifying causes, the principal and most common is the mechanical irritation of the vac- cinated spot, (as by rubbing,) by which a common inflammation is sub- stituted for the specific, and a common sore produced. Erysipelatous inflammation may also supervene, and interfere with the formation of a regular vaccine pustule. Vaccine may, perhaps, be affected by or combine with some forms of constitutional disease, and thus take on a hybrid state. All cutaneous affections disturb the regularity of its progress, if they do not hinder the success of the operation, and no physician vaccinates as willingly from a pustule on the arm of a pa- tient known to labor under scrofula, herpes, or lues venerea, &c, as 230 from a healthy subject. There is a lurking doubt, in the mind of every one, however scornfully he may regard the humoral pathology, whether he may not, by vaccinating from such a case, communicate a mongrel disease. 1 am disposed to lay some stress upon the progress of maturation of the vesicle, although this may be slightly hastened or impeded, without detracting from the value of the pustule. Thus, the temperature of the season, if high, may occasion it to anticipate twenty-four or thirty- six hours perhaps ; and severe cold on the contrary, by checking the cutaneous circulation, may retard it in an equal degree. The debil- ity or robustness of the subject may give rise to like results. The pustule should be prominent and clearly defined, and the areola distinct and vivid. There should attend, some febrile disturbance of the general system. The appearance of the scar, as above described, I consider as of much importance. We should re-vaccinate when this peculiar appearance is wanting, and when the scar is smooth and resembles that of a burn. I do not find the observation made by any writer, but I have cer- tainly noticed the occurrence of a doubtful or spurious vesicle, to cause much difficulty in procuring, subsequently, the satisfactory results of vaccination in the production of a regular or genuine pustule. Vaccination is, of course, best and most successfully performed with fluid lymph, taken immediately from the vesicle, but this simple mode of communication is not always possible. When required to be transported to a distance, or kept for any length of time, it may be preserved by various methods. The fluid is caught on a small plate of glass, which is pressed closely against another of similar size and shape, and the edges waxed, to prevent the access of air. We receive It on the points of quills, likewise protected from the air by envelopes. Cotton thread is dipped in it, and laid aside with equal care. But in the scab we have the most convenient means of preserving and transporting this invaluable agent. It has been kept for years, and found capable of communicating the genuine disease, just as when recent. It may be protected from the contact of air and moisture, by immersion in softened wax and spermaceti. It is scarcely necessary to remark, that the first scab alone possesses the specific vaccine character; if this falls off, or is rubbed off too early, another may succeed it, but possesses none of its useful properties. C imate undoubtedly influences much the susceptibility of the hu- man, constitution to vaccine. The missionaries to Siam were endeav- oring to introduce it into that country many years before they succeeded. Perhaps this may have been owing in part to the difficulty of preserv- 231 ing the vaccine matter in very hot weather. This is well known in the southern states, where it is common to cease vaccinating during the warm months, and procure a new supply of vaccine from the north at the approach of winter. Some have strenuously urged the propriety of recurring occasionally to the udder of the cow, the original source of vaccine, to ensure its gen- uineness, and renew it from time to time ; but it may now be looked on as settled, that its primary and essential characteristics are un- changed and unimpaired, by any imaginable number of transmissions. Nay more, it is obviously improved by thus passing through the human system ; it is so modified as to have become a milder malady, though not less effectual in its influence on the constitution. A person inocu- lated directly from the cow, always suffers more, much more, it is^aid, than one who receives the infection from a human vesicle, and as far as has been ascertained, with no corresponding advantage to compen- sate. Among the animals which have been found capable of receiving and communicating the vaccine, are the horse, the ass, the camel, the buffalo, the goat, the sheep and the baboon. It has been doubted whether variola does not exert a reciprocal in- fluence upon vaccine ; whether it tends to prevent its introduction into the system, or in any manner or degree modifies it and disturbs its regu- larity when so received. But the mo^t positive proof has been obtained, of the transmission of perfect vaccine, through constitutions previously subjected to the variolous impression. It has been in this way brought across the Atlantic, by the successive vaccination of individuals, among the passengers and crew of the vessels, many of whom were known to have had the smallpox. Hence we may infer fairly enough the in- correctness of the opinion that, vaccine is only variola modified by pas- , sing through the system of a lower class of animals. Much has been said of the difficulty of communicating the disease more than once to the same constitution. Gregory, of the smallpox hospital, declares that "it is impossible or nearly so, to reproduce the vaccine in anything like its genuine form, where the cicatrix left, by a preceding pustule is perfect, and the result of a perfect vesicle." Dr. Darrach, of Philadelphia, in experimenting on this subject, found that the repeated insertion of the matter in the arms of vaccinated chil- dren, occasioned a local disease, exactly similar to that produced by the first operation, with the exception that the pustule and scab were much diminished in size. In none of these cases could fever, or any other constitutional effect, be discovered. Unprotected children were, with complete success, vaccinated from one of these scabs not larger 232 than a line, (one twelfth of an inch in diameter,) which was the result of a fourth insertion of the virus. The duration of the influence of the vaccine—the permanency rather of the effect which it has wrought upon the system—has been denied by some who are staunch believers in its temporary power to destroy the susceptibility of the body to the invasion of smallpox. But the mass of facts collected under this head, certainly goes* to prove, that whatever may be the result of the vaccine inoculation—whatever the impressions made by it upon the organism—this result, these impres- sions, are not likely to be impaired or obliterated by any process of time, or any changes in the state of the system from any cause. Of two hundred and fifty cases collected by Dr. Gibson, " in which small- pox is said to have occurred after vaccination, it appears that by far the greater number had been vaccinated less than two years." In Dr. Thomson's account of similar eruptions, they occurred at various in- tervals after vaccination, from a few days to fifteen years, not warrant- ing, in any degree, the suspicion that the power of the vaccine is weak- ened or exhausted by time. I am nevertheless disposed, on the ground of seeking the highest ultimate security, to advise re vaccination. It is possible that the first infection may have been something less than com- plete in its action on the constitution. It is also possible that the vehe- ment energy of an epidemic variola may require extra protection by recent and thorough subjection of the system to the mild influence of the vaccine. To ascertain the true influence of vaccine upon smallpox, is an ob- ject of the utmost importance. I will, therefore, briefly and formally recapitulate the points fairly established, by a due consideration of the facts collected on every side. First. Vaccination is no longer to be regarded as exhibiting the abso- lute power of preventing the access of smallpox. In some persons it does seem completely to destroy the susceptibility to various contagions ; in all it diminishes notably, though in different degrees, the liability to be infected. Second. The introduction of the vaccine virus into the system in its genuine form, and in the proper manner, never fails to produce there such changes as to modify certainly the future influence of the vario- lous poison, if, under any circumstances, it should affect the consti- tution. Thirdly. The modification thus asserted, does not appear to consist essentially in a diminution of the violence or duration of the first sta^e, the eruptive fever. This, though it is in general very slight, may be as severe as in casual smallpox. 233 Fourthly. Nor does it appear to imply essentially a diminution of the quantity of eruption upon the skin, although the number of pustules is usually very limited in smallpox after vaccination. Fifthly. The great power of the vaccine unquestionably consists in modifying the progress of inflammation in the variolous eruption. Hence, the slighter degree of cutaneous irritation, which terminates in numer- ous instances without secretion of either lymph or pus—the less amount of matter formed in the pustules (when effusion does occur)—the sud- den check given, in a majority of cases, to the suppurative process after it has commenced—the early disposition to rapid drying. Hence, the absence or transient duration of ophthalmia, which, with ulcera- tion of the cornea and destruction of the eye, constitutes the worst and most unmanageable sequela of unmodified smallpox. Hence, the rare occurrence of sloughing of the cutis, and consequent pitting, seaming and scarring of the skin. It has now become, happily, as unusual as it once was common, to see a person deformed with these marks of small- pox. Hence, lastly,-the infrequency of what is termed secondary fever, and its mildness when it does show itself. This is well known to be the most dangerous of the several stages of unmitigated small-. pox; it is tedious in duration, and leaves scarcely one constitution in a thousand, without inflicting severe injury and permanent deterioration. The convalescence from smallpox is, on this account, in the unpro- tected, notoriously slow. On the other hand there is no convalescence more rapid or more perfect, than that of a patient who has been assail- ed after vaccination. He recovers both perfectly and promptly. "Observe," says Dr. Gregory, "how strikingly opposed to (con- trasted with) each other in this respect, are the influences of inocula- tion and vaccination. Inoculation lessens the quantity of eruption, but does not alter in the slightest degree the progress of inflammation in that which is thrown out. Vaccination on the other hand, while it does not (necessarily) affect the quantity of eruption, always influences more or less the progress of inflammation in it." Sixthly. Nor can it be denied, that as far as we have a right to draw our conclusions from the tables of mortality published in reference to this question, vaccination tends much more surely and effectually to the prevention of fatal results, than inoculation. Thus among the cases stated to us by Doctors Bell and Mitchell, as occurring in Philadelphia in 1823-24, out of 248, 64 had been previously vaccinated, 1 only died ; 7 had natural smallpox previously, three of these died ; 9 had been inoculated, 3 of these died ; 13 unknown, no deaths. Of those entirely unprotected, (155 in number,) there died 85, more than one- half—a dreadful mortality. 234 It is surely impossible to set in a stronger light the advantages of vaccination, than is done in the above paragraph. Results similar to these are given in the annual reports of the National Institution of Great Britain, and in every other authentic document, without excep- tion, to which we have access. If we ask, how has this ancient and justly dreaded pestilence been deprived of its terrors, and shorn of its fatal energies, what shall be the impartial answer ? Not by any change in the nature of the case, not by any loss of its inherent power over the human constitution, for the mortality among the unprotected is most appalling—greater than that of yellow fever, or perhaps even the plague, amounting every- where, it would seem, to fully one-half. Nor is it owing to such pro- tection as inoculation affords, for that practice has been obsolete for the last quarter of a century. But it is clearly attributable, and we do not hesitate to ascribe it, to the kindly influence ofthe vaccine—the most valuable among the generous benefits conferred upon their fellow men, by the cultivators of the divine art of healing. Measles—Morbilli—Rubeola.—A specific form of fever, eruptive, contagious, inflammatory. It is often epidemic as well as contagious. It is difficult to communicate by inoculation, but Home and Speranza affirm their success—employing blood taken from the vivid patches of eruption ; and Von Katona inoculated great numbers successfully both with blood so taken and tears. Symptoms.—Rubeola makes its appearance with the ordinary tokens of catarrh. There is rigor often, followed by heat of skin, headache, hard and frequent pulse, soreness of throat, watery redness of the eyes, sneezing, a hard and dry cough, nausea and retching. In chil- dren, convulsions occasionally attend. This state of things may con- tinue for many days, but usually on the fourth the eruption breaks forth, at first visible on the face and arms, gradually spreading over the body. It is in patches of small red spots, rough and a little ele- vated. The fever generally abates, but not always on its coming out. The eyes suffer much from it, the adnata being covered and the lids swollen. It begins to fade on the seventh, and soon dies away, the cuticle desquamating in minute branny scales. In the progress of measles, or at the subsidence of the eruption, pneumonia is very apt to develope itself. At this latter period, diarrhcea of very obstinate character often arises. Rubeolous ophthalmia is apt to be persistent. The prognosis in measles is generally favorahje, and the danger is fairly proportioned to the attendant maladies above mentioned, the pul- 235 monary inflammation especially. In children the convulsions are occasionally, though not often fatal. It sometimes happens that the fever is of low typhous type, which is unfavorable. The " striking in," or sudden disappearance of the eruption, is also unpropitious, and excites well grounded alarm. The diagnosis does not seem to me difficult; yet it was not until nearly the end of the 17th century, that measles were separated from smallpox, a confusion which we should now regard as impossible. It may be confounded with scarlatina, which has indeed been called confluent measles. This very phrase suggests a distinction, for the patches of rubeolous eruption are usually separated by notable inter- vals. In 1829, however, I saw some cases in which they were nearly confluent. In scarlatina the deep diffused redness of the tongue and mouth is diagnostic. The catarrhal affections are prominent in mea- sles—the sneezing, coughing, &c, and the ophthalmia, which is often absent and very seldom severe in scarlatina. Pathology.—One might almost venture to declare that rubeola con- sists in the combination of some peculiar exanthema with catarrhal fever. This affects the human constitution but once, a rule present- ing very few exceptions. The eruption may occur alone, a circum- stance not unfrequently met with in rubeolous epidemics—the rubeola incocta of Good, R. sine catarrho of Willan, the bastard measles of common people. Now by this form the susceptibility to a second attack is not destroyed nor even impaired. Other varieties of measles are noticed by writers—R. nigra, R. maligna, R. variolosa. I have met with none of these. The concurrence of measles with typhous fever, presents a livid eruption, with great danger, a compound of nigra and maligna. Treatment.—It often happens that the catarrhal symptoms which precede the eruption, are not sufficiently severe to call for any reme- dial management, and the nature of the case is first shown by the ap- pearance of the red patches on the surface. Under such circumstan- ces it is best not to interfere, farther than to keep the patient at rest in bed, and on low diet, regulating properly the temperature of his apart- ment, which should be moderately but not unpleasantly warm. In an occasional case something more may be required. If there are tokens of pulmonary inflammation, and the pulse will bear it, vene- section should be resorted to, and the cautious use of the lancet followed by the administration of a cathartic, combined with a diaphoretic, as the solution of epsom salt in the infus. rad. serp. The vascular excite- ment being thus reduced, the diaphoretic should be continued, with some demulcent and anodyne preparation, to relieve cough and procure 236 rest. Cups or leeches to the chest may be demanded, and the thorax enveloped in warm poultices, if the dyspnoea be severe. In children affected with much gastric disorder and convulsions, the emetic is use- ful—given perhaps while the subject is in the warm bath, and followed by a mercurial cathartic. The eyes should be kept clean with tepid water at first, and afterwards washed with mild astringent collyria. If diarrhcea comes on upon the subsidence of the eruption, small doses of opium will restrain it, aided by the cretaceous mixture with kino, or by small doses of acet. plumb. The pectoral uneasiness remaining after measles, is best removed by the persevering application of successive blisters to the chest, or the irritation of the tartar emetic ointment, while we administer full doses of Dover's powder nightly. The sudden disappearance—" striking in"—of the eruption, is always alarming, and apt to be attended with convulsions in children ; and in adults, with dyspnoea and abdominal distress. If the pulse be full and hard, we must bleed freely; but if on the other hand, as is more common, the patient has sunk into a sort of collapse, we must resort to the highest order of stimulants. The hot bath, of 100° Fah. at least, must be made ready, while we apply sinapisms to the cold and pale, or livid surface; the camphorated tincture of opium, with the volatile alkali, and hot wine or brandy, must be given boldly and in abundance, until the skin becomes warm and the pulse rises. When rubeola is accompanied with fever of typhous character, it is proper to premise a mild emetic, after which a mercurial cathartic will be of service, followed promptly by the stimulating diaphoretics, which should be persevered in, adapting the doses to the condition of the patient and the effect produced. The convalescent from measles requires to be treated with caution. His diet must be mild and unstimulating, though nutritious, and he must be clad warmly, and guarded from all exposure. Scarlatina—Scarlet Fever.—A contagious eruptive, pyrectic dis- ease, characterized by a peculiar efflorescence of a very florid red hue, whence the name designating it. First described about the middle of the 17th century. It is often epidemic, as well as contagious. It has been communicated by inoculation, and as has been asserted, with the same effect as in smallpox, of procuring a milder disease. As a gene- ral rule, it attacks but once the same subject. Scarlatina is divided by writers, commonly, into three varieties, S. simplex, S. anginosa, S. maligna. I regard these as mere 'differences 237 in degree of violence and intensity. The attack is ushered in with ir- regular shivering, attended by oppression at stomach, and nausea, with occasional* vomiting ; then succeed heat of skin, thirst, frequent pulse, and headache, with sometimes delirium. The eruption ap- pears generally on the second day, but may postpone until the 3d or 4th, showing itself first on the face and neck, and gradually spreading over the trunks and limbs, until it almost covers their surface. On the succeeding day the lining membrane of the mouth, fauces and pharynx becomes inflamed, with ulceration of the tonsils and uvula, in the anginose form. The tongue throws off its fur and assumes a deeply red color, the surface being at first smooth, but soon shining with elevated and projecting papillae ; it is acutely sensible to the touch, or to the application of temperature either above or below its own. The efflorescence, which in many cases is almost confluent, is bright red, hot, dry, little elevated or rough, indistinctly papular. The skin seems thickened. On the 5th and tfth days it begins to fade, and des- quamates gradually in minute branny flakes. At this time the hands and feet are swollen, and for some short period the new surface remains morbidly sensible, especially that of the mouth. The inflammation in the anp-inose form is not always attended with ulceration, but some- times the tonsils are covered with flakes of lymph or false membrane. In bad cases the eruption comes out irregularly and is ready to recede. When this occurs, congestion or inflammation of some internal organ is prompt to follow, and we have either dyspnoea with thoracic pain, or vomiting and purging, or convulsions. If the patient be not quickly relieved, the pulse sinks, the countenance becomes ghastly, the com- plexion pale or livid, the skin cold, and death rapidly hastens on. During the prevalence of an epidemic scarlatina, especially if of ma- lignant or severe character, we meet with cases, among exposed sub- jects, of sudden convulsion or coma, with flushed face, injected eye, attended usually with nausea and retching. There is sometimes, but not always, efflorescence on the skin, especially of the face and neck. Such attacks are occasionally fatal within a few hours apparently by the vehemence of cerebral disorder. By the term scarlatina maligna, I would designate those cases in which the fever assumes the typhous type. This is common in some localities, where the epidemic visitations of scarlet fever are highly dreaded. The eruption in these attacks may be early or otherwise. The throat is affected with ulceration, which has a tendency to slough, is of ash color, and gives out a fetid odor, and an acrid discharge, ex- coriating the nostrils, offending the stomach and intestines, and produ. ing vomiting and purging. The internal organs are often attacked at 238 the onset; there may be delirium, often quiet and playful, dyspnoea with mucous rale, and intestinal or peritoneal inflammation. The ter- mination of this variety is often fearfully hurried, taking place from the 3d to the 5th day. Recovery is very slow and for a long time doubtful. The convalescence from scarlatina is attended in many cases with anasarca, and in some with general dropsy. The kidneys, which in- deed rarely fail to exhibit tokens of disease during the attack in the morbid qualities of urine excreted, almost uniformly suffer more or less during convalescence. The discharge is either scanty and high col- ored, or turbid and tinged with blood and strongly albuminous. Autopsy.—The appearances on examination after death, vary. In some, there is engorgement of the brain, and vascularity of the mem- branes, with effusion. In others, the lungs are congested and hepa- tized ; in others still, there is injection of the mucous surface of the stomach and intestines. As we should expect, the kidneys are variously altered in appearance; showing congestion, inflammation and granu- lar or fatty degeneration. Diagnosis.—I have not found it difficult to distinguish scarlet fever from measles, which it most resembles, by the want of catarrhal symp- toms in the fever of incubation ; by the confluent extension, and the peculiar appearance of the eruption, which in measles is in patches, more distinctly papular and more prominent. The scarlet tongue, with elevated and swollen papillae, is also characteristic. They differ much in the sequelse to which they subject the patient. The books make a confusion between scarlatina and cynanche maligna. In the instances of the latter formidable pestilence which I have met with, the eruption was not general or much diffused, and the tongue continued furred thickly to the end. Prognosis.—Scarlet fever assumes usually a mild form, and the pro- portion of deaths is small. The type of fever in the first place, and in the second the degree in which the internal organs suffer, would indi- cate the force of the attack. Thus, if there were delirium or convul- sions, or the ulcers of the throat assumed a gangrenous aspect, or dysp- noea supervened, and especially if with any or all of these there were combined a premature disappearance of the rash or efflorescence, we should know the patient to be in serious danger. Anginose and malignant scarlatina will be found attended every- where with a large proportional mortality. I am apt to lay some stress even in the early stages upon the appear- ance of the urine. If this excretion goes on freely enough and with but a moderate deposite, the prospects of the patient are probably good. 239 In bad cases it is sometimes nearly suppressed, sometimes bloody or thick, and of highly offensive smell. Treatment.—In general it will be sufficient to commence the manage- ment of the case with a mild cathartic. For children, I prefer the castor oil; in adult cases, a combination of epsom salts with magnesia, or rhubarb, and some aromatic. In the great majority, no farther interference will be necessary. Small doses of tinct. op. camph. are useful to tranquilize the restlessness of the patient, and determine to the surface. In general the patient will be apt to suffer under ordina- ry circumstances from the " nimia diligentia medici." Attacks of more than ordinary violence however occur, in which we are called on for farther aid. If the vascular excitement be specially high it may be reduced by the lancet. The throat being much inflamed, we may apply leeches at the angle of the jaw or on the neck. An emetic will relieve occasionally the oppressed stomach, if it be not emptied by spon- taneous vomiting. After the eruption shows itself, the cathartic should be abandoned, and the case trusted to diaphoretics. Currie, Gregory, and other high authorities, advise strongly the cold affusion in scarlet fever, and attribute to it the best results; while, on the other hand, those who consider the cutaneous eruption in the exan- themata as a metastasis from the mucous membranes, which they re- gard as the seat of primary irritation, deprecate the application of cold water as extremely dangerous. Truth lies between them ; and in general we may decide that the remedy, though safe, is not usually necessary, or capable of the striking good effects which some would teach us to expect from it. Should any form of visceral inflammation arise in the progress of the case, it must be combated with the usual remedial measures. I am not aware that the connection with scarla- tina modifies the necessary treatment. In Scarlatina maligna, it is prudent to begin with a prompt emetic, followed by a mild dose of calomel. The cordial diaphoretics are early required, and may be combined with other stimulants in requisite amount. Cinchona, the volatile alkali, and the tinct. op. camph. are among our best remedies. The hot bath should be used, if the surface is cold and pale, or livid, and sinapisms extensively applied. If the bowels are not moved by the mercurial, enemata should be adminis- tered. The throat should be washed with tepid water and steamed, and if there be from the ulcers much fetid discharge, likely to irritate the stomach, the emetic may require to be repeated. Great confidence is placed by many practitioners, in the exhibition of the infusion of cayenne pepper, both as a local corrective of the 240 morbid condition of the gangrenous ulcer, and as the stimulant best adapted to the exigencies of the case. The dropsical affections which supervene so often during convales- cence from scarlatina, must be treated as formerly advised, under the head of hydrops, with the modification, that they allow and require an early and free use of tonic and aromatic formulae, as the infus. cinchon. with rad. serp. and camphor, in small doses, with nitrat. potass, and nitrous ether. I ought not perhaps to omit, that the German homoeopathists propose the use of belladonna as a preventive of scarlatina in all its forms. They imagine it to excite a state of disease similar, or identical with scar- latina. The speculation is ingenious, but it is not sufficiently confirmed. My own experiments with the belladonna have been altogether unsat- isfactory, but there is testimony enough in its favor to encourage far- ther trial of it. Erysipelas is interesting from its complex character and relations. It is variously divided and subdivided. We may recognize three forms : erysipelas verum vel acutum ; erysipelas phlegmonodes vel sub- acutum ; erysipelas erraticum. Acute, febrile Erysipelas is a true exanthem. Its contagiousness is established. It becomes epidemic and associates itself with typhus and with puerperal peritonitis. It is not in any degree self-limiting nor self-protective. In the phlegmonoid and erratic forms indeed, it sometimes adheres with unconquerable tenacity, generating, as Copland phrases it, " a constitutional diathesis ;" in some subjects returns fre- quently from slight causes. Febrile. Erysipelas attacks with chill, succeeded by headache, nausea, heat of skin, frequent pulse, delirium, pain in head, back and limbs. The eruption shows itself on the second day, appearing first on the face and head, with diffuse redness and swelling, especially of the eyelid of one side. The inflammation is not florid but of dusky hue ; with burning and itching, returning slowly, when made pale by pressure. It penetrates all the cutaneous tissues. Vesications form under the cuticle, with oedema and sometimes sloughing of the subcutaneous cellu- lar membrane. It extends sometimes within the mouth, spreading to the fauces, pharynx and larynx, and the patient may be suffocated by oedema glotidis. During the epidemic prevalence of erysipelas in the south and west, some years since, (from 1841 to 1846,") this cavity was so generally at- tacked, that the disease came to be known by the appellation of " black 241 tongue," from the intense inflammation and discoloration of that organ. The ordinary duration of the attack is about nine or ten days. The prognosis depends chiefly on the condition of the patient. Spo- radic is less dangerous usually, than epidemic erysipelas, and different epidemics vary much in malignancy and proportional mortality. In pure air and during early life, there is no very great risk, unless some complication is present, such as fever of typhoid character, or the parturient state. In advanced age, in childbed, in crowded hospitals and ill-ventilated domicils, many die. The dark hue of the inflamed skin ; the soft quaggy feeling of the part, denoting gangrene of the cel- lular tissue; or dusky vesication with oozing of offensive matter; delirium, protracted, low, and muttering ; coma, or prolonged vigilance are bad symptoms. So is the extension of the inflammation within the fauces. Autopsy shows usually the brain and its membranes injected with blood, and inflamed ; effusions sometimes in the cavities, or on the sur- face of the emphalon. Treatment.—Unlike the other exanthemata, erysipelas requires prompt but judicious interference. Sporadic erysipelas in the young and robust and in the country, demands generally the antiphlogistic treatment; V. S., active purging and the antimonial and saline diapho- retics. Epidemic erysipelas, as occurring in cities and dense populations, is of very difficult management. In hospitals and when the fever is of typhoid character, depletion is almost forbidden ; mild cathartics, with the use of diaphoretics somewhat cordial, such as camphor and am- monia, precede the resort to cinchona, wine, and other stimulants, which often require to be freely used. As purgatives, colchicum with magnesia are recommended by Graves : calomel with camphor by Copland. I combine opium and calomel to keep the bowels soluble, determine to the skin, and procure sleep and ease. Locally, the inflammation is treated in an infinite variety of modes. Nitrat. argent, is rubbed all around its margin to circumscribe it, and placed upon it as a lotion and an unguent. It is perhaps, the most useful of all our applications. Cold and warm water ; dry powders ; lard ; ung. mere. fort.; laudanum ; poppy heads ; chloride of lime and carde°d cotton, are eulogized. Seeking the comfort of the patient, I encourage him to try several of them, and choose for himself. Erysipelas Phlegmonous—St. Anthony's Fire—differs much in its history from exanthematous erysipelas. Here the eruption precedes— the fever is symptomatic—in some violent—in many scarcely pro- 31 242 nounced at all. The local inflammation which selects in preference, like the exanthematous, the face and head, but is met with all over the body and very frequently fixes on the lower extremities, is the impor- tant element. It is less diffuse—the swelling projects more, with throb- bing ; and pus is apt to form under the skin, which ulcerates. Its usual cause is said to be intemperance or bad living. In the treatment I would improve as much as possible the condition of the constitution. In a robust plethoric patient I would resort perhaps to venesection, to low diet certainly. The bowels should be moved by a resinous purgative or mercurial. Alkalies with diuretics form a very useful combination—magnesia and colchicum or infusion of cinchona and serpentaria with carbonate of soda. Stimulants are not often ne- cessary, but they may become so in an old or enfeebled subject. Local treatment is of great importance. In such as will bear them free incisions through the swollen and inflamed parts are frequently beneficial. When inapplicable I resort to nitrat. argent, applied freely over the whole discolored surface, which may then be fomented or poul- ticed. Dr. Physick blistered the parts ; others put on alcohol, ammonia, turpentine—nay, the actual cautery. Erysipelas Erraticum is a very common form of disease in overfed children and women of gross habits. A strip of skin some inches in length and of a finger's breadth becomes red with itching and burning; or the ear or the eyelid is thus thickened and inflamed. After an hour or two, the eruption disappears from that seat and shows itself in another. Continuing to annoy the patient in this way for a day and night with restlessness, some nausea and slight fever, perhaps it goes away—or in unfavorable cases one of the wandering attacks becomes fixed and passes into erysipelas phlegmonodes. Treatment.—Low diet—a saline purgative—a tepid bath. The lan- cet is sometimes used, but I have not found it necessary. Dengue.—Scarlatina Rheumatica of Copland.—An arthritic fever with cutaneous eruption. This exanthema appeared as an epidemic in the southern states in the summer of 1828, having prevailed previously in the West Indies. Occasionally met with still sporadically, as noticed by Dr. R. Arnold of Savannah in 1848. The first symptoms are usually swelling of some of the smaller joints with immobility. Fever soon comes on—seldom with chill ; there is much prostration of strength, headache, pains in back and joints gene- rally. A rash or miliary efflorescence occasionally shows itself. On the third or fourth day fever subsides, leaving behind it great languor, 243 nausea, furred tongue, great depression of spirits, stiffness and pain of joints continuing, though rather less severe than at first. At a period not very regular, the fourth, fifth or sixth day perhaps, all these symp- toms are relieved by the coming out of the characteristic eruption, florid, elevated, in undefined patches, at first on the face, then on the trunk and extremities. When fully developed it is attended with burning and itching—febrile excitement returns and with it the arthritis becomes again severe. After a duration of two or three days the eruption dis- appears and the patient recovers; but the swelling and stiffness of the joints subside very slowly. Diagnosis.—It is not certain whether this is the same disease men- tioned by Rush as " breakbone fever," and by Mellis as existing in Cal- cutta in 1825-26. It probably is. Sporadic cases may be known by the combination of a primary arthritis with an eruption coming on at the subsidence of the first febrile attack, and coincident with or produc- tive of a secondary fever and arthritis, which subsides with it. The nausea and depression persist until the exanthem appears and are end- ed only by its full development. Cause.—Dengue is contagious and at times epidemic—beyond this its origin is unknown, like that of other exanthems. It seems to be confined to the warm season and hot climates. Prognosis.—Death from dengue is rare, and only to be feared in the aged and infirm ; but deformity and lameness frequently remained— and convalescence was always slow. Treatment.—After numerous and varied experiments, I learned to con- fide exclusively in the management of dengue by anodynes and dia- phoretics. On the first access of pain, which was usually severe, and sometimes brought tears from the eyes of the patient and cries from the weak, I administered opium in free doses, preferring the combina- tion with camphor. A warm bath, if at hand, hastened the relief sought for, and the sufferer was left to sleep, covered warmly. On waking, if pain returned, the dose was repeated, and thus the violence of the attack was without fail restrained. The determination to the skin hastened, too, the appearance of the characteristic and essential eruption, and a few days spent in bed enabled the patient to pass with comparative comfort through the course of a self-limiting disease. The troublesome sequela of a quasi rheumatic inflammation of joints and muscles was thus altogether or in great part evaded. After the experience afforded by a few early cases I saw no farther need either of venesection or purgatives. In a very few who could not bear opi- ates in any form, I had to substitute other diaphoretics, which with warm baths and confinement to bed constituted the whole method us 244 medendi. These suffered more and recovered more slowly, but in the end perfectly. I dwell on the confinement as necessary, for exposure to cold air either postponed the coming out of the exanthem or repelled it, and prolonged the attack with great aggravation of the constitutional symptoms, nausea, fever, &c, with additional risk of deformity and lameness of joints. I add only that the slowest and least perfect recov- eries were met with (and some deaths too) in those treated by vene- section, active purgatives and antimonials. DISEASES OF THE URINARY ORGANS. The kidneys are the only viscera whose function is exclusively excretory, and this depurative office is of such importance that it can never be impeded or imperfectly performed without serious risk and grave disorder of the system. The urine contains numerous elements, each of which must be thrown off from the blood, as injurious when re- tained. A knowledge of its normal composition, and its ordinary vitiations is absolutely necessary to the physician. The nitrogen of the ingesta—effete—finds its way out hence in urea and uric acid ; as the carbon does by the lungs and skin, and the hy- drogen by the liver. The kidney is liable to inflammation both acute and chronic. Acute nephritis, like other phlegmasice, comes on with chill succeeded by fever. Severe pains are felt in the loins, aggravated by pressure or motion, and extending down generally on one side, to the bladder, and even the testicle, which is drawn up, with aching in the hip and thigh of that side. There is distressing nausea and great thirst. The urine is scanty, high colored and albuminous. The causes of acute nephritis are external violence, great fatigue ; violent, rough exercise, as on horseback ; certain irritants produce it, as turpentine, cantharides ; and sometimes cubebs and copaiba. It is ascribed to metastasis of the exanthemata and of gout, and of rheuma- tism. It cannot fail to follow soon or late the presence of a stone too large to pass into and through the ureta to the bladder. The diagnosis is not difficult. We separate it from nephralgia, which alone it resembles, by the presence of fever from the com- mencement, which does not belong to the history of the latter, though it may arise in its course. - Prognosis.—If of one kidney, accidental and from transient cause, 245 it is attended with little risk, in a good constitution. If both kidneys should be at once affected, there would be danger in the impediment to the excretion of urine, which always oppresses the sensorial system, soon giving rise to fatal coma. The presence of a concretion must destroy the organ when too large to admit of farther distension of the pelvis and ducts. Autopsy shows the kidney in various states according to the period at which death occurs—congested, inflamed, destroyed by abscess. The brain is deeply injected with dark blood which contains the une- liminated urea. The treatment of acute nephritis is of necessity antiphlogistic— venesection, purgatives, oily and resinous,with large emollient enemata ; cups over the loins, and warm fomentations to that region and over the pubes; and when the bowels have been well moved, free doses of opium with antimonials, to relieve pain and determine to the surface. Chronic nephritis presents similar symptoms with less intensity. At first a feeling of fatigue readily brought on, with aching in the loin and in the side and groin and testicle—urine high colored, scanty, albuminous, turbid. Exercise increases the symptoms—the patient emaciates with dejection of spirits. There is usually a febrile par- oxysm in the evening with restlessness. Cause ; diagnosis ; prognosis ; autopsy—are all such as described under the head of acute nephritis. The treatment consists in local depletion, keeping the bowels solu- ble, and the employment of the less irritating diuretics, such as buchu, digitalis, colchicum. Some prefer the alkaline and neutral salts, the carbonates of soda and potassa, and the acetate of potassa. There is relief often obtained at the watering places, rather I think by the amount of fluid drank, than its quality. Urines are morbid in quality and quantity. The average excretion in health is about thirty-two ounces in twenty-four hours, varying ac- cording to season and circumstances. Diabetes consists in augmentation of quantity ; insipidus only thus : mellitus with substitution of large addition of sugar and deficiency of urea, which is left in the system. Not less than 42 pounds have been passed thus per diem. The opposite condition of anuria—paruria inops—is more frequently met with as a symptom in certain diseases, as in cholera asphyxia and yel- low fever. It is always unfavorable and injurious. It must not be con- founded with suppression of urine, or its retention in the bladder. If ever idiopathic, it produces great disorder of the system and especially of the brain, with stupor and coma, from the poisonous effect of the 246 constituents of urine retained in the circulating fluids. In less degree it is associated with dropsies, perhaps as cause, more probably as co- incident effect of some common cause of both. Urines are morbid in quality by change of proportion of normal ele- ments ; defect of some constituent principle. In gout and rheumatism we have undue amount of uric acid, and the urates ; in diabetes, defect of urea; and here also, the presence of a new body, sugar; and in oxyluria, oxalate of lime and sometimes blood corpuscles and blood itself, and albumen and fatty globules in Bright's disease, or albuminuria. Every practitioner should be familiar with the more simple tests by which the qualities of the urine may known. Paper colored by lit- mus will show whether it is acid or alkaline. When albuminous it will show a coagulum if heated in an iron spoon over the flame of a lamp; and when a few drops of nitric acid are mingled with it. The concur- rence of these tests will form a correct diagnosis of albuminuria. With a good microscope we can detect crystals of oxalate of lime. For more minute examination and analysis, the young physician may refer to the works of Bird and Prout. The majority of these changes and vitiations result not from primary disease in the kidneys, but in the organs of digestion and as- similation. Yet though this is ordinarily their history, I am ready to admit, with Holland, that the kidneys, though more rarely, may be the original seat of the difficulty, by the impairment of their function. Hence result the several concretions known as gravel, renal and urin- ary calculi, and stone in the bladder ; which consist of phosphates, lithates and oxalates of soda, ammonia, lime. The presence of these is known by deposites from the fluid when cold ; by chemical analysis ; by the use of the microscope ; by the irritation they occasion in passing, when small enough to pass through the ureter and urethra, and their being found after passing ; and by certain symptoms which they oc- casion in the urinary organs, while present in the kidney, the ureter, the bladder, and the urethra. These are mechanical in all cases but one, known in modern pathol- ogy as Oxyluria, and but recently diagnosed. The symptoms of oxyluria depend on the presence of oxalate of lime in the urine. It is attended not only by the mechanical sufferings which belong to the history of all other urinary concretions, but shows itself by the uniform develop- ment of nephralgia ; combined with the worst annoyances included in the history of dyspepsia. There is no fever, nor any token of local inflammation. The pulse is slow and soft, generally ; the mus- cular strength not good, fatigue coming on promptly, with increase of the aching in the loins, hips, back and thighs. Paroxysms of intense • 247 suffering are apt to assail from time to time with an ill-defined periodi- city, in which the groin and testicle are affected, the latter being ve- hemently retracted. Flatulence attends or follows a paroxysm—constituting what has been called nephritic colic. The urine is amber colored—may show neither deposite nor morbid contents on chemical analysis, but the microscope detects the crystals of oxalate of lime diffused throughout, acicular, cubic or dumbbell or kidney shaped. The frequency of this morbid state has been recently discovered to be great. It is ascribed to a special vice of assimilation. The treatment of a paroxysm of nephralgia in the subject of oxyluria requires the free use of opium or rather of morphine, which can be more promptly made available by its concentration, and disturbs the stomach less. The hot bath is serviceable—and warm fomentations to the loins and lower part of the abdomen. Tics or flashes of pain running through the bladder and to the end of the penis betoken the passage of a concretion through the ureter, which when accomplished, gives immediate and great relief. Its exit from the bladder must be aided as far as possible by procuring a large flow of urine by diuretics—and retaining the discharge until a full stream is ready to be projected forcibly. The transition from nephralgia to nephritis which sometimes occurs, must be watched. If the skin becomes hot and dry with or without a chill, and the pulse hard and frequent, venesection local and general will be necessary. A purgative will often relieve the severity of pain even purely neuralgic. I do not hesitate to employ for the same purpose as an anesthetic, chloroform in proper amount. To correct the oxalic diathesis, we must pay strict attention to the diet: not more than a moderate portion of nitrogenized food should be allowed, though the subject as a dyspeptic would suffer too much from confinement to vegetable aliment exclusively. Certain articles, con- taining oxalic acid and lime, are to be shunned. Wines and malt liquors are to be avoided. The bowels should be kept regular, and muscular fatigue and mental anxiety evaded as much as possible. The nitro-muriatic acid has been highly eulogized ; I have seen it fail. Colchicum and magnesia for short periods are beneficial. The mineral waters—those especially which contain carbonic acid—do service, but must not be persisted in too long. Local counter-irritation is of service. Granville's liniment, or tinct. aconitine, may be chosen. In general terms, the treatment of those urinary disorders in- volving the presence of morbid urines, with or without deposite or concretion, has not been, as yet, much advanced by the application of chemical knowledge. We know no certain means of correcting our 248 • the tendency to form such concretions within the kidney, or to dissolve them when formed. We still hope for the discovery of such means, and must seek for them perseveringly. The indications to be followed are, to determine to the skin, whose function is adjuvant to or con- trasted with that of the kidneys, by warm clothing, frequent bathing, friction, &c, and diaphoretics ;—to improve the condition of the diges- tive functions, by careful attention to diet, and by the use of such tonics as act favorably upon the stomach, among which iron is gener- ally preferred ;—to correct any special tendency or diathesis discovered to exist by those chemical reagents which promise most, as the use of alkalies in the uric acid diathesis, and nitro-muriatic acid in oxy- luria;—to relieve undue determination to or congestion in the kidneys) by local depletion, counter-irritation, and the employment of the mild aquseous diuretics and those which have been found specially adapted, —as colchicum, uva ursi, buchu ;—and lastly, by careful observance of all such rules of regimen as may be required in every special case to bring up the system of the patient to its best condition of general tone and health, as by traveling, voyaging, visits to watering places, in- terruptions of occupation, bodily and mental, and repose of body and mind. Bright's disease—Albuminuria.—Granular or fatty degeneration of the kidney is one of the most serious diseases of these organs. It is known by the name of the distinguished writer who first called the attention of the profession to it; by a term expressive of its most prominent symptom ; and by phrases denoting its alleged pathology. It is a chronic affection, gradually undermining the constitution with a long train of symptoms not well defined, and affecting most of the or- gans and functions. The complexion is sallow and anemious ; the muscular system weak with emaciation ; the appetite defective ; diges- tion impaired, with diarrhcea or alternate torpor of bowels; there is oedema and at last general dropsy. The urine is highly albuminous, sometimes bloody, with micturition. The cause is not clearly known. It is often connected with previous disease, following scarlatina and smallpox, &c. ; and ascribed to intem- perance, mercurials and scrofulous affections. Walshe says it is owing to a primary vice of the blood. Autopsy shows the cortical portion of the kidney granulated and in a condition resembling the fatty degeneracy of the liver. The treatment is uncertain, and far from generally successful. Vene- section is advised in the early stages, and in patients in whom loss of blood can be borne, both general and topical. The mercurial cathartic is preferred by some—by others the hydragogues, as jalap with cremor 249 tartar. As diuretics the acetate of potassa with colchicum, buchu and digitalis. Tonics are exhibited—iron, zinc, gentian and cinchona are chosen. A warm climate should be sought. Diabetes.—Inordinate secretion of urine. The quantity of this excre- tion is varying continually with the difference of temperature, moisture of air, food, drinks, states of body and emotions of mind. Some headaches are regularly attended with large limpid flow of urine; hysteria and certain other nervous affections strikingly exhibit the same symptom. I once saw a case in which about 24 lbs. were discharged in 18 hours. The patient was a mulatto woman between 60 and 70 years old, who seemed much debilitated by it. It was connected with no obvious cause, ceased suddenly, and she recovered promptly and entirely. The books speak of a diabetes insipidus: I have never met with it, unless the above may be so regarded. Diabetes is usually character- ized by a peculiar vitiation of the inordinate amount of urine, which contains sugar and presents little or no trace of urea. The fluid is sometimes frothy, giving out a faint subacid smell, and attracting flies and other insects. Many pounds of such urine are discharged daily for weeks together ; the strength of the patient decreases rap idly and emaciation ensues. The duration of diabetes mellitus varies much however; it is often connected with bulimia and polydypsia, the diges- tion being very good and the appetite insatiable, and of course prolong- ing his life. There is even in some, a stage in the progress of the dis- ease in which fat is deposited, disappearing as the case grows worse, supervening again if it is arrested, as the first stage of recovery. It may last for months and years. I saw a fine young man die of it in little more than a fortnight. The degree of profluvium has an influ- ence on its duration doubtless, and this varies from 18 lbs. to 42 per diem. In advanced stages there is a constant sense of weariness in the loins; irritative fever is present, highest in the evening; the mouth and general surface are very dry. The cause is not well known. It is ascribed by some to intem- perance • but I have met with it in three persons remarkable for their abstinent habits. The promptly fatal case above mentioned, was in a gentleman who had never during his 25 years of life tasted either wine or ardent spirits. He attributed his attack to the fatigue of constant standing at his desk. Pathology.__Diabetes mellitus consists in some obscure vice of di- gestion and assimilation. The development of sugar takes place in 250 the stomach itself; it has been found there, and in the intestines and upon the feces. (Bernard says sugar is always formed in the liver.) It abounds so much in the urine, as to be strongly perceptible to the taste, and to attract flies. The fluid contains, also, frequently the torula cerevisii, or yeast-plant, and ferments rapidly. A portion of the uneliminated urea is found in the blood. Watt regards diabetes as a cachexy, like gout and scurvy. Some maintain its dependence on a primary morbid condition of the great sympathetic nerve. Autopsy shows little or nothing to account for the symptoms. The body is much emaciated. The kidneys are sometimes fatty. Prognosis generally unfavorable, though some patients recover. There always remains a strong tendency to relapse. The danger is proportioned to the amount of fluid discharged, and the proportion con- tained in it of sugar ; this Todd looks upon as the diuretic which urges the kidneys to morbid activity. Treatment.—On chemical principles,vegetable diet has been absolutely prohibited, and the patient kept exclusively upon animal food, as highly azotized. All fermented drinks are ordered to be abstained from. Bouchardat affirms positively, that " if all amylaceous matter be taken from the food, sugar will disappear from the urine:" but Todd denies this. There is no doubt however, that this course of management is productive of very useful results. Opium and the mineral acids have been, of all medicines, most confided in, and are very freely used. Combined with them some pre- scribe iron, lead, zinc, as tonics ; others cinchona, kino and catechu. The bowels are to be kept soluble during this treatment by the resinous purgatives, aloes, rhubarb, &c. V. S. has been employed in some robust subjects; it is said with benefit. More frequent advantage is alleged to have been derived from topical depletion by leeching and cupping the loins, and from counter-irritants applied to the same re- gion. Emetics frequently repeated and long persisted in, are affirmed to have been decidedly serviceable. Cystitis.—Inflammation of the bladder may be acute or chronic. The former is rare, except as supervening on the latter, a fatal instance of which once occurred under my care. Symptoms.—It is readily known by the locality of the suffering— the incessant micturition and dysuria; febrile irritation runs high, with restlessness and delirium. The chronic form is not unfrequent in advanced life, when we have 251 similar symptoms in less urgent degree. The urine is full of thick mucus; is sometimes loaded with phosphates; sometimes alkaline ; the frequent calls to pass water wear out the contractile powers of the sphincter, and the fluid dribbles away constantly, with scalding and offensive smell. The cause of cystitis is sometimes difficult to detect. It follows upon excess, debauchery, and intemperance. It may arise from mor- bid conditions of the urine when containing irritating matters, solid and fluid ; or it may be the result of a gonorrhceal affection extending upwards along the urethra into the bladder, or of gleet with stricture, or of the remedies employed for the cure of these affections. Autopsy shows thickening of the bladder, sometimes to a very great extent, and even ulceration. Treatment.—In proportion to the acuteness of the attack and the youth and vigor of the patient, the antiphlogistic regimen should be instituted and carried out with energy. Venesection will sometimes be required more than once; and we may generally leech the pubes or perineum with much advantage. Warm fomentations should be assiduously applied. The bowels must be freely moved with oily or resinous purgatives, aided by large tepid enemata. Opiates must be administered to relieve the severe suffering of the patient; they may be combined usefully with relaxants and dia- phoretics, as ipecacuanha and camphor. Some advise alkalies and diuretics. I have however, found them irritating and injurious, with the exception of magnesia and digitalis, which may occasionally be properly prescribed. Subacid mucilaginous drinks may generally be allowed. These last mentioned remedies are better adapted in chronic cystitis, which is also benefited by the use of the thermal springs and sulphur waters. Cytherismus, cystorrhcea, or " irritable bladder," demands similar treatment with the affection just spoken of. Indeed it is hardly to be distinguished from it. We may remark the absence of febrile excite- ment,°far less emaciation and general disturbance of the constitution as diagnostic. We may venture upon a less timid employment of diuretics here. Vegetable articles^ this class, which combine some tonic qualities, as uva ursi and buchu, deserve a preference. Infu- sions of these and a solution of tannin are injected into the bladder with good effect. Common green tea is also employed in the same way. THE END. J NLM032783773