.!W V. ■|t,i-l!t- ''«..!?! vt, '11 m '^ HI... V.,, (-S. l^liimTi,-' * » i..i;,..,.................:, ........i.llil.lilUJi.il........ .liiill.llim.iiliiii.l!- ','c'V",iiiililiillljiililjil.Uii 73 |\vi Surgeon General's Office wb C/ec/ton,. ISHB* No. //£ & £ 4 r ^/^^/t^Y'^ LETTERS A YOUNG PHYSICIAN JUST ENTERING UPON PRACTICE. )/ JAMES JACKSON, M. D., LL. D. PROFESSOR EMERITUS OF THE THEORY AND PRACTICE OF PHYSIC IK THE UNI YEB31TY AT CAMBRIDGE ; LATE PHYSICIAN IN THE MASSACHUSETTS GENERAL HOSPITAL ; HONORARY MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY OF LONDON } CORRESPONDING MEMBER OF THE ACADEMY OF MEDICINE AT PARIS, &C. &C. &C I' l^l' BOSTON: PHILLIPS, SAMPSON AND COMPANY. NEW YORK: J. C. DERBY. 1855 Vs/B JI3L X le 5 p,/n, No &Jht pressure, but on pressing the fingers somewhat into the abdomen while the patient was on her back. She was not aware that there was any tumor, or that any was suspected, but she complained at the moment when I touched it, and did not acknowledge any like tender- ness upon pressure in any other part of the abdomen. The pain, however, extended beyond its seat, particu- ON DISEASES OF THE INTESTINES. 251 larly above it. She had one symptom, AYhich I have never known in any other case. This Avas pain in the iliac quarter on sitting down and on rising from her chair. It was not a severe pain. There was not any strongly-marked constitutional affection, though she felt less well than usual. The remedies employed were cathartics, leeches tAvice and blisters tAvice, over the seat of the tumor. Under the use of these she greAY better, but at the end of a fortnight the tumor could still be felt. I then ordered an ointment of iodine and hydriodate of potass to be applied over it, and under the use of this she got quite well within two or three weeks. Whether the ointment helped it is uncertain; but, in respect to the benefit of the other remedies, I felt no doubt, as manifest relief folloAved each one of them. In this case the tumor could be covered entirely by a half-dollar. She has not had any return of the disease. It was I believe at an earlier date that I saw Mr. B——, a young gentleman, in consultation, who had acute pain in the abdomen, somewhat of the character of colic pain. It was severe, and he was on his bed. I saw him, I think, on the second day of the attack, and was told that he had had a similar affection not many weeks previous. On examination I found dis- tinct tenderness at the spot before described, but there 252 ON DISEASES OF THE INTESTINES. was very little, if any, tumor. By remedies like those used in the last case he was soon relieved entire- ly. I inquired from time to time afterwards, and found that he had not had a third attack. Though the evidence of a tumor was very equivocal, and at the most it was very small, I have ahvays suspected that the disease Avas the same as in the preceding cases, and that its recurrence Avas probably prevented by the remedies. If so, he gained by the severity of the case, which obliged him to seek medical aid at once. The folloAving is a case of much greater severity and duration, Avhich, hoAvever, I consider as similar to the others in its essential character. The patient, Mr. R----, AYas past middle life, a business man, of active habits, and of a distinctly nervous temperament. He had been sick, much of the time in bed, for two or three months before I Avas called to him in consulta- tion. He had a good physician, who was not, however, acquainted with the disease. This man had a large tumor, tAvo inches in diameter, Avhich came under the spot before described on the borders of the iliac quarter. I do not mean that the angle of the lines described was over the centre of the swelling. The tumor laid nearer the surface than either of the others, and felt as if extending deeper. In other words, it was thicker than the others. It was painful and ON DISEASES OF THE INTESTINES. 253 tender to the touch. There were febrile symptoms, which had been varying from time to time. The digestive apparatus was all wrong. He was so sick that his life was considered in danger. Leeches and vesication had decidedly good effects as regarded pain and soreness, and the size of the tumor was lessened somewhat under the use of them. Strong cathartics, acting freely, afforded him great relief, so that he never felt as if he had enough. The quantity of faeces was very large, more than his food seemed to account for. The evacuations never caused any marked change in the swelling, as if an accumulation in the intestine had taken place. For a Avhile he gained in strength and spirits, took food well, and the tumor became smaller. But when he had been sick five or six months a new trouble came on. This was insanity. This occasioned his removal from town, and I saw no more of him. This occurred ten or more years ago, and I believe he is still living with his mind deranged. So far as I have been able to learn, the first disease has never been troublesome since he left town, and probably it has subsided. The termination of this case was the worst I have ever known. There was not, however, anything to show that the two diseases were connected, except that one followed the other. I will give you one more case, and a very interest- 22 254 ON DISEASES OF THE INTESTINES. ing one. It is that of a young physician, Dr. H----, who had been engaged in unwonted labor three or four months before his sickness. It occurred in the summer of 1846. When I first saw him he Avas on his bed, prostrated, with a very bad and anxious countenance, modified in expression by opium, which he had been taking freely; skin hot, pulse hard and frequent. His abdomen Avas very hard, painful and tender. His Avorst pain ay as in the right iliac quar- ter, and I found there a tumor in the usual place, of which he was not aAvare. This was very tender to the touch; a silver dollar would about cover it. His own recollection, of the preceding part of the disease particularly, has been recently given to me in the fol- lowing words: '' The disease commenced, I think, about twelve days before you saAv me. At that time, Avhile driving out of town in the evening, and through some low ground, after leaving a very hot room, I became much chilled. It was not merely a sensation of coldness, but a distinct rigor, the effect lasting several hours. This was folloAved in a day or two by tenderness of the abdomen, and a general sensation of being ill. The tenderness increased continually, so that, for sev- eral days before I saw you, the motion of the vehicle over the pavement caused me great pain. On Satur- ON DISEASES OF THE INTESTINES. 255 day the pain and tenderness Avere constant, and it seemed as if I could count every stone I rode over. At night I went to my bed and took laudanum very freely. The agony was such I could not remain in bed, and much of the night I was Avalking about the room. I continued the laudanum through the night, but do not think much of it was retained; at all events it did not produce sleep, nor at all mitigate the pain. On Sunday morning I went out as usual, but the motion was so painful I could not allow the horse to go beyond a walk. After seeing a few patients I felt that I could do no more. I then got some leeches and went home to apply them, but finding that I was growing Avorse, sent for you soon afterwards. At this time my abdomen was very hard all over, my face, as I saw in the glass, of a dark purplish color, my breathing very short, labored and painful; in fact, I thought I Avas dying. l"ou immediately opened a vein. The blood at first was very thick; it looked to me like tar, but it soon came to move freely and ran a good stream; this you allowed it to do till I was faint. The relief, as to the pain and dyspnoea, was decided and immediate. You then directed twenty leeches to be applied to the abdomen (I had previously applied a few), and in the evening you and Dr. Bige- low advised a repetition of the bleeding, and I believe 256 ON DISEASES OF THE INTESTINES. about as much blood Avas taken as in the morning. No blister was applied over the abdomen then; but, some time after, you.directed a succession of them to be applied over the hard bunch, AYhich appeared in the right iliac region, to promote absorption. This bunch disappeared quite slowly, and it was a number of weeks before the tenderness, AYhich followed it, was gone. During my convalescence I had repeated attacks of pain, resembling colic, but have never had any since, nor has there ever seemed to be any obstruc- tion or difficulty in the bowels since that time, although it took me more than a year to recover my strength. Previous to your seeing me the action of the bowels was regular." This case differs from all others I have seen in its violent acute symptoms ; it caused me to fear general peritonitis and a fatal result. The relief following the bleeding and subsequent purging, removed my fears. But, though its violence was overcome, the disease continued for a long time. Colics occurred, as Dr. H----has stated; and the tumor remained always somewhat tender, and at times painful. The suffering was increased by food, if taken in more than the most moderate quantity, even Avhen the appetite was suffi- cient and the whole disease much abated. Fruit and acescent articles were especially hurtful to him. His ON DISEASES "OF THE INTESTINES. 257 feelings led him to a constant desire for full purga- tives. As in other cases of the kind, the relief from them was decided, though not of long duration; and the discharges were ahvays more copious than could have been expected, from the quantity of food taken. I do not remember any disease in Avhich I have noticed this peculiarity so strongly marked, except organic affections of the liver. Since this letter was Avritten a friend has very kind- ly handed me two cases, which he observed during the last year, and which appear to be of the same descrip- tion as the foregoing. The language in which he describes the cases differs from mine, as any two men may differ in relating the same thing. I had had a conversation with him on the subject, and that led him to take special note of these cases. Two cases observed by Francis Minot, M. D. 1' Pain in the abdomen, with active febrile disturbance. Relief after leeches and purgatives. Tumor in the ilio-coecal region, remaining after convalescence. " A little girl, aged eleven years, who had generally enjoyed good health, became ill on Sunday, October the eighth, 1854, Avithout known cause. She felt chilly, lost her appetite, and was inclined to lie on the sofa all day. She went to school the two following days, 22* 258 ON DISEASES OF THE INTESTINES. though not feeling well. On the tenth she had great pain in the abdomen, accompanied by vomiting, and followed by an evacuation of the boAYels, the first since the seventh, though they had previously been perfect- ly regular. " I found her on the tenth in bed. The face was flushed, pulse one hundred and ten, tongue slightly coated. She complained of severe pain in the abdo- men, referred to the right side, and occurring in par- oxysms about once an hour, leaving her comparatively free in the intervals. She could lie only on her back; the least motion, and even drawing a long breath, also causing pain. The abdomen was moder- ately full and resonant. On the right side it was very sensitive to pressure, the tenderness being exces- sive in the iliac region. A cathartic of calomel and jalap was ordered. Before it" operated the patient had a sharp rigor, followed by heat and perspiration. After the enema she had a large solid dejection. She derived great comfort from a fomentation of spongio- piline, and got some sleep after taking opiates. " On the twelfth her general condition was about the same. She lay with her legs drawn up, and sup- ported by pilloAvs, the slightest motion causing pain. The face was pale and expressive of much suffering, but not anxious. Skin of natural temperature; tongue ON DISEASES OF THE INTESTINES. 259 covered Avith a thin, brownish, pasty coat; breath foul; pulse one hundred and twelve, rather hard; respiration twenty, easy; thirst, headache. The ab- domen was extremely tender throughout the right side, but mostly so in front of the anterior superior spine of the ilium. Considerable fulness above and in front of the same point Avas evident to the eye. Four leeches were applied to the seat of pain, imme- diately after which there Avas great relief to the pain. In the evening she was able to move her limbs a little. " On the thirteenth I found a smooth round tumor, feeling like an egg, just in front of the spine of the ilium. On account of its tenderness, it could not be freely examined. In the course of the day she had a very copious spontaneous dejection, the first part of which consisted of hard, dry lumps, the remainder being soft. She also passed much Avind. After this, the general condition was much improved. The pulse fell from one hundred and six to ninety. The tender- ness, except over the tumor, Avas greatly diminished. " The next day I Avas able to examine the tumor Avith more exactness, and made the following record: ' Its centre appears to be two inches from the ilium, on the right side, on a line drawn through the two superior spinous processes. It is globular, and smooth. 260 ON DISEASES OF THE INTESTINES. Its limits cannot be exactly felt, as the examination gives considerable pain.' The patient had two abun- dant dejections, after medicine, in the course of the day, and was altogether better in the evening. "Her improvement was uninterrupted, though slow. She could not dispense with the pillow under the right thigh before the sixteenth, nor could she lie on the right side, though she was able to sit up in bed. On the fifteenth the tumor is noted as being ' about two inches long by one broad.' " On the twentieth I recorded as follows : —' She has been well since the last visit (seventeenth), and has not been confined to the house. The tumor is felt deep beneath the surface, in the right iliac region. It is hard and round, feeling like a horse-chestnut, and of about the same size, almost entirely free from ten- derness.' She recovered perfectly, but I cannot say whether the tumor ultimately disappeared." " Pain and tenderness, with a deep-seated tumor in the ilio-coecal region, with slight febrile symptoms. Convalescence in four days. " A married woman, aged about forty, was confined for the eighth time on the 21st July, 1854. Nothing unusual occurred during the labor or convalescence. During the night of the third and fourth September she ON DISEASES OF THE INTESTINES. 261 was attacked with severe pain in the abdomen, which was increased when she lay on the left side. No cause could be ascribed for this attack, unless too much exertion in lifting her children. " On the morning of the fourth she was in bed, pulse ninety-six; tongue nearly clean; skin of natural temperature; no headache, nor pain in the back or limbs ; no chill; had had no dejection for three days, except a slight one yesterday. Decubitus dorsal. Every movement of the body was painful, and she could not lie on the right side. Abdomen moderately tympanitic, everywhere soft, not tender, except in the neighborhood of the spine of the ilium, on the right side, where it was extremely tender for a space four inches square. A smooth globular tumor was felt in the same place. It was a few inches in diame- ter, lay very deep beneath the surface, and was very sensitive to the touch. In the course of the day the pulse rose to one hundred and twenty. (Six leeches to seat of pain. Castor oil, followed by enema.) "September 5th. — The patient experienced great rehef after the application of the leeches. She had four dejections. Is now free from pain, and feels much better. Pulse eighty-eight, tongue moist, some appetite, no thirst. The tenderness of the abdomen 262 ON DISEASES OF THE INTESTINES. has much diminished, but the tumor is with difficulty felt, on account of its depth. " September 7th. —Feels quite well, and free from pain. Is still in bed. Bowels free. Tumor cannot be distinctly felt. " September 8th. — Sitting up. Free from pain and tenderness." The cases, Avhich I have related, differ from each other in their severity and duration, and in many important details. If I could recall all I have seen this would be more fully exemplified. I have not seen one case of the disease which has proved fatal; so that no examination post mortem has enlightened me upon its seat and particular characteristics. What, now, are the symptoms common to these cases and which may be regarded as essential to this disease ? They are pain in the right iliac quarter, but not confined to this, for it often passes beyond the limits of this quarter, particularly upward; and a tumor, varying in size, so deep-seated in the abdomen as not to be felt Avithout some direct pressure on the part, more or less tender, sometimes very tender. This tumor is to be felt near the outer edge of the right rectus muscle of the abdomen, Avhere this is crossed by a line drawn horizontally from the ON DISEASES OF THE INTESTINES. 263 anterior superior spinous process of the right ilium. It must not be understood that the centre of the tumor is to be found exactly under the angle formed by the lines above mentioned, only that some part of the tumor lies under it. This may not be mathemat- ically correct; but I believe that the indurated body will always be found, Avhen the fingers are pressed down as near to this angle, as one would come in an examination of this sort. Constitutional affections attend this disease in some stage of it, but they vary much in severity ; and so also does its duration vary. I may add, as a characteristic of this painful tumor near the coecum, that purgatives give so much relief that the patient is always anxious to have them. Perhaps it may be true of all diseases, in AYhich the coecum and colon are concerned, that the patient has a strong desire for something to relieve those intestines from ihe faecal matter detained in them. I have mentioned the coecum as an organ affected in this disease, but I have not shown that this is true. We must now consider what is the organ affected; in which of its coats, or tissues, the affection is seated; and what is the nature of the affection. I cannot answer these questions Avith an assurance of being right. I have supposed that the coecum was the organ affected, that the disease was seated on or" in its 264 ON DISEASES OF THE INTESTINES. serous coat, and that this disease was an inflammation. There are, however, great objections to this supposi- tion ; it is upheld mostly on the ground that there are greater objections to any other. In talking with my medical friends, none more satisfactory has been suggested to me. If there were absorbent glands, lacteal or lymphatic, in the situation of the disease, the explanation would be easy. I think it will be readily admitted that, in the cases I have related, the tumor is formed by the process of inflammation. The part is painful and tender; often very tender. Unless in the case of Mr. B., I have never seen the disease at its very beginning; and if that was the same as the others, it subsided so soon as not to enlighten us upon its nature. In all the others the tumor has enlarged and diminished gradu- ally, as might happen to a phlegmon not passing on to suppuration. It does not, however, come within our notions of a phlegmon, if, as I believe, it never termi- nates in suppuration. The tumor has never subsided suddenly, so as to justify a suspicion that it has dis- charged pus into the intestines, or elsewhere. Nor have I ever found it to subside, or to be diminished suddenly, after a purgative, as might happen if a faecal mass had been confined in the coecum. Indeed, the feeling of the tumor does not resemble that of an ON DISEASES OF THE INTESTINES. 265 accumulation of faeces, such as I have sometimes met Avith. It accords better, though not exactly, with an enlarged lymphatic gland. It might be supposed that it occupies, or extends through, all the coats of the coecum. But then, it would be such an obstacle to any contraction of that organ, as to cause great pain at the time ; so that the patient would get to have a dread of cathartics, even though they might be fol- lowed by relief. But, as I have said, the patient is always, or very often, anxious for cathartics. Can there be a suppurative process on the mucous membrane of the coecum, and is the tumor, in any way, a secondary affection ? I have seen such a dis- ease of the coecum, and had no hesitation in deciding what it was. The case proved fatal, and fully con- firmed my diagnosis. The symptoms were very different from those I have stated as belonging to this painful tumor. MM. Dupuytren and Grisolles, of Paris, and, I believe, some other French writers, have given an account of phlegmon and abscess in the iliac fossoe. A slight knowledge of these diseases, especially the name employed by Grisolles (Tumeurs phlegmoneuses des fosses iliaques), might lead one to suppose the affections to be the same; but it is not so. I am acquainted with those phlegmons, most common in 23 266 ON DISEASES OF THE INTESTINES. the puerperal state, but seen in other states. I have been consulted about one, in a man, since I haA'e been engaged in writing these letters. These phlegmons almost always suppurate, as is particularly shown by M. Grisolles, and as my limited experience confirms. I first became acquainted with this disease in examin- ing a woman post mortem at our almshouse, more than fifty years ago. That case was so remarkable in one point, that I will diverge from my path to put it on record. The abscess contained more than a gill of pus. There was involved in it, lying in this bed of pus, a portion of the external iliac vein. Where this vein passed through the parietes of the abscess, at both its upper and lower part, the vessel was clogged up by coagulated lymph, showing that the adhe- sive inflammation (in Mr. Hunter's language) had taken place within the vein, as it had in the surrounding cellular membrane. But, further, between these tAvo portions of lymph suppuration had taken place within the vein. The pus in the vein was somewhat colored by blood, but not so much as to leave any doubt as to its character. The case had been a slow one probably. The subject of it was an abandoned woman, who had been brought to the house in an exhausted state. You observe that the peculiarity of the case was that the vein was insulated in the cavity of the abscess, ON DISEASES OF THE INTESTINES. 267 and had gone through the same processes as the surrounding parts, without having had any opening, by Avhich it had communicated Avith them. On a young admirer of John Hunter, as I was, this case, illustrating his description of the different processes of inflammation so distinctly, made an impression, Avhich has not been effaced by time. I am sure that the essential circumstances are correctly stated, though I have done it from memory. I believe I have a a record of them, but cannot now put my hands on it. I have stated more than once that suppuration has not occurred in any case of this painful tumor near the coecum. On saying this lately to an ingenious and learned friend, to whom I had been speaking of this disease, he asked the following question : " May not your disease have been tuphlo-enteritis; and may it not be that in the cases, Avhich did not terminate fatally, the nature of the affection Avas not discovered ? " This is a fair question, and I leave it to others to ansAYer it from observation, if an opportunity occurs. I replied to him that since the first case I saw of tuphlo-enteritis, I have not seen one, which has been proved to be so, that I did not recognize at once; that this disease occurs mostly in children, though not in them solely; that its symptoms are usually, within 268 ON DISEASES OF THE INTESTINES. the first few days, much more violent than those in my cases at so early a period ; that vomiting is, I believe, among the early and obstinate symptoms in tuphlo-enteritis, while in my cases it is much less remarkable, though it occurred in some of them. To this I should add that the little tumor felt in tuphlo- enteritis is, I think, to be found somewhat loAYer, and not so near to the median line as the tumor I have described. I submit all this for consideration ; with the hope that others Avill be able to explain the disease, I have thus brought to notice, more perfectly than I can do. In describing cases of the disease under considera- tion I have stated the remedies employed more or less fully. I Avill bring them into one view, premising that they must be used with greater or less freedom, according to the violence of the disease. The indica- tion is to bring about resolution in the inflamed part. It is very probable that the final result would be the same Avithout medical aid, but there are tAvo reasons for adopting active treatment. First, there is usually so much pain and distress when the physi- cian is called, that present relief is a great object. This relief treatment will afford. Second, in the instances which I have seen, the disease has proved more severe and more lasting, the longer it has con- ON DISEASES OF THE INTESTINES. 269 tinued before the appropriate treatment has been adopted. This is an approximation to the truth, if not a perfectly correct statement. When colic, or great pain in the bowels, exists at the commencement; of the treatment, opium should be given, in some form, until it gives ease. If, indeed, there be a hot skin, a frequent and hard pulse, and the patient be sufficiently vigorous, venesection should be the first remedy. In the case of Dr. H. the benefit of free bleeding was unquestionable. The depletion will probably, in all cases, diminish the pain and dis- tress ; and, after it, opium will act more kindly than before. Leeches should be applied Avhere venesection is not admissible, or not required; in number from six to twenty, according to circumstances. If there be much pain the opiate should be used first. After the bleeding a purgative should be given. After bleeding the purgative Avill probably act more readily and more easily, as the loss of blood will, if I may so express it, liberate the intestine. On the following day a blister should be drawn over the seat of the tumor. This and the other remedies must, of course, be repeated, or not, according to circumstances. Through the whole treatment rest should be en- joined, and the diet should be very moderate and simple, until the disease is evidently much lessened. 23* 270 ON DISEASES OF THE INTESTINES. If the treatment is not begun early, exacerbations are very apt to occur. They must be guarded against as far as possible; and, if they take place, active measures should be adopted at once. In an old or severe case the tumor will remain for a time with some tenderness, after recovery has taken place in all other respects. In this state I think the external use of iodine may be useful. At least the tumor has gone off under this remedy sooner than I had anticipated, and the patient's mind has been kept easy, and no injury has ensued. LETTER XIY. ON CONSTIPATION OF THE BOWELS. Constipation of the bowels is among the most common evils, as respects health, among the inhabit- ants of cities. It is occasioned in part by their diet, but probably much more by their sedentary habits. The same habits induce the same evil among persons living in the open country. The great extent of this evil is shown by the multitude of remedies for it; of quack remedies, the sale of which has enriched their proprietors. It is not strange that persons, unin- formed on this subject, and experiencing daily the evils of constipation, should employ the pills and draughts advertised and puffed by their mercenary proprietors. Why should we speak with reproach of these persons ? The efficient elements in most of their patent medicines are, I suppose, the same Avhich are employed by regular physicians. Most of them are valuable articles, and some are exceedingly Avell adapted to the purpose in vieAY. The objections to 272 ON CONSTIPATION OF THE BOAVELS. them are that they are used without discrimination as to the cases, for which they are respectively best fitted; and, what is much worse, the sufferers are induced to take medicine instead of relying on diet and regimen, the more natural modes of relief. The tendency to constipation is constitutional in some persons. Whether it is derived from some pecu- liarity of structure, or Avhether connected Avith some modification of the vital poAvers, I am not prepared to say. There are men Avhose external appearance is modified by this deep trouble, or at least I fancy so. You may meet such a one daily in the street, moving with a regular but rather slow gait, thin, bony, look- ing down, his body slightly bent forward, having an anxious countenance, with an expression as if Avorn by a hidden grief; with a skin dry and somewhat coarse or rough, and a dull complexion, rarely showing any red color. This melancholy-looking man attends to business, and very probably is growing rich. In conversation you find him more cheerful than you had 'anticipated, and quite bright at times. But you dis- cover that he is limited in all his conduct, not Avilling to eat, drink, or sleep, out of his OAvn house; and reminding you, perhaps, of a horse tethered out. You may help such a man, but you cannot make him aneAV. ON CONSTIPATION OF THE BOWELS. 273 What, then, shall we say to one habitually consti- pated in the bowels ? We must make him acquainted with the causes Avhich have produced the evil, and with the hygienic rules adapted to overcome it. First, a laxative diet should be directed. Among the articles adapted to this purpose, coarse bread, bread made from meal, and not from the fine flour of the grain, may, perhaps, be called the principal. In the fine flour we have the nutritious portion of the seeds, AYhich has been procured by sifting it from the meal. In this case the hull is left on the sieve. For nourishment alone this hull is of very little value ; but far other- wise when we take into view its effect on the bowels. The more coarse the meal the better for the purpose now in view. Indeed, it is found better to employ the Avheat simply cracked. This cannot be made into bread, but if soaked from two to four hours in warm water, so as to make a species of mush, the effect of this preparation on the boAvels is very great. It is, however, an article which some stomachs do not well bear. I cannot pass by my notice of this article without stating the obligations our community is under to my friend, Dr. John C. Warren. We had been in the habit of employing rye meal, and sometimes Indian meal, as laxative articles, and had thought that rye 274 ON CONSTIPATION OF THE BOWELS. had some peculiar property of this kind. It was known that wheat was a better grain for nutriment than the rye or maize; but wheat being used, by us in New England, only in the state of fine flour, it AYas regarded as a constipating article. Many years ago Dr. Warren recommended the bread made from the wheat meal, SAveetened with molasses. This bread got the name of dyspepsy bread; a name given to it, I believe, by the bakers. It was introduced not be- cause it Avas adapted to pure dyspepsy, but as a remedy for habitual constipation. It is true that, Avhen this bread overcame the latter complaint, dyspepsy in cer- tain cases was removed, or alleviated, showing that it was caused by the constipation. Some years after this, the same distinguished gentleman introduced the use of groats, or cracked wheat, of AYhich I have spoken above. The advantage of having bread of a laxative charac- ter is, that this article is in such constant use. It enters with most persons into every meal, and often in a large proportion to other articles. There is another form in which the meal, or coarse flour, may be employed with advantage, especially by those who cannot afford to use expensive fruits. This is mush, or hasty-pudding, made from any of the grains, the rye perhaps being the best. Butter may ON CONSTIPATION OF THE BOWELS. 275 be used with this pudding, and molasses should be added as increasing its value. White mustard-seed was greatly in vogue here, some thirty years ago, to regulate the bowels, and thereby to do many other good things. It was recommended by Cullen, I think, but Avas revived by some accident at the time I refer to. It Avas taken in doses of from one to eight teaspoonfuls a day. In many instances it acted very kindly, but it too often failed, or pro- duced some inconveniences, and it fell into disrepute. It should not, hoAvever, be quite forgotten. The articles we call fruits are most of them very useful and very agreeable remedies for the difficulty Ave have in view. Generally speaking, those which are succulent and tender are to be preferred; and those which are sweet are, perhaps, rather better than such as are acid. To this last remark there are some exceptions. Beginning with the berries, which Ave find in the summer, in our climate, we go on to the pears and apples in the autumn. As these, the apples especially, last through the winter and spring, we get a supply of fruit for most of the year. Of the pears, those Avhich are hard are not very valuable, if they are at all so. The apple may be used without cook- ing, by many persons; but they are better for all, especially for those with tender stomachs, after being 276 ON CONSTIPATION OF THE BOWELS. cooked. They should be cooked in their skins, that there may be the least possible loss of their juices. The good pears are too tender to make this necessary, but they are not injured by cookery. One advantage of cooking these fruits is, that the stomach will bear more of them, than Avhen in the crude state. For the purpose we have in vieAV, the sweet apples are rather better than others. It is remarkable, however, that some dyspeptics can bear a sharp acid apple better than a SAveet one. The same persons will bear ripe currants better than the SAveet berries. This -will not seem so strange, if you bring to mind that the acidity of the stomach, which troubles dyspeptics, is that which arises, from fermentation of the food. It may be produced by acids taken into the stomach, especially those of unripe fruits; but not so readily by the acid of a mature fruit, such as currants are in the last Aveek of July and in August. Looking for fruits at the different seasons of the year, I have provided for all except the last half of the spring, and the first month of the summer. But all persons cannot command the delicate fruits. In the absence of these, oranges may be resorted to. These are found among us at all seasons; but the best, the most mature, are to be found in the spring. We have also the resource of the dried foreign fruits, at all seasons. The most ON CONSTIPATION OF THE BOWELS. 277 valuable of these are figs and prunes. The latter are made better by steaming. I think the best time for the use of fruit is at breakfast, though it may be taken at dinner if proper room is allowed for it. The most agreeable time for oranges is before sitting doAvn at the breakfast-table. Two of them taken at this time are all-sufficient in many instances. I must not omit the rhubarb plant, which resembles the acid fruits. This may be used in May, and continued till midsummer. It should be stewed with sugar, and taken at breakfast or dinner. Though this article is called the pie-plant, let it be noted that the pie-crust is not essential to it; and to those of tender stomachs it is injurious. Thirdly. Vegetable food generally is more laxative than animal food. This is particularly true of the tender and succulent vegetables. There are two arti- cles, which come under the name of vegetables at our tables, which are especially useful, and which in reality are fruits. These are the squash, the winter squash especially, and the tomato. Fourthly. To the foregoing I must add that ole- aginous and fatty articles have a laxative effect. The only vegetable oil we are accustomed to is that from the olive, much more used in other lands than in ours, and certainly of great value. We get a vegetable oil 24 278 ON CONSTIPATION OF THE BOWELS. in the nuts, especially in that called the oil or butter nut. To those, who have not access to other laxative food, this nut may be found very useful. Animal fat is serviceable in the same way, and pork is the best article of this kind, on account of its fat. I knoAV that this is contemned, and even thought injurious, by many persons who are not Jews. To some stomachs it certainly is offensive, even though it be of the best quality. But to many persons our NeAV England corn-fed pork is easy of digestion, highly agreeable, and, as the phrase is, very wholesome. That is the term which, in my early days, many delicate persons employed, when they meant that the article was good for the bowels. Let me here mention another article, on which the polite are apt to froAvn, and Avhich Ave can hardly recommend to young ladies; this is the onion, of AYhich I am reminded by mentioning pork. It is quite valuable to those who cannot bear the acescent vegetables. There is still another useful vegetable, scarcely admitted on genteel tables, or not without some apology. I refer to beans. The objec- tion to them is that they often cause flatulence. For some persons this is a sufficient objection, in Avhatever way the article is prepared. But most persons can bear beans very well if they be well cooked. They should be boiled so as to be thoroughly tender, and ON CONSTIPATION OF THE BOAVELS. 279 then baked slowly, but not so as to be quite dry. Some black pepper may be added to them. Pea-soup is still another dish to be had in respectful remem- brance. Both the peas and the beans are wholesome to some, though not to all persons. I have mentioned a variety of articles for the pur- pose in vieAV, and it is desirable to have a variety to choose from. I have, however, omitted some which might be mentioned. Some are very useful to one person, and are not at all so to another. People get tired if confined too much to the same article, and want a variety to suit the palate. Lastly, one may be procured when others cannot. It is not to be understood that persons of constipated habits should be confined to the articles pointed out above. On the contrary, these should be taken Avith others, more or less, as the case may require at dif- ferent periods. But none of them are to be relied on as medicines for a temporary purpose. Generally, their good effects do not show themselves until they have been taken for three or four days in succession. I have treated of the diet fitted to obviate habitual costiveness. Next to this should be placed bodily exercise. In many instances this is all that is wanted. Care in diet is seldom sufficient without it. I say to the sufferer under constipation, " Get exercise any 280 ON CONSTIPATION OF THE BOWELS. how, in any mode; but, if you can, let it be on your feet. Walk two hours every day, and as many hours as you can on a holiday. It is best to walk with an object, if possible. It is best, also, to get one good walk soon after breakfast; but walk in the evening if you cannot get leisure at other parts of the day." Walking is better than riding or driving for the pur- pose now in view; but circumstances sometimes forbid this, such as lameness of one kind or another. Then, if possible, let the patient get on horseback. In all this I have reference to citizens, the inhabitants of cities, or of large and busy towns. A resident in the country, who does not get his living by labor in the open air, more than half the year may resort to gar- dening. This is the most luxurious exercise one can have, if he has any taste for the pursuit. There is one other mode of exercise, Avhich may be enjoyed wherever there is water at hand. This is rowing in a boat. Though the oarsman is not on his feet, he brings all parts of the body into use. This exercise seems to belong to our sex, but it may be allowed to the other, when they are in secluded places; and some of them knoAY how to excel in this as they do in most handiworks which they undertake. Many persons learn for themselves the influence of habit in keeping up the regular action of the bowels; ON CONSTIPATION OF THE BOWELS. 281 but they do not always learn this before the middle of life. The morning, soon after breakfast, in the majority of cases, is found the most convenient time for this purpose; and almost any one, by a little care, may avail himself of the readiness of the human body to be influenced by habit, so as to fix on such a part of the day as he pleases. Persons who are much troubled by hemorrhoids, or by prolapsus ani, will find it best to get their evacuations just before bed- time. The advantage is that such persons derive benefit from assuming the horizontal position for a time after an alvine dejection. I must give a cau- tion connected with this subject. One should not allow himself to strain, nor to hurry himself from a regard to habit, nor for any other reason. In this way he may induce hemorrhoids, or prolapsus. These are great evils, of which feAY persons are aware except those who have suffered them. It is best to get a dejection from the bowels once a day. There are some Avho get two a day, and feel the better for it; but they are rare exceptions. One should strive to get one by all reasonable means; but persons of infirm health are sometimes unduly anxious on the subject. They are made fidgety and really unhappy if they miss a day. I believe it conduces to good-humor to be regular on this point; but I could 24* 282 ON CONSTIPATION OF THE BOAVELS. bring good evidence to shoAV that a man may have a very good share of health, and a great abundance of generous good-humor, though he should relieAre the bowels only once in four days. Such a case is singu- lar, no doubt, but there are many instances of persons who have very comfortable health, while they get relief only once in forty-eight hours. Nature docs not lay down universal rules on all points. The great object of maintaining sufficient evacua- tions is not attained by all men, though they folioav the directions above given with exactness. This some- times arises from a constitutional peculiarity, but for the most part it is produced by a long neglect of the hygienic laws. When this neglect has arisen from wilfulness, and not from ignorance, you may say a man deserves the punishment which nature inflicts upon him. If this be true, it is not the business of the physician to leave him to his fate. He must try to alleviate the evils, however induced, and gently, but firmly, to persuade his patient to return, as far as he can, to the right path. What noAY shall Ave do to the patient who cannot overcome the habit of constipation by such means as have been pointed out; by diet and regimen ? The reply is, in general terms, that, when we are obliged to resort to art, we must imitate nature as nearly as ON CONSTIPATION OF THE BOAVELS. 283 we can. By imitating nature in this case, I mean that we should strive to bring about the end in the quiet and easy manner in which nature does it. Further, as men in health do not effect the object in view per- fectly, and equally, every day, we must be satisfied if, by art, we can succeed pretty Avell on the whole, though not every day. By trying to keep up to the mark, without failure, we shall be liable often to over- step it. The simplest and safest of remedies for habitual costiveness, in a large proportion of instances, is the injection into the rectum of cold water, to the amount of one or two gills. This remedy may be used every day, with ordinary care, for many years, Avithout any injury. It is successful in the cases where the faecal mass is brought to the rectum and delayed there. If the failure takes place above, so that the faeces are not brought down, this remedy will not ansAver the pur- pose. It is true that, in certain extraordinary cases of constipation, benefit has been derived from injecting three or four pints of Avater. In this way the fluid may be made to pass up the colon, and, probably, even to the coecum. But that is not a method to be adopted for ordinary cases, and it is of these I am treating. In the cases, for which the daily or frequent use of 284 ON CONSTIPATION OF TnE BOWELS. injections can be adopted with success, it is proper to give instructions for the convenient management of the process. Few men will adhere to this remedy, if they must be put to great trouble every time they use it. The first question is, what instrument shall be used ? I think it very certain that the best instru- ment, to be used on one's self, is a metallic syringe Avith a curved pipe. This should be kept with pipe screwed on to the cylinder, so as to be ready for use without delay. After it has been used, it requires only to be made clean externally. Plain water only being used, it does not require any care for the internal part, except to throw out any remnant of the water which may be in it. Such- instruments are to be found among us, holding nominally six ounces, but really holding about four ounces. They are better than larger ones, though they must sometimes be used tAvice, because they are as large as it is convenient to handle. If you would have the best, get a philosophi- cal instrument-maker to supply you a brass syringe furnished with a metallic piston. The pipe should be silvered over. There are other instruments, which may appear to you better at first sight, but they do not wear so well. This is true of all which have flexible tubes, or India rubber in any part of them. They get out of order very often; they require more ON CONSTIPATION OF THE BOAVELS. 285 care each time they are used, and the use of them is not attended with the same facility. For a sick per- son, lying in bed, Mawe's instrument, or one on the same principle, is better than the syringe above de- scribed. The French instrument, which goes off upon pressing a spring, is very convenient in some respects. It is of comparatively little moment what instrument is employed, if there be a valet de chambre, or a waiting maid to take care of it. Not so when one takes the Avhole matter into his own hands. I will not omit one hint more, although one does not want to dwell too long on the affairs now under consideration. This is, that it is best to pass the instrument sideways under the body, sitting in a Avater-closet, or on the appropriate cabinet, and then rising up to bring the handle of the syringe against the wall of the apartment; then, by carrying the body gently toward "the wall, the piston may be pressed firmly and yet gently into the cylin- der. The treatment just stated is insufficient for those cases, m which the faeces are not brought down to the rectum. Besides, there are many persons who cannot succeed in using injections, and more who will not submit to the trouble of this simple and safe remedy. We must then administer medicine, and in doing this our object should be to employ the mildest and 286 ON CONSTIPATION OF THE BOWELS. safest article which will suffice. If there wTere one such article, which Avould prove the best for every case, the matter could be easily settled. This is what is pretended by every quack, who advertises his own wonderful discovery of a pill, or powder, for this purpose. And the patient, Avho has found an article, which suits himself, after having tried a dozen, is very apt to recommend it to his friends as fitted for all men. We doctors, like the tailors, find that coats of the same size, and proportions, and fashion, will not suit every individual. My own course is to study the circumstances of each case, and endeavor to an- ticipate which among the milder cathartics is most likely to be suitable and efficient. I say suitable, for the article must be one, which will give the least inconvenience as to the taking it, and in its effects on the stomach and bowels. I say efficient, for AYe want an article which shall be tolerably sure to act with regularity as to time, Avithout over-acting. Persons Avho might be relieved by injections, but who will not use them, will probably find the saline medicines, in small doses, but largely diluted, the most suitable for them. Such are many of the natural mineral waters, among which the Congress Avater from our Saratoga is as extensively famed, and as justly, as any. In most instances a pint of this water, taken before breakfast, ON CONSTIPATION OF THE BOWELS. 287 is sufficient. This may be divided into two, or more portions. For some persons a quart is required; but here we must watch lest there be some harm from so large a potation. It is true that there is scarcely any liquid of which so much can be taken with impunity as these natural waters, when containing a due quan- tity of carbonic acid. Very similar in their effects to these waters are the articles known as Seidlitz and Rochelle powders. The most convenient of these arti- cles is sold under the name of Butler's tasteless Seidlitz powders. A common soda powder is enough for many persons. I ought to add that some succeed very well with a cheaper, though less agreeable article. This is the sulphate of magnesia, or any similar neutral salt having a laxative power, taken in the dose of a teaspoonful, but dissolved in half a pint of water. This may be made less disagreeable by adding sugar and peppermint-water, ginger, or some other aromatic. The morning, before breakfast, is the best time for using any of the articles above named. The break- fast may be taken shortly afterwards without any harm. From various causes, perhaps, none of these saline articles suit some individuals. For such we must furnish a medicine of greater efficiency, and given in a smaller compass. These are required especially for 288 ON CONSTIPATION OF THE BOAVELS. those Avhose boAvels are sluggish ; in Avhom, probably, there is a great delay of the faeces in the colon. You Avill find some delicate and feeble women in this class. In them it would seem as if there Avere a real want of muscular pOAver in the coecum and colon; the more Avhen there is not any aid from bodily exercise. But very many, who require similar aid, are men of strong constitutions, who eat and drink freely, and Avho are fitted for hard Avork, but do not indulge themselves in it. In these cases I sometimes suspect that one great process of the large intestines is carried too far. The absorbents take up too much of the liquid con- tained in the mass brought down through the ileum. Among the very convenient and efficient medicines for persons of this class is aloes. It is the substantial part of Anderson's pills, which have had the most extensive celebrity among the English and their descendants for three or four generations, and, I believe, it enters largely into many other patent articles of the same character. It is ordered as a shop medicine in the regular pharmacopoeias, alone, or in combination, in the form of pills; and it is the es- sential part of that grand old domestic tincture known under the name of Elixir Proprietatis. So far it would seem that aloes Avould meet all one's wishes; but like most of the good things on earth, it has its ON CONSTIPATION OF THE BOWELS. 289 defects. I do not refer to the pain it sometimes causes in passing the bowels; for, though it has this fault, the same is true in a greater degree of many other articles of its kind. What I do refer to is its tendency to produce haemorrhoids. This is true of some other similar articles, but not to the same extent. It is a reason for using this medicine watch- fully, and for forbidding it to persons who have haemorrhoids, or any other disease about the rectum. Rhubarb is another article employed with great satis- faction by many persons. Some men chew it daily, and some when specially needed; and for those, who do not object to the taste, this is a good mode of using the article. The nicest pieces are of course selected, and usually the Turkey rhubarb is preferred for this purpose. The medicine may, however, be made into pills, or into an infusion, and be combined with some aromatic article. The tincture is valued highly by some individuals, but it is objectionable because most persons require of it a larger quantity than it is AYise to administer daily, or frequently, of a spirituous article. Rhubarb more often causes griping than aloes. I might go on to mention many other well- known articles for the purpose in view, such as scam- mony, colocynth, sulphur, magnesia, etc., etc. Sul- phur and magnesia are comparatively bulky articles. 25 290 ON CONSTIPATION OF THE BOWELS. The sulphur, however, is now and then found to an- swer very Avell, especially for persons liable to hemor- rhoids. The magnesia is a favorite with many per- sons subject to acidity of stomach. It is not, liOAvever, an article to be commended for frequent use. It is sometimes found to accumulate in the intestines. But an evil much more common is that it is slow in opera- tion, often keeping up an uneasiness for many hours, and causing many small dejections, instead of one sufficient one. It has been found that a combination of moderate cathartics will act more kindly than any one alone; and sometimes a powerful article may enter into the mixture, in an extremely small dose, without injury, and, perhaps, Avith advantage. It is a convenience of such an addition that Ave can get a sufficient dose in a small compass. Gamboge has been employed in this way. I am not, hoAvever, disposed to favor this article, as it sometimes proves treacherous; that is, it will act with undue violence. Strychnia is employed in the same way at the present day, and with care it may be employed with advantage in cases hard to manage. But it should be given in a very small dose, not more than one twelfth part of a grain in a dose containing other articles. After trial the dose of strychnia may be increased. When it is used two ON CONSTIPATION OF THE BOAVELS. 291 precautions are necessary; one, that the medicine should be prepared very faithfully, by a responsible person, to insure the equal distribution of the strych- nia through the mass into AYhich it enters; the other, that the patient should be apprised of the properties of the article, that he may not at any time take more than the dose prescribed. We should rarely employ such heroic medicines. There are many safer combinations than those into which these articles enter. There is one in our phar- macopoeia, AYhich is quite equal to our common needs, when faithfully prepared. This is the compound ex- tract of colocynth. Though there is some aloes in this article, it is very rarely hurtful. Indeed, I have never been satisfied that this preparation has brought on hemorrhoids in any case. This may receive, in combination, any other medicine of small bulk which the occasion calls for. There is one, often prescribed for rheumatism, Avhich acts so pleasantly on the boAvels that I think it Avould be frequently employed, if it could be brought into a small bulk. This is the resin of guaiacum, of which the dose is one drachm. It may nOAV and then be convenient to remember this. It should not be taken in the form of tincture, as the requisite dose would contain too much alcohol. I have been treating of habitual constipation. We 292 ON CONSTIPATION OF THE BOWELS. meet, occasionally, instances of very great and obsti- nate constipation, Avhich are to be regarded very differ- ently. In some of these we see good reason to suppose that' the constipation depends on some organic or some mechanical difficulty; or on inflammation in some part of the intestines. In all cases of peculiar consti- pation, we must bear in mind that such obstacles may exist; and, if so, that our cathartics would not only fail to do good, but might do harm. We must, there- fore, proceed with great caution and circumspection, as the seaman does Avhen he fears sunken rocks. We should examine carefully in the usual seats of hernia. If there be nothing found in them, we should ascertain whether there is any tender spot in the abdomen upon slight or deep pressure; whether there is any tumor or indurated organ in that cavity ; and whether there are such constitutional symptoms as attend inflamma- tion. If there be obstinate vomiting, our fears should be more awakened. If we find no evidence of such local difficulties as have been referred to, we should follow the plain indi- cation to purge the bowels. We should try the safe remedies; that is, such as will not do harm if they are retained. I would not, therefore, begin AYith calomel, unless when the stomach is so irritable that it is not likely to retain other medicines. In such a ON CONSTIPATION OF THE BOWELS. 293 Dase one or two doses of calomel may determine the current doAvnward, and leave the way open for more active medicines. You may be surprised that I say more active medicines; but, in truth, calomel is slow in its operation; it starts the mass, but does not carry it through; so that I often compare it to the scraper used by the chimney-sweep, which requires a brush after it to bring away the soot. Besides calomel, other medicines in small bulk are best, when the stomach is irritable. The compound extract of colocynth is a very good article. But after these, or at first, if the stomach is quiet, castor oil is the most appro- priate. This medicine excites secretions sufficient to soften the faeces, while it promotes the peristaltic motion, so as to carry fonvard any mass Avhich may have accumulated. The neutral salts may answer the purpose; but it appears to me that, Avhile they cause copious watery secretions, they do not so act on the muscular coat as to insure the removal of the solid matter. Oftentimes in such cases there is a difficulty in keeping the medicines upon the stomach. Then we may resort to preparations of senna or jalap, or both together, which should be given in liquid form, and in small doses, frequently repeated. There is an article, AYhich I introduced into use at our hospital, well known among us, under the name of the com- 25* 294 ON CONSTIPATION OF THE BOAVELS. pound infusion of senna. Besides the senna, it has jalap, supertartrate of potass, and manna, in its com- position; and with these the compound tincture of senna. Where it is desirable to have the stimulus of the tincture, this preparation may be used with advantage; but, otherwise, there is a more modern preparation, which is better. This is the fluid extract of senna. ■ One advantage of this extract is, that in the same dose it is about twice as powerful as the com- pound infusion above mentioned; a great advantage when you have to do Avith an irritable stomach. Other articles will ahvays suggest themselves, when there are objections to the above named. In these cases we should also avail ourselves of injections into the rec- tum, which should be large in quantity, and more or less stimulant, as circumstances may indicate. I shall mention one which I hold in high estimation in all obstinate cases; this is a mixture of oil and water. Avith soap to make the oil miscible with the water, and to break it up into small globules, Avithout so much soap as to make the oil entirely disappear. Iu one of these obstinate cases I should use the follow- ing : — take a heaping tablespoonful of soft soap, half a pint of olive oil, and a pint and a half of warm Avater, and mix them thoroughly; the Avhole of this should be used at once. It may be necessary to repeat both ON CONSTIPATION OF THE BOWELS. 295 the purgative medicines and the enemata. There are cases, mostly in persons Avho have been much neg-. lected, where you find a great mass of faeces impacted in the rectum. In these it is best to resort to me- chanical means, using something like a scoop to break up and dig out the mass. Where there is reason to suppose that there is a mechanical obstacle, analogous to hernia, or where an inflamed organ constitutes the obstacle, the treatment must be varied to meet the circumstances. To go into all the possible circumstances Avould lead me too far. I will say, however, that where there is reason even to suspect an inflammation in the intestines, blood- letting at an early stage is the most important remedy. It serves to relieve the distress and to liberate the bowel; for then it can yield to the effect of a cathartic. Let me add further, that in blind cases, a masterly inactivity should be adopted. This requires more true courage than the exhibition of the most heroic remedies. I must make a small addition to this long letter, in respect to diseases of the rectum. I have ref- erence to hemorrhoids, prolapsus ani, and the fissure, or crevasse of the rectum. What I wish to say in regard to these is, that the greatest and most perma- nent relief may often be obtained by an operation. 296 ON CONSTIPATION OF THE BOAVELS. As I have not practised surgery for nearly half a century, I shall not be suspected of Avishing to exalt my own art. I have, hoAvever, called in the aid of a skilful surgeon in many such cases; a number of these have been ladies, who have subsequently ex- pressed great gratitude to me in consequence of the relief they have obtained. It is in bad cases of piles, external or internal, most especially Avhen bleeding, that I have found surgery thus useful. In milder cases other well-known remedies succeed, into the consideration of which I shall not enter. In all cases of prolapsus and of fissure I believe the sooner an operation is performed the better. If the prolapse is slight, the slighter will be the operation, and AYith proper subsequent care there will be an end of the trouble. The subsequent care has reference to the habitual costiveness, to which the tendency is increased by the operation. Diet will often overcome this after a few weeks or months ; for, at first, some gentle laxative medicine is required. But, at the worst, a daily injection of cold water may become necessary. After a little habit this is found not a very troublesome affair, and the relief from the daily annoyance of the disease is beyond all price. LETTER XV. ON BILIOUS DISEASES, BILIARY AND URINARY CAL- CULI, AND IRRITABLE BLADDER. In this letter I have a little to offer on several dif- ferent topics, but only a little. You hear every day of bilious diseases, and diseases of the liver. Mes- merizers, and people of that sort, accuse the liver very frequently. I have often said that the liver is like the greatest rogue in the village, who is accused, upon suspicion, wherever any mischief has been done. Such an one has so bad a reputation, that it is not thought a libel if you speak ill of him. I may almost say that there are some among the brethren, who hardly think of the liver but as an organ for the production of dis- ease. When I began practice, some of my elder brethren, excellent men too, almost always referred an obscure chronic disease to the liver. They talked familiarly of old liver cases, without a definite notion of any particular disease. I believe that some of the mesmerizers talk of the liver as being rotten, or all 298 ON BILIOUS DISEASES, ETC. decayed; states of the organ which the morbid anato- mists, who cannot see through the parietes of the abdomen, are not well acquainted AYith. The term bilious is applied indiscriminately to dis- eases, in which much bile is discharged from the stomach or bowels, and to those, in which the bile is entirely wanting in the alvine discharges. In both cases, calomel and blue pill are regarded as the appro- priate remedies. Now, the liver is an organ subsidiary to the stomach and intestines, just as the salivary glands are to the mouth. In the greatest proportion of cases, which are called bilious, the real disease is in the stomach or intestines; and by this the liver is provoked to pour out its secretion, just as the salivary glands are Avhen any acrid matter is taken into the mouth, or when its mucous membrane is inflamed. In these cases calomel is often very useful; but it should not be given merely because there is too much bile, or too little. It is undoubtedly true that a disease in the liver itself may be attended by an increased secretion of bile, or-more frequently by a deficiency of this secretion. Chronic diseases in the liver are not rare among us, though not very frequent; but acute diseases of the liver have very seldom occurred under my observation. I have known acute hepatitis sufficiently well marked. I have, also, sometimes ON BILIOUS DISEASES, ETC. 299 met with abscesses in the liver, the existence of which was not suspected during life. There is no doubt that hepatitis is much more common in warm climates, than with us; and this is so especially in Bengal. But even there the doctors are too ready to believe that "it is the liver," if there is any pain in the right side. A few years ago a young friend of mine was there with a pleurisy attended by effusion in the right thorax, and was treated unhesitatingly as having hepatitis. Not mending under the treatment, he went over land to England, and hurried home by a steamer. Here the true disease was discovered at once. This was not done by guessing, but by the use of the senses. I have thought it useful to make these general remarks, although I do not design to go into the diseases of the liver generally. But I wish to make some observations on jaundice, as one of its most common diseases. The name jaundice is sometimes loosely applied to cases where there is only a yellowness of the skin. In jaundice proper there is not only the golden color of the skin, but also high colored urine, staining the linen yellow, and an absence of bile in the faeces. This last is essential. These symptoms seem to show that there is an obstruction in the common bile duct. 300 ON BILIOUS DISEASES, ETC. I know that this is denied; and there may be cases in which the obstruction is not discovered after death. It is, hoAvever, clear, when these symptoms exist, that the bile does not flow into the intestines. The causes of the obstruction are very various, and we have not any certain means of distinguishing them during life. They are sometimes such as cannot be overcome. An organic disease at the right end of the pancreas may involve the common bile duct, and close it perfectly. Large calculi and other causes may do the same. But there are some causes of obstruction, Avhich are removed by the spontaneous action of the parts. One of these is a gall-stone stopping the passage and at length finding its wray into the duodenum. I have long suspected that another is a disease of the mucous membrane of the common duct in some part of its course, or at its mouth. It is very probable that this difficulty is combined Avith the calculus in some in- stances, and that when the vascular fulness of the mucous membrane has subsided, the calculus is allowed to pass. Though I entertained this opinion, it had never occurred to me to employ bleeding for relief, until led to it by accident. About twenty years ago I had a patient at the hospital, convalescent from typhoid fever, Avho Avas taken Avith pain in the region of the liver, and with other symptoms of inflammation, ON BILIOUS DISEASES, ETC. 301 not very severe ; but with these there were the signs of icterus. On account of the inflammatory symp- toms I applied leeches on the right hypochondrium. Within forty-eight hours the bile flowed through the intestines, and the symptoms of inflammation subsided. This did not prove that my opinion was correct, but it gave me a hint. Not long after, I employed the same remedy in a case of icterus, also at the hospital, and here, also, there was entire relief within forty- eight hours. From that time I have continued to use this remedy. I have tried it in cases at all periods of the disease, from the second day to the fifth week. Many of these cases have been seen in consultation. In three instances, and, I believe, only three, the relief has not followed this treatment, and yet the patient has subsequently recovered. In all the other cases, where it has failed, the disease has proved fatal. In most of them, examinations after death have shown some obstructions, which could not be overcome. Indeed, this has been true of all, in which examinations were allowed. I have not a record of my cases, but the instances in which leeches have been followed by relief cannot be less than twenty. I have failed to give immediate relief, to an adult, where I have used less than eight good leeches. But this has happened, I believe, only twice, and in those instances .26 302 ON BILIOUS DISEASES, ETC. a second leeching has been followed by relief. The relief has been shoAvn by the appearance of bile in the faeces within forty-eight hours after the leeches. Now, I think it cannot be considered accidental that relief should folloAV within this space of time, when the remedy has been employed at such various periods of the disease. I do not ask any one to admit, and I am not sure myself, that this proves that the disease con- sists in an inflammation of the bile-duct; but certainly it is a good ground on which to employ the remedy, until something better is pointed out. I am aware that icterus goes off spontaneously in some cases, and probably it would have done so in many of mine; but not just at the periods when it did. It has some- times been objected to this treatment that it is debili- tating. I will take this occasion to say that I think debility, and that of a bad kind, is much oftener pro- duced by powerful drugs, than by blood-letting of any kind. Though I now feel almost hopeless when jaundice does not yield to the leeches, yet I do not say that nothing more should be tried. I should not be Avilling, if it were my own case, to omit the trial of some remedies which have been followed by recovery ; but I should employ them merely as desperate remedies. The passage of gall-stones through the ducts is ON BILIOUS DISEASES, ETC. 303 often attended Avith severe pain. In some persons, pain from this cause occurs frequently, not obstruct- ing the passage of bile every time, but once in four or five times, as it may happen. It is a great object to give relief to patients suffering in this way. I have seen several such cases, for which I have directed the bicarbonate of soda in liberal doses, such as a drachm tAvice a day. So far as I have known, the disease has disappeared in every instance, after con- tinuing the use of this medicine for several months; but some of the patients have lived at a distance from me, and I may not have been rightly informed- respecting them. In connection with the above, I have a remark to make with respect to urinary calculi. Cases of this sort usually go into the hands of surgeons, and my acquaintance with them has not been extensive. I had understood that the mulberry calculus (the oxalate of lime) was of rare occurrence. Now, it has happened to me to have had five cases of this calculus within three years; three of these within the last year. In each case, the calculus has been examined by Dr. John Bacon, on whose report I place entire reliance. I mention this as showing that the mul- berry calculus is not a rare occurrence in this vicin- ity. 304 ON BILIOUS DISEASES, ETC. An irritable bladder is among the common troubles of old men. The first symptom, which attracts atten- tion, in most instances, is a frequent micturition in the night-time. Sometimes this does not occur in the day; and, when it does, it is not so inconvenient as in the night. This is attributed in many instances to an enlargement or an induration of the prostrate gland; sometimes in the middle lobe only. When it is so, the disease may become very grave, and may prove fatal. But in a very large proportion of the cases I have seen, the results have not been of a serious •character. I have introduced the subject principally to say this. I feel assured that many persons have suffered a good deal from their apprehensions under this malady, and accordingly have not been satisfied without the trial of troublesome, if not very powerful remedies. To one affected with this malady, I would say, " take care of your general health, keep every- thing well balanced, do not make yourself Aveak by confinement within doors, and do not fear a diet sufficiently nutritious, nor too readily omit the use of wine, if you have been accustomed to it. But then I would add, Avatch the effect of your diet, and omit acids, or wine, or anything else, Avhich, on careful observation, appears to aggravate your disease. Above all, keep your bowels regular. Have you haemor- ON BILIOUS DISEASES, ETC. 305 rhoids or prolapsus ani, seek relief from the surgeon. If diet and exercise will not keep the bowels regular, use cold water injections ; but avoid purgatives, and certainly harsh ones." These remarks in regard to the state of the boAvels are founded on the connection, which I have found to exist, betAveen the rectum and the bladder in these cases ; and on the suspicion that sometimes the trouble in the bladder has originated in disease in the rectum. Here is a short letter, but you may think it long enough, as it does not furnish you with many weapons for the relief of disease. I am sensible of the defi- ciency, yet I hope the letter may be of some use to you. It guards you against folloAving popular no- tions ; and may induce you not to employ violent remedies till you are assured that they are needed. 20* LETTER XVI. ON BOILS. Boils are among the troubles for which your friends will laugh at you, rather than sympathize with you; and it is best to laugh, too, if you can. But a boil is a sore trouble; proverbially so. It Has fallen to my lot to study the natural history of boils someAvhat, and to study, also, the treatment of them. The common accounts of them are too superficial. Dr. Watson, in his lectures, gives the most correct description of them which I remember to have seen; but it is brief, and I think something may be added to it with advantage. A. furuncle, or boil, commences in the form of a pimple. It is a hard pimple, though very small at first; and sometimes, but not always, it is the seat of a stinging pain which calls attention to it. When pressed upon, the part is found to be someAYhat sensi- tive. Within two or three days this becomes a pus- tule ; or, in other Avords, a little pus is formed on its head, the pimple enlarging. A soreness comes on, and ON BOILS. 307 the tenderness increases; and those, who watch their sensations, feel as if something Avas piercing slowly through the true skin. This sensation sometimes conveys the idea of a caustic eating slowly through the cutis. At the end of about a week this process, in which the disease is, in fact, extending through the skin, is finished; and then the swelling begins to in- crease, as if from something placed under the skin. We may, perhaps, regard the primary disease as terminating at this period. There is, then, something formed under the skin which acts like a foreign sub- stance. I take it that this something is fibrin, or coagulable lymph, deposited in the subjacent cellular membrane. I am not sure whether this is all, or whether a minute portion of the cellular membrane is involved, and, undergoing a species of gangrene, con- stitutes, Avith the lymph, the foreign substance. It would seem that what follows consists in the effort to separate and thrOAV out this slough, or foreign matter. From this period, early in the second Aveek of the disease, the SAvelling and the pain increase. The ex- tent of the tumefaction varies in its diameter from three quarters of an inch to tAvo inches. In some cases an erysipelatous inflammation is added, and this spreads over a space equal to the back of the hand, or even more. The part thus affected puffs up more or 308 ON BOILS. less, but this swelling usually subsides in three or four days. It is not concerned in the regular process of the boil. In the first week, while the disease is extending through the cutis, the pustule enlarges, and more or less matter is formed. This is accompanied by a burning pain, which the inexperienced attribute to the purulent matter. If it be a bad boil, the patient thinks he has already suffered enough, and punctures the pustule, with a sanguine hope of.relief. For a short time, perhaps, there is some relief, but Avithin two days, if not in one, he finds the swelling and the pain decidedly augmented. Then, probably, he is charged by those about him with carelessness, and Avith having taken cold in the boil; or, perhaps, it is thought that he has used the wrong salve, or the Avrong poultice. It is thus that philosophical nurses and goodies are always ready to explain the changes in a disease, which meantime is pursuing its OAvn proper routme. The suppuration goes on beneath the derma, and at length an opening takes place, so that some matter is discharged from the depth of the boil, and this matter is often colored, more or less, by blood; but the end is not yet. On the other hand, it is then, at the end perhaps of the second week, that the great soreness is first noticed; the soreness which is proverbial. ON BOILS. 309 There is not any other disease, known to so large a pro- portion of mankind, in which the soreness is so great as in this; and thence the common phrase, " as sore as a boil." This soreness has its seat in the inner surface, by which the core or slough is enclosed, and to which it is attached. Accordingly, in cases where the parts open so as to expose this core to view, if you touch it, and, still more, if you attempt to draw it out, the patient screams with the pain. It is like tooth-draAY- ing. When the opening has taken place, you do not find a cup, but rather a boggy mass, from which the pus oozes out. In the course of the third week there comes a period, when the patient feels that the pain and soreness have abated; matter is discharged more freely, and the swelling is evidently diminishing. In twenty-four or forty-eight hours from this period, a little ragged wad makes its exit from the cavity; then the parietes come together, and, in another day or two, the trouble seems all over. When the core has been looked for, and is at length brought out to sight, some disappointment is often experienced. It is smaller than was expected, even when it is in its most perfect state. The truth is, that, from the moment it is de- tached from the living parts about it, the core shrinks; and that is the time when the tenderness subsides. Besides, it happens in most instances, that the core or 310 ON BOILS. slough is not discharged in an entire state. It has been decaying, and I may say rotting, before its sepa- ration ; and, Avhen detained aAvhile before its expulsion, it separates into parts, which are washed out with the pus. After the discharge of this substance is quite completed, there is not much more suffering, provided the part is defended from injury; but another week passes even then before the skin is quite sound and well, so as to bear pressure Avithout inconvenience. From the first pimple to this termination, four, and often five, Aveeks are occupied; but the really painful period is one or two weeks, according to the severity and extent of the boil. For, as neither all men nor all oak-trees are of the same size, so the furuncle, also, varies in its magnitude. The description I have given is that of the disease in its most regular and most usual course. But, like its betters, the boil has its varieties. If you Avatch an apple-tree from the time when its blossoms have fallen and the fruit is set, you find this fruit falling off almost daily, at every period of its growth, varying accord- ingly in size, and often imperfect in shape; and, at last, when you come to the gathering, the apples differ in shape, as well as in size; for, in a large proportion of them one half is more perfectly developed than the other. So it is with boils at the present day; and, I ON BOILS. 311 doubt not, if there had been some close observers attending Job, the remarks I have made AA'ould have been written down in his book. The variety, so com- mon as to have acquired an appropriate epithet, is the blind boil. This is only a dwarf, sometimes ill-shaped, and like some human dwarfs it may have a sharp temper. It seems to me that, in the case of the blind boil, the boring through the cutis, or derma, and forming the core, which I have described as the first stage of the disease, is not perfected. This process stops in some part of the swollen cutis, and the core is not formed, or not fully. The swelling is not so large as in the perfect boil; and the duration of the Avhole disease is shortened. As this stoppage may take place at any point in the cutis, so the tumor will vary in magnitude. Moreover, the suppuration is very imperfect, and the bleeding is large in proportion. The other varieties are marked only by imperfections in different degrees, as happens to the apples. I must except, hoAvever, one variety, in Avhich, soon after the boil opens, a fungus rises, circular in form, wdth a flat head, a quarter of an inch or more above the sur- face of the skin. No core is seen. The fungus is exquisitely tender. After four or five days it sinks down, and there is formed a much larger cicatrix than in other cases. It seems that a considerable portion 312 ON BOILS. of the cutis is destroyed. We must infer that there is not any core in such a case, but that some injury is done to the parts which prevents the healing for a time, just as happens Avhen a wound in the flesh will not heal because there is a piece of dead bone in the bottom of it. But I cannot trace over the whole pro- cess in accordance with this view of the case. It is a hint which may lead some one to a discovery of the true pathology in this little affair. It seldom happens that one boil comes alone. More commonly there are several in succession, and not rarely a dozen or twenty. Some persons count these successive boils by hundreds. These will be recurring during one, tAvo, and even three years. It is not un- common to see two, and sometimes there will be found four or five, on the same person at one time; but not all of the same age. When large numbers occur in succession, I believe it will be found that many of them are small. At some periods boils are epidemic. In 1852 and 1853 they Avere very common in this country, and in Europe also. During these years there Avere many persons, who could boast of the large numbers they had endured. Happy the man Avho can point out the causes of the diseases he sees! If one could show any peculiar state ON BOILS. 313 of the system giving rise to boils, he might, perhaps, learn how to prevent them. I am not the happy man in this instance, though I have been watching persons affected with the disease for very many years. In -each individual instance you will find ingenious people around the patient, who can explain the matter quite to their own satisfaction. In one case butter and gravy, and other articles called rich, are accused as the source of the evil. In another it is low living which is suspected. I first learned that many boils occurred in succession many years ago. I then had two patients, one of whom had them for a year, the other for eighteen months. One of these was a gen- tleman, then young, of a very thin, spare habit, with sharp and distinct features, a dry skin, abstemious in his diet, and regular in his whole course of life. The other was a lady, also young, above common size, plump, rather fat, rotund, with a soft skin, looking as if she lived on fat things. Comparing these two cases carefully, I could not find anything common to them; but the contrary. The young lady was living at her ease, though she could not be called indolent. The gentleman was one of our active merchants, never idle. I have been equally unfortunate since the time when I saw these two patients. Others have differed from each other as much, and in every way. They have 27 314 ON BOILS. been of almost all ages, all temperaments, all habits as to diet, etc.; some perfectly healthy in their con- stitutions, others far otherwise. • Among them some have been tuberculous. The subjects of boils are comforted with the assur- ance that they are, or will be, the better for them; or, at least, that they are saved by them from internal diseases. One cannot prove that assertions like these are ill founded. I can only say that I have looked carefully and honestly for evidence, in support of them, without success. A valued friend of mine, a lady between forty and fifty years of age, has raised blood, more or less freely, from her fourteenth year; and has* at times been much impaired in health other- Avise, though always exhibiting a great power of endurance, with the aid of a very strong mind. Since she was forty she has had boils for two or three years. During those years, and since, she has suf- fered severely from the same complaints as before. This has not happened under my observation, for she was living at a distance from me, but I have the facts on good authority. Though I cannot point out the peculiar fault in the constitution, or habits of patients who have boils, I can shoAv how they are brought on in some cases. Blis- ters produced by cantharides will commonly heal in a ON BOILS. 315 few days, if the cuticle is not turned off from them. But, Avhen it is, they often take on a new inflamma- tion, for a time will not heal, and become sore blisters. As these sore blisters are healing you will, not unfre- quently, find them surrounded by a thick crop of pustules of various sizes. Watching the patient, you may find these pustules followed by others of a larger size, much feAYer in number, and at a greater distance from the blister. Next, at a still greater distance, you will find a boil, and then another, and another. In such a case you may find the same trouble continuing for many months. Where poultices have been applied to boils you wrill often find similar pustules on the margin of the circle covered by the poultice, and a new crop of boils extending from them. Nearly forty years ago I made an issue on the breast of a consump- tive patient. He shortly afterwards AYent to Cuba. On his return he told me that he had a constant suc- cession of boils during his absence. They began near the issue, and they continued to show themselves' for nine months. The tuberculous disease went on, ap- parently undisturbed by the disease on the skin. It is Avell knoAvn that patients, whose skins become sodden under hydropathic treatment, are very often affected by boils; at first numerous and small, after- wards fewer and larger. At least I believe that they 316 ON BOILS. pursue this course, just as happens when they arise from blisters; only, after the Avater treatment, as I take it, the boils come at once on various parts of the body, instead of starting from a central point. The cause in these cases is much the same as exists in the the poultices. Let it be understood that many persons are afflicted with this same disease, without having been subjected to any of the causes above described. Having been thus full in the description of boils and in the discussion of their causes, I come now to the treatment. Is anything useful to be done to the part affected ? Can anything be done to prevent the recurrence of the disease ? As to the first question I reply, unequivocally, in the affirmative. The boil cannot be jugulated, as it has no neck ; but its head may be split open in its embryo state, and there will be an end of it. I endeavored to describe the disease from its very com- mencement on this account. One.could not say with entire confidence, on examining a pimple, that it would, or would not, become a boil. It has not certain and specific characters. But if a man has had one boil, and soon after has a pimple, such as I have described, the probability is that this will grow into another boil. If he has had two or three boils ON BOILS. 317 about his hand and arm, and a pimple comes in the same region, it is almost certain that that will grow into a boil. Now, what I have to say is, that if you carry the point of a lancet through the middle of that pimple it will dwindle away. The sooner this is done, after the pimple is formed, the better. The treatment succeeds if adopted on the second or third day; and even later it does some good. If done late the disease is not entirely overcome; it is blighted and is short- lived. This treatment is not worth trying after the fifth or sixth day ; not after the affection has extended deep into the true skin. You will sometimes see, when the pustule has just formed, if the cut does not cross exactly in the centre, that a half, one-sided pustule will be formed, yet the disease will not come to much. Be it noted, however, that this operation will not succeed, if it be not performed thoroughly and exactly. The lancet should be plunged through the cutis, beginning just outside of the pimple, and be carried through this pimple, at the same depth, dividing it as near as may be into two equal parts. The difficulty in the treatment is to discover the pimple on its first formation. Occasionally it will come in a quarter, which the patient has not thought of, and often Avhere he cannot see it. But usually the pimples come in the vicinity of the previous boils, 27* 318 ON BOILS. as on the head, on one of the limbs, or on the parts around the pelvis. If the patient is apprised where the pimple Avill probably come, he may, by feeling round the suspected region, be sure to ^discover it at its first coming. For this purpose let him examine himself twice a day. He may fancy that there are pimples where there are not, but the physician will decide that matter; or, if both should be in error, it is not a great evil to feel the lancet three times, if one boil can be saved by it. Let me give one example. A gentleman, about seventy-five years of age, called me to see a boil formed on the hairy scalp, near his ear. It was not of the largest size, but it proved a sore trouble to him. Nothing had occurred to explain the occurrence of it. Before this was well, he sent for me to see another, much smaller, in the same vicinity, which had been coming four or five days. I divided this freely, and with as much success as I had promised him. The disease went on, but the boil Avas much smaller than the first. He noAY realized the importance of Avatch- ing for the pimples, and he had six in rapid succession, all under the hair. I divided each one, and arrested the disease in each case. I began the use of the sulphate of quinia as soon as the third boil commenced, which was the first I saw in the state of a pimple. It ON BOILS. 319 required some days before I arrived at a sufficient dose of this medicine to affect the system ; the patient being an old man, I had been very cautious in the use of it. From the time the constitutional effect of it appeared the pimples ceased to show themselves. In this case we have an instance of the tendency to a recurrence of boils ; of their tendency to keep in one neighborhood, Avhich is not always but often shoAvn; of the effects of an early division of the pimples ; and of the effects of the quinia, which I shall treat of presently. Now, as to the second question ; when a patient has had several boils can anything prevent their further recurrence ? To this I cannot give so confident an answer as to the first question ; but I think it may be done in a large proportion of instances. If a man has had ten boils in succession, you cannot be sure that he will have one more. If, then, you administer your medicine, and he has no more for a year, you cannot be sure that the medicine has produced the exemption. But if you use the same medicine for a number of persons, of whom some have had three boils, some ten, and so on to a hundred, and if in the largest number of these persons the disease does not recur, you then have a right to believe that the disease was arrested by the medicine. Now, this is what has 320 ON BOILS. happened in my practice. For twenty or more years I have given the sulphate of quinia with the result above described. In observing the effects of this medicine in intermit- tent fever and intermittent headache, it appeared to me certain that it did not produce its beneficial effects by acting as a tonic. In those diseases the paroxysms cease without any evidence of increase in strength, as measured by observation of any of the functions, organic, or animal. In AYhat Avay, then, does the cinchona, or do the other remedies, operate ? It has seemed to me that they operate by taking aAvay, or overcoming, the susceptibility to the disease. This at first was only an hypothesis. It was, however, suffi- ciently plausible to lead me to bring it to the test of experiment. Not to make a long story, I will say at once that I have given the sulphate of quinia, the most convenient preparation of cinchona, for many years, on this principle, in various diseases ; that is, in cases of boils, of styes upon the eyelids, and of some eruptions which have kept recurring in different parts of the body, though not severe in their character, and in various painful affections. Of the effect in these last I treated in another letter. The result has been very satisfactory. I do not say that success has always followed this treatment. It certainly has not; but ON BOILS. 321 the results have been satisfactory in so large a propor- tion of instances, as not only to justify the practice, but to make me regard it as my duty to pursue it and to point it out to others. I have the less hesitation in saying this, inasmuch as the treatment is not of a kind likely to be injurious. In stating my opinions on this subject I am not anxious to make any claims to originality. The hon- est truth is, that I cannot tell whether I got the first hints from any one else, or not. It is the truth I have cared for, in this and other cases, and this I wish to present to others; and not a statement of the rela- tive claims of those, who may have been thought the original discoverers. A day or two before I began to write this letter, after looking into various works in respect to boils, I took up the excellent, and well- known lectures, by Dr. Watson, of London. I had not any recollection of a mention of this disease by him, but I found a brief, and, as far as it went, a cor- rect statement on the subject. I was surprised to find that he noticed, what I had not found done by any one else, the commencement of a boil in " a tender knot, just beneath the surface," which I regard rather as a pimple; also, that he mentioned, as practised by some persons, cutting « the hard tumor through While it is yet crude," and the use of the sulphate of 322 ON BOILS. quinia in certain cases; but this as a tonic, and not probably in the full doses which I deem necessary. My practice, however, was not derived from Dr. Wat- son. I could mention various things, for AYhich I am indebted to this learned and sagacious professor, but the treatment of the disease under consideration is not one of them. His work was published in 1845, and did not reach me till a year later, while the treatment, Avhich I have described, was adopted ten or twelve years before that date. It is Avell, perhaps, for me to state, distinctly, the extent to Avhich I use the sulphate of quinia. In the case of an adult, I give from twelve to sixteen grains of that article, divided into three or four doses, on the first day; and if the peculiar effects of the medicine on the head or ears do not take place, I increase the quantity, the next day, by four grains; and continue to increase the quantity daily by four grains, until there is some evidence that the patient has got as much as he can comfortably bear. On the day after some inconvenience is occasioned by the medicine, I lessen the daily allowance by four grains. If this is borne well, or whatever daily allowance is borne with ease, I continue the same for four or five days, and then gradually bring the quantity down to two grains in a day. I prefer not to omit the medicine entirely ON BOILS. 323 for three or four weeks. I state here the course Avhich I deem necessary to secure all the good effects, which the medicine can afford; but I will add that I have reason to believe a shorter course of the medicine will often suffice. Some persons have been too impatient to do all I now advise, and have done well. Others, however, have been obliged to go back and begin the treatment over again. What I deem essential is to beo-in with large doses, so as to make a distinct im- pression on the system as early as possible. This having been done, smaller doses afterwards will main- tain this good impression. Though we have no inter- mittent fevers in our region, except casually, I believe that the same principles should govern the use of the quinia in that disease. It is A'ery probable that arsenic might produce all the good effects Avhich the quinia does, in cases of boils, but I have never tried it. I must say a few words on the local treatment of boils. And, first of all, do not apply poultices to them. It is enough that they may occasion an in- crease of the disease. At particular times they are thought to be comfortable; but, on the whole, I regard them as dirty and troublesome applications, and as often causing much discomfort to the patient. They are endured under the popular notion that they are 324 ON BOILS. necessary to bring the boil to its proper end; that they draw to the surface the noxious humors. I always pay so much respect to popular notions as to bring them to the test of experience, if I do not see any certain objection to so doing. I did this long ago as to poultices for boils, and I became satisfied that there was an error on this subject. Occasionally, for a few hours, a warm and moist application is soothing. For that purpose a fomentation with warm Avater may be directed. A better thing, however, Avhere it can be had, is a piece of spongio-piline, Avet in warm water. This may be Avet AYith ease at any moment, and is free from some of the evils of a common poul- tice. But much soaking of any kind is bad. For the rest, the simplest applications are the best. The spermaceti cerate, or something like it, is sufficient to protect the diseased part from irritation, and that is all which is needed. A piece of linen, or lint, spread with the cerate may be kept in its place by very nar- row strips of adhesive plaster. Until some discharge has taken place one dressing will last for two or three days; aftenvards, the dressing should be renewed as often as cleanliness requires. Let me add one more direction to be observed, at least as long as the soreness of the part continues, and this I shall add ON BOILS. 325 in words which I read more than fifty years ago, and have never forgotten, written I believe by Mr. Sharpe, of Guy's Hospital, namely, " Do not cleanse the sore too curiously." 28 LETTER XVII. ON THE TREATMENT OF TYPHOID FEVER. This letter shall be devoted to the treatment of typhoid fever. I need not describe the disease. You already know it as the continued fever seen every- where in New England, and to be found, probably, in every part of the world. In our seaports we have had the yellow fever, occasionally, within the last sixty years, if not before. In my day, the spotted fever, so called, prevailed for several years in different parts of New England. The typhus fever, as understood at the present day, has occasionally been seen among us; but, probably, always imported from abroad. But the continued fever, called typhoid, is the disease which is never absent from us, and which, in some seasons, prevails extensively, now in one place and now in another. It is the treatment of this disease I Avish to discuss. Can this disease be shortened in its duration, or dimin- ished in its violence, or its danger to life lessened, by ON THE TREATMENT OF TYPHOID FEVER. 327 treatment ? These are interesting questions, and it is worth some trouble to ascertain the true answers to them. Every year many persons suffer from this disease, and some very severely; many die, and that at an early period of life, when just entering on its active duties; and, of those who survive, many have their vigor lessened and their comfort and usefulness abridged for months, and even for years, after the disease has left them. Can these evils be dimin- ished ? I believe that the opinion has been gaining ground among us, for twenty or thirty years past, that the above questions must be answered in the negative. Or, if it is thought that any benefit can be derived from treatment, it is maintained that this is of very small amount. This view of the subject is favored by my friend Dr. Bigelow, in his admirable " Discourse on Self-limited Diseases." There is a great presumption in my mind that any opinion advanced by Dr. Bigelow is Avell founded. In this community his decisions have a most deserved weight and influence; and most especially among those who are the most competent judges. It gives me great pleasure to bear testimony in public, as I have often done in private, to his high claims to respect as a scholar and philosopher. The discourse 328 ON THE TREATMENT OF TYPHOID FEVER. to which I have referred is full of wisdom. I could say more, but I will restrain myself from a fear that AYe may be thought to be bandying compli- ments. In the discourse on self-Hmited diseases Dr. Bige- Ioav says, as follows: " Before quitting the subject, I beg leave to intro- duce the opinion of one or two medical writers, in regard to the possibility of interrupting or breaking up this disease by means of art. M. Louis, of whose researches in regard to typhoid fever, it is but small praise to say that they are more exact and comprehen- sive than those of any living writer, is of opinion that the disease cannot be thus intercepted. ' Experience,' says he, ' has shown that a well-marked typhoid affec- tion is not capable of being broken up.' To this tes- timony of one of the most eminent teachers in the French metropolis, it may not be amiss to add that of an American physician, Avhose opportunities for observ- ing the disease in different parts of New England were extensive, and Avhose Essay on Typhus Fever well merits an attentive perusal. The late Dr. Nathan Smith, in the course of some remarks on the possibility of interrupting this disease at its commencement, ob- serves : ' During the whole of my practice I have never ON THE TREATMENT OF TYPHOID FEVER. 329 been satisfied that I have cut short a single case of typhus, that I knew to be such.' * " Having said thus much, I leave the subject of the tractability of typhus and typhoid fever to the light of future investigation. It is but justice to state, that numerous and highly respectable authorities are declared in favor of the efficacy of art in shortening and mitigating these diseases; and it will be a source of gratification to the friends of humanity and science, should it ultimately be settled that the active treat- ment now usually pursued at the commencement of cases, is instrumental in lessening their duration, severity, or danger." It will be seen that my friend is an unwilling doubter; and no one would be more pleased than he, if it can be shoAvn that any check can be given to this direful disease, and that the questions I have pro- pounded can be answered in the affirmative. I am not prepared to assert, positively, that they can be so answered. But I believe that I can bring so much evidence on that side of the question, as to justify the * At the time of the publication alluded to, the distinction between typhus and typhoid fevers had not been well made out. The distinction is good, though writers of authority differ on thfl 330 ON THE TREATMENT OF TYPHOID FEVER. trial of active remedies under proper circumstances; nay, so much, as to make it our duty to try them until further evidence shall show that there is some fallacy as to that which I shall adduce. It is from my report on typhoid fever in the Massa- chusetts General Hospital, made in 1838, that I shall derive the evidence referred to. Without going into all the particulars, I will take what relates to the effects of emetics. This report Avas grounded on the cases of that disease in the hospital from 1822 to 1835, inclusive. From this it appears (pp. 7 and 8) that on a fair estimate there was one death in about eight cases. Among those admitted to the hospital in the first two weeks of the disease, one hundred and fifty took emetics before or after admission ; of these one hundred and fifty, thirteen died, being 1 in 11.53 In the same period eighty were admit- ted Avho did not take emetics ; of these ten died, being 1 in 8.00 The difference is very striking. But of the one hundred and fifty Avho took emetics, some took them earlier and some later in the disease. It has been thought that the earlier this and other active and depletory remedies are administered, the greater the ON THE TREATMENT OF TYPHOID FEVER. 331 benefit. See how far this is confirmed by the same report. Fifty-nine entered the first week of the disease, and took emetics in that week; four of these died, being 1 in 14.75 Thirty-one entered the same week, and did not take emetics ; of these three died, being 1 ha 10.33 Ninety-one entered the second week, and took emetics either before or after • admission ; of these nine died, being 1 in 10.11 Forty-eight entered the same week, and did not take emetics ; of these seven died, being 1 in 6.85 The advantage was on the side of those, who took emetics; but more decided as to those who entered the first week, than as to those who entered the second. The last had not probably been so well nursed in the first week as the others. But also they had not on an average taken the emetic so early; and that, no doubt, made a difference in favor of those entering the first week. My own experience taught me long ago that emetics were most useful when taken within the first three days of the disease. This is confirmed by the hospital cases. It appears from the report that thirty- two patients took emetics within the first three 332 ON THE TREATMENT OF TYPHOID FEVER. days of the disease; of these one died, 1 in 32 Twenty-seven took emetics within the last four days of the first week; of these three died, being 1 in 9 Undoubtedly these last numbers, relative to those Avho took emetics in the last four days of the first week, are less favorable than would be found if the number was larger; for the proportion of deaths is greater than in those who entered the second week, and took emetics, and of whom the larger part, no doubt, took their emetics at a later period of the disease than the above twenty-seven. If, now, we inquire what was the effect on the duration of the disease in those, who took emetics and recovered, it does not seem to have been much if any- thing to the advantage of those taking emetics later than the third day. But as to those who took emetics on either of the first three days the benefit is unequiv- ocal. Of those who took emetics on the first day of the disease, the average day of convalescence was the 14.66 Of those who took emetics on the second day, the average day of convalescence was the 15.32 Of those who took emetics on the third day, the average day of convalescence was the 16.46 ON THE TREATMENT OF TYPHOID FEVER. 333 While of those who took emetics on the fourth, fifth and sixth days of the disease, and recov- ered, the average day of convalescence was the 19.45 It cannot surely be attributed to accident that these results were so favorable to those, who took emetics, among cases not selected but taken as they came, through many successive years. But I feel assured that the result would have been found much more favorable had all those, who took emetics at an early period, been properly managed afterwards. To the best success of this mode of treatment it is necessary that great care should be taken after the first relief from the emetic. However well the patient may seem, he should be treated as a sick man. The emetic should be followed by an active cathartic on the fol- lowing day, unless it should itself have had a powerful operation on the bowels. Probably this was done in most of the cases. And then, for a week at least, however well the patient may appear, he should be restrained from all efforts of body or mind, and should be kept on a very moderate, bland vegetable diet. Though the headache and pain in the back and limbs be removed, the pulse restored to a natural frequency, the chills and heat subsided, still the liability to the disease remains. Therefore the disease is easily 334 ON THE TREATMENT OF TYPHOID FEVER. lighted up anew; and, if great errors are committed, it may return in its full force, and run through its entire period. All this I have learnt, long ago, in private practice. Now, Avhen we consider the situa- tion of patients Avho resort to a hospital, and that they would not go there if they had the comforts of good homes and careful attendance, it will be seen that feAV of them will get the full advantage, Avhich an active treatment at the onset of the disease might have afforded them. I am in truth surprised that so large a proportion of those, to Avhom my report refers, did derive such marked benefit from this treatment. Such would not commonly be the result in hospital practice of large cities. I think it may be explained in part by the recollection that, in our hospital in its early years, the great majority of the patients Avere of our native stock, and bred up with some regard to the rules of prudence. In reading accounts of successful practice from a medical man, however honest we may think him, it is necessary to guard against the disposition on the part of the reporter to see the results in a favorable light. If the result is not in every case all he could wish, he is prone to charge the patient with some commission, or omission, wThich may explain the failure. The sugges- tions in the last paragraph are not however to be looked THE TREATMENT OF TYPHOID FEVER. 335 at in this light. I do not say that the patients re- ferred to were very imprudent. I say that I wonder that there Avas so much prudence among them, as the good results give evidence of. I must beg, also, to call to mind some circumstances respecting these cases. The patients were not treated by me from the begin- ning. The number Avas small for whom I prescribed the emetics. I did not plant the trees, and feel a paternal solicitude in watering them. A very large proportion of these patients had their emetics before they entered the hospital; probably some days before. Nor, when they got there, did they all come under my care; a good part of them were under the care of my colleagues. Those acquainted with our hospital knoAY that the case of every medical patient is taken down on the day of his entrance by the house physi- cian. He then notes the remedies employed before the admission of the patient. The attending physician dictates daily, if the case be an acute one, the state of the patient and the treatment to be pursued. This is all placed in the case-book within twenty-four hours. There is no chance for interpolation at a subsequent period. The attending physician, in going his rounds, cannot be supposed to bear in mind every typhoid patient, whose treatment began with an emetic, and to make his reports more favorable accord- 336 ON THE TREATMENT OF TYPHOID FEVER. ingly. Still less can it be suspected that the case- book would be falsified in any instance, in order to make a favorite remedy appear to more advantage. See, now, how the statements in my report on ty- phoid fever were obtained from the hospital books. I made out large blank tables, having columns for every important symptom and for the remedies employed; distinguishing those administered before and those after the entrance into the hospital. Then taking the hospital books in their order, from the beginning, I entered the name of each patient in my tables, and the entries relative to him in the corresponding columns. The particulars had to be sought out patiently, for the records had not been made with reference to such a use of them. To go through three hundred cases in this way was the labor of my spare hours for several months. It was not until the work was finished that I went over the cases to obtain the results as to the symptoms of the disease, its treat- ment, and its favorable or unfavorable termination. These results, then, were as faithfully represented as could by any means be done. More especially whether death occurred more or less frequently under one mode of treatment than under another, was ascertained so certainly, as to preclude all chance of error. ON THE TREATMENT OF TYPHOID FEVER. 337 Is it asked if those patients who took emetics did not before, or afterwards, employ other remedies ? I reply, that they did, probably in every'instance. Then, I may be told, that I might be misled in attributing the favorable results to the emetics. I answer thai the other remedies employed were, no doubt, the same as for those who did not take emetics. I say, no doubt, because all Avere treated by the same physicians; and that in their treatment the physicians were guided by the same general principles in one set of cases as in the other. I should hope that a benefit was obtained from this after treatment; but this would not show that the difference between the two classes of cases was not to be attributed to the only difference in their treatment, namely, that emetics were given to one class, and not to the other. If, lastly, it be asked, why emetics were not administered to all the typhoid patients, I reply, that many of them were admitted at too late a period to do this with advantage at the hos- pital; Avhy they Avere not administered before the admission of the patients, must be answered by those who had the care of them. I presume, however, that most of these did not get medical advice early; and that, in some cases, the physicians did not think well if the practice, or found some objections in the cir- cumstances of the particular patients,under their care. 29 338 ON THE TREATMENT OF TYPHOID FEVER. There are other remedies, besides emetics, for the utility of which my report affords some evidence; of AYhich, cathartics at the commencement of the disease, and antirnonials in doses not sufficient to induce nau- sea, or vomiting, are the principal. On these points I must refer to the report in the Transactions of the Massachusetts Medical Society. I am aAvare that one doubt may lurk in the minds of some of my brethren. That is, whether there was not some error as to the disease in those patients, who Avere vomited early, and in Avhom the results were favorable. I say there is not any reasonable ground for such distrust. In examining the cases in the hospital books, Avhich had been called typhoid fever, I threw out all which Avere doubtful, as is stated in the report. But did we know how to diagnosticate the disease? One answer to this is, that in every fatal case, which Ave had denominated typhoid fever, and in which the small intestines were examined properly, the disease in Peyer's glands was discovered. Another ansAYer is, that a very large proportion of the patients who were vomited early, were brought to the hospital, and there underwent the disease for a longer or shorter time; and the records made there satisfied my mind as to the disease. At last, then, comes the plain question, whether I was able to distinguish the ON THE TREATMENT OF TYPHOID FEVER. 339 disease. To this I shall reply plainly. I watched and studied this fever through three or four seasons when it was epidemic, and the sporadic cases of it for more than twenty > years before our hospital was erected; and I made it most especially my study to recognize it on its earliest days. I believe that I studied it successfully; but I must leave it to those who know me, to decide that point. And, noAY, a few words at parting. I shall take the risk of repeating what I have said before, in my desire to impress on you what I think essential to your well doing. The sick-room is to be the field of your labors. To everything which occurs there you are to give your attention, and every step there should be under your direction. Questions of the deepest importance are constantly arising there for your solution; questions on the constitution of man, on the powers and the machinery by which his functions are performed, on the manifestation of disorder in those functions, and the causes Avhich may induce disorder, on the mode of restoring health, or of guarding against all aggraA'a- tions of disease, so as to allow the best chance for a favorable result by the spontaneous efforts of nature. These, and the like questions, will be arising constant- ly, and you must be prepared, as far as possible, to 340 ON THE TREATMENT OF TYPHOID FEVER. meet them. Look at the gardener going forth to his labors furnished with all the tools and appliances which can aid him in his cunning work, — thinking no preparation too great, no precaution too small, if he can thereby make success more certain. See him seeking for each plant the site most fa\rorable to it, and furnishing it AYith the soil best adapted to its wants. Notice how minute are his directions to his laborers, trusting as little as possible to their discre- tion. Do not cares of the like sort, looking to great and small things, belong to the physician, avIio has to do with AYhat is so immeasurably more important than the fruits and flowers of the garden ? He must be clear, and exact, and minute, in his orders to the nurse, as the gardener is to his laborers; remembering that everything may depend on the more or less, on the hoAY and the when. - For these duties the physician cannot be prepared without the utmost familiarity Avith the sick-chamber. This is to the physician what the garden is to the cultivator; the place for Avhich all his studies and labors should prepare him, and where he should forever be advancing more and more tOAvard a perfection which he can never reach. INDEX. Abscess in tonsils, 154. " " " treatment, 155. Abscess in liver, 299. Agriculture, compared to medicine, 12. Ail-, in intestines, salutary, 243. " " " injurious, 243. Alimentary canal, the mutual influence of its parts, 236. Animal system, its organic diseases, 46. Animal Magnetism, 93. " " common doctrine in respect to it, 99. " " another doctrine, 99. Anxiety, cause of dyspepsy, 213. Apoplexy, 74. Appetite, a pre-reqnisite to the regula- tion of diet, 217. Bile, as a cause of disease, 132. " false notions respecting, 132. Bilious diseases, 297. Bladder, irritable, 304: Bleeding, in pneumonitis, 165. " " haemoptysis, 191. Boils, 306. " their varieties, 310. " blind, 311. " come in succession, 312. " sometimes epidemic, 312. " their causes, 313. " treatment of, 316. " local treatment, 323. Brain, an out-growth of the organic sys- tem, 44. Brandy, 223. 20* Brandy, caution as to its use, 224. Bronchitis, 158. " treatment of, 161 Calculi, biliary, 302. " urinary, 303. " mulberry, 303. Catarrh, 158, 160. " treatment of, 162. Cause of disease, 36. Cells, division, multiplication and uses, 45. Cholera Infantum, 132. " " diagnosis, 134. " " treatment of, 141. Chorea, 85. " its treatment, 85. " fatal, 86. " attending second dentition, 147. Clairvoyance, 102. " tested, 103. Clergymen, how far liable to haemop- tysis, 201. Coffee, 222, 223. Cold, a, 158. Colon, enlargement of, 243. « » " treatment, 244. Combination of cathartics, 290. Condiments, 218. Constipation of bowels, 271. i< « " common in cities, 271. a " " causes of, 271, a " " treatment of, 276. 342 INDEX. Constipation, great and obstinate occa- sionally, 292. « treatment, 292. Convulsion fits of children, 69,110. it n » » causes, 69. u u « " treatment, 70. Costiveness attending dyspepsy, 210, 218. « treatment of, 219. Cure of the sick, 16. u a a priest, 16. u « « physician, 16. Dejections in Cholera Infantum, to be analyzed, how, 136. " as to their frequency, 281. Dentition, 107. " cause of disease, 107. " second, 145. « " treatment of, 147. Diarrhoea, in dentition, 110. " in teething children, 129. " before the period of dentition, 130. " attending dyspepsy, 210. " treatment of, 239. Diet and regimen, 17 " in infancy, 112. " errors of, 212. » " " in quantity, 212, 226. « " " in quality, 212. " " " in frequency of meals, 212. " for a dyspeptic, 217,221. " for constipation, 273. Directions as to medicines, &c, 38. Double consciousness, case of, 94. Dreaming, 92. Drink, for a dyspeptic, 222. Drugs, powerful, caution in their use, 13. " powerful, abuse of them, 13. " the temper with which they are used, 14. Dysentery, 240. Dpspepsy, 203. Dyspepsy, its local symptoms, 205. « treatment of, 211, « medicinal treatment of, 229 " its subsidence in old age, 231. Education, 7. EDteritis, in teething children, 112, 133. Epilepsy, 61, " paroxysm of, 61. " apoplectic, 63. » its termination, C4 « its proximate cause, 65. " its exciting causes, 66. " its treatment, 67. Evidence, examination of, 27. Examination of cases, method of, 28. Exercise, want of, cause of dyspepsy, 213. " 227. " for constipation, 279. Faint turns, in epilepsy, 63. Feeding, of infants, 113. Fissure, or crevasse in rectum, 295. Flatulence in stomach, 207. " " " how far decep tive, 207. Food, liquid, tepid for infants, 118. " solid, for infants, when, 118 " how often, 118. " animal, 119. " withheld in night, 120. " under disease, 121. " vomiting and regurgitation of 208. u « u u a caused by some tenderness of the stomach, 208, " vomiting of, long-continued, a case, 20S. Furunculus, 306. Gall stones, 302. Gastritis, in teething children, 112,133. Gout, 171. " treatment of, 171. Gruel, mode of preparation, 115. Haemoptysis, 179. INDEX. 343 Haemoptysis, from a tuberculous cav- ity, 179. " from aneurism in the thorax, 180. " case of, from exhalation in lungs, 181. " diagnosis, 185. " frequent recurrence of, 189. " treatment of, 189. " prognosis in, 195. " three cases of, 196. Headache, 49. " sick, 49. " " treatment of, 51. " intermittent hemicrania, 54. treatment of, 56. " chronic, 57. « " treatment of, 59. " in pregnancy, 59. " attending dyspepsy, 211. Heartburn, its causes, 207. Hemorrhoids, 235. Hippocrates, 18. Holyoke, Dr., his character, 19. Hosmer, Dr., case of, 192. Hydrocephalus, 72. Icterus, 299. Iliac quarter, 247. Influenza, 161. Insanity, 104. " treatment, 104. Intestines, diseases of, 232. " physiology, 233. " pathology of, 235. " causes of disease in, 238. " mode of studying their dis- eases, 242. Irritable bladder, 304. Jaundice, 299. Liberal profession, 9. Liver diseases, suspected, 244,297. " « acute, rare, 298. a " chronic, not very rare Living beings, the simplest, 42. L----'s, Captain, case, 194. Magnetism, animal, 98. Medicine, imperfect as an art, 12, 23. " " " " " not so. comparatively, 12. " practice of, not limited to the use of drugs, 15. Minot's, Dr., cases, 257, 260. Mucous membrane, inflammation of, 111. " " eruptions on, 111. Navigation, compared to medicine, 11. Nervous system, 42. " " an outgrowth of the organic system, 44. " " its organic diseases, 46. " " ~' its normal functions, 47. " " its simple diseases, not explicable, 48,49. Neuralgia, 87. Non-naturals, 112. Pain, 87. " its treatment, 89. " or uneasiness in breast, attending dyspepsy, 211. Painful tumor near the coecum, 248. Case I. of the above, 248. " II. of the above, 250. " III. of the above, 251. " IV. of the above, 252. " V. of the above, 254. " VI. of the above, 257. " VII. of the above, 260. Painful tumor, near coecum, symptoms of, 262. « " its situation, 262. " " not fatal, 262. " " its pathology, 263. " " diagnosis, 264. « " treatment of, 268. Palpitation of the heart attending dys- pepsy, 211. Palsy, 74. 314 IND EX. Palsy, its treatment in certain cases, 76. " cases of, 77, 78. " facial, 79. " " its treatment, 79. " " cases of, 80, 81. m " from lead, treatment, 82. " mimotic, 82. " " its treatment, 84. Peritonitis, in right iliac quarter, 247. Phlebitis, with suppuration, 266. Phthisis, 173. " varying with age, 173. " treatment of, 174. " long-continued, after haemop- tysis, two cases, 197. Physician, the true, his pretensions, 15, 16. Pneumonitis, 164. " how far dangerous, 165. " treatment of, 165. Principles, application of to practice, 10. Profession, liberal, 9. Prolapsus ani, 295. Quack, 16. " remedies, 271. '* " objections to them, 272. Quinia, its mode of operation in certain cases, 320. Regurgitation of food, 208. Rheumatism, 167. " acute, 167. Rheumatism, treatment of, 168. " local, 169. " in small joints, 169. Sick-room, conduct in, 25. Sleep, perfect or imperfect, 92. Somnambulism, 93,100. Spirit-rappers, 104. Symptoms, objective, 30. " subjective, 30. Tea, 222, 223. Teething, 107. Tumeurs phlegmoneuses des fosses ili- aques, 265. " case of in a man, 266. " case of in a woman, 266. Typhoid fever, treatment of, 326. " " effect of emetics on, 330. Ulcuscula oris, 111, 150. " " hereditary, 150. " " acute, 152. " " treatment of, 152. Uvula, elongation of, 156. " amputation of, 157. Vein, suppuration within, 266. Vertigo attending dyspepsy, 211. Vesication in haemoptysis, 191. A'omiting, in dentition, 109. Vomiting of food, 208. Weaning, 121. " age for, 123,124. " season for, 124. Wine, 223, Worms in the intestines, 148.